APNA 29th Annual Conference Session 4027: October 31, 2015 Image - - PDF document

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 1

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This presenter has no disclosures or conflicts of interest There are no off label medication uses described in this presentation. At the end of the presentation the participant will be able to:

 Describe types of court ordered treatment

and how they are similar and different

 Identify strategies to engage persons court

• rdered to treatment.

 Identify factors that can interfere with

therapeutic engagement

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 2

 Alternative Treatment Order (ATO):  Usually generated in the hospital as part of

certification of treatment need continuation

 No criminal action has taken place  There is no “ criminal record”  Most commonly initial order is for 90 days (up to

60 days inpt and the remainder outpt)

 Issue of ATO is completed by a j udge in a civil

court (often on the inpatient unit)

 State dependent regulations. Need to know the

mental health code for YOUR state.

 Judge is not part of the treatment team  Used for court ordered treatment when a

persons’ criminal action is thought to be directly related to substance use disorder, meeting DS M-V

• criteria. Examples:

 DUI: “ super” intoxicated; multiple instances; no

• ther criminal behavior

 Breaking and entering/ larceny: for the sole purpose

• f obtaining money or goods to sell to support

substance dependence

 Uttering and publishing: for financial support of

substance dependence

 Open intoxicants/ public disturbance/ public

intoxication: likely multiple charges

 Used for court ordered treatment when the

criminal action is directly related to a diagnosable mental illness, meeting DS M-V

• criteria. Examples:

 Assault: perhaps due to paranoia  S

hoplifting: perhaps during manic spending spree

 Disturbing the peace: psychotic behavior that leads

to arrest

 Uttering and publishing: poor j udgment in regards

to relationships (being scammed)

 Resisting arrest: even simple questions by police

may lead to fear and fleeing

 Also Veterans’ Court, Human Trafficking Court

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 3

 Mental health court participation is voluntary  Therapeutic j urisprudence is used to

encourage treatment engagement (Munetz, Ritter, Teller

& Bonfine, 2014)

 Treatment adherence for 6+ months  Regular scheduled court appearances

 Early st age every other week, then less frequent

 Drug/ alcohol testing (tether sometimes)

 May also be a probat ion requirement. Regular and random.  May be eliminated in later st ages of sentence

 Meeting with mental health staff  Meeting with probation officer  ATO: not voluntary; court ordered;

medications likely “ administered” ; stigma; anger about order; denial of illness

 SOBRIETY COURT: shame/ guilt; focus on

addiction AND mental illness; initial denial or “ easy way out”

 MENTAL HEALTH COURT: denial of illness;

distrust of system; lesser of 2 evils? ; symptoms of illness (paranoia, etc)

 S

tandard psychiatric evaluation

 Look for correlat ions bet ween subst ance use HX, MI sympt oms and

legal issues

 S

ubstance use evaluation

 Age first tried or was given alcohol or other substances (this may be in

utero)

 Age of regular use; what was used  Drug of choice; length of use  At what point did drug/ alcohol use become a problem?

 Legal history

 Age of first arrest or contact with “ authorities”  Jail versus prison  Violent versus nonviolent offenses  Remorse versus no remorse

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 4

 What exactly happened?

Why ATO/ MI Court/ S

• briety Court?

What’s your story?



Why t he involunt ary hospit alizat ion/ arrest ?



Hospit alizat ion hist ory?



Experience with medication trials?



Age/ underst anding of illness/ accept ance of dx?



Prior arrest s, DUI’s or charges?

 Prior S

A history? Consequences of use/ absence of treatment?



First offense? If not , ot hers?



Drug of choice? Combinat ion dependence?



Use of one subst ance t o count eract anot her?



Medical marij uana card?



Driving offenses versus ot hers?



Physiological and/ or psychological dependence?

 Mental health history?

Treatment history?

 Acknowledgement / awareness of mental illness?  Age when symptoms first developed (not necessarily seen by others)  Various diagnoses (childhood vs. adolescence vs. adult)

 ADHD?

ODD? Conduct DO? Ant isocial PD? BAD? S chizoaffect ive

 Treatment modalities utilized

 Medicat ions  Therapy – group, individual; specific t ype  DBT; CBT;  12-st ep or ot her similar self-helps?  Prior probat ion?  What has been most helpful to you in the past?

 Defined: “ an essential function for

psychiatric nurses as they reach out and connect, align, partner and collaborate with people in order to help them… to establish trusting, helpful relationships.” (Polacek, et al, 2015)

 Facilitated when RN is committed, dedicated, listen and

encourage using a partnership model of problem solving and shared decision making (Guneskara, Pent land, Rodgers and Pat t erson, 2013)

 Hindered by:

 vicarious t rauma, lack of knowledge and/ or supervision, lack of

confidence by RN



denial of illness, stigma, and metacognitive deficits (inability to form accurat e percept ions of self or “ t hink about t hinking” ) (Polacek, et al, 2015)

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 5

 JOINING  We are in this together

 “ Y

• ur inpatient doctor/ probation officer / j udge has ordered this

t reat ment out of concern about your welfare.”

 “ What did your probat ion officer see t hat allowed him/ her t o refer you

t o t he specialt y court rat her t han have you sent enced t o j ail? ”

 “ What can I do t o help you succeed t hrough t he st ages of your

t reat ment ? ”

 “ I am commit t ed t o helping you succeed.”  “ The goal is for you t o get t reat ment and feel bet t er.”

 V

ALIDATION

 “ Of course you feel/ think this way”

 Making sense of emot ions in cont ext of what ’s happening or happened

 Trauma informed:



t reat ment wit h assumpt ion t rauma has occurred

 People will not come back if they do not feel

welcomed, respected and understood

 People do not instantly feel engaged, it is a

process;

 When court ordered to treatment there is an

underlying assumption that:

 The person likely has denial about t heir illness  The person likely has had prior negative experiences in treatment  The person is worried about out come (such as j ail) versus recovery  The person has been traumatized (trauma informed treatment)  The person has been st igmatized  The person has limited resources and supports

 Impact of illness, substance use, crime



How did your illness/ use/ crime effect t he relat ionships you were/ are in?



What are t he negat ive t hings t hat have happened in your life t hat are most ly related to your illness/ use/ crime?



What ’s t he longest period of t ime you have gone wit hout alcohol or drugs

• n your own?

(wit hout being in j ail, t he hospit al, et c.)



Who are t he people t hat you believe have been most effect ed by your use

• f alcohol/ drugs?



What is in it for you if you change t his cycle?

 Impact of change



Are t here people who may come back in your life if you change t his pat t ern?



If you change t his pat t ern, what ’s one t hing you’ d like t o see yourself accomplish?



If you aren’ t buying alcohol or drugs, what would you like t o do wit h t hat money? (i.e. t he calculat or challenge)



What are your hopes and dreams for t he fut ure?

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 6

 What makes sense?  ATO: help symptoms get under control; monitor and

management side effects; psychoeducation as tolerated; medication education; “ golden opportunity”

 Folks are really smart and can argue against t he ATO…

t hink t wice about t his. Is it psychosis t alking? Bot t om line is t hat t he prescriber MUS T be obj ective and willing to set clear enforceable limits for the fut ure benefit s of t he pt .  S

• briety Court: if the substance use is self-medication of or

causing symptoms, treat accordingly.

 S

• met imes sobriet y is t he best medicine. Don’ t assume medication

is necessary, but rather can it be helpful  Mental Health Court: medication treatment is most likely

needed; GOLDEN RULE: educate, start low, go slow

 May be treatment naïve and therefore slow titration of any

medicat ion is imperat ive. Educat ion about side effect s is a must in gaining t rust . Predict ing reduct ion of some of t he experiences (sympt oms) t hat led t o legal problems may help. Bot t om line if there is great resist ance is that this is part of their sentence.

EVIDENCED BASED PRESCRIBING PRACTICE IS WHAT MAKES SENSE

Thank you for your Attention!

 S

• briety courts produce cost savings of $3000
• $13,000 per client, including prison costs,

revolving door arrests and trials

 S

• briety courts are 6 times more likely to

keep people in treatment long enough to get well

 Of people with substance use disorders

without supervision of a j udge and

accountability plans, 70% drop out of treatment prematurely.

 S

• briety court recidivism rate is 27%

compared to over 60% for non-court clients.



(MI St at e Supreme Court Administration, 2012)

APNA 29th Annual Conference Session 4027: October 31, 2015 Gentz 7

 Judicial interaction with participants is vital

 Court twice a month during early st age, then less frequent

 Monitoring and evaluation measure goal

achievement and effectiveness of goals

 How’s it coming looking for work?

How many meetings a week?

 Regular and random drug/ alcohol t est ing

 Interdisciplinary continuing education

promotes effective sobriety court

 Weekly team meetings to review cases and update progress

 Partnership between sobriety court, public

agencies and organizations

 Use of CMH professionals (t herapist , prescriber, public defenders,

shelt er associat ion, et c.

(SAMHSA, MI St at e Supreme Court Administration, 2012)

 Evolved from sobriety court model  2 million arrests in the US

per year involve persons with mental illness

 About 15%

• f men and 30%
• f women booked

into j ail each year have mental illness

 83%

• f j ail inmates w/ mental illness did not

have access to mental health services

 550,000 people w/ serious mental illness are

incarcerated in j ails and prisons

 900,000 persons with mental illness are

under some sort of community control

(NAMI websit e; Hiday, Wales, Ray, 2013)

 Best practice is to sentence/ release person

AS AP after arrest to reduce negative effects

• f incarceration (Osher, St eadman & Barr, 2003)

 Over 75%

• f participants in mental health

court (MHC) had no re-arrest after 1 year

(Hiday, Wales, Ray, 2013)

 Re-arrests of MHC completers more often

were drug/ alcohol related vs against persons

 Graduates of MHC have fewer re-arrests and

longer time before re-arrest than TAU group

(Hiday, Wales, Ray, 2013)