Involuntary Mental Health Interventions
and
Coercive Practices in Changing
Mental Health Care Delivery Systems:
The Consumer Perspective

Jean Campbell, Ph.D. Missouri Institute of Mental Health

Introduction

Someone once commented to me that because people who are labeled as mentally ill have so little resources and power in their lives, that their rights as citizens of the United States -- constitutional rights--assume even greater importance to them. In other words, issues of freedom and liberty may have greater value to people that have little material resources, and are disempowered as a consumer health group. In addition, the potential of being involuntarily incarcerated in a psychiatric hospital where you may be forced to submit to services and drugs you do not want may make your freedom and rights more dear to you.

In discussing involuntary mental health interventions and coercive practices, the value of freedom and choice in services, the negative consequences of coercion, the ubiquitous stereotype of the violent mental patient, and the perceptions of coercion by consumers need to be considered. These issues infuse the context of this discussion, but may not be apparent in the more narrowly framed research and policy questions addressed by mental health professionals.

In a focus group (concept-mapping) of mental health consumers who brain stormed types of service outcomes that should be measured, autonomy, freedom and empowerment on the one hand, and coercion, threat, and force, on the other hand, were important issues mentioned by consumers. Consumer perceptions of coercion produced two related conceptual domains: the positive value of choice and liberty in defining one's quality of life, and the negative outcomes of coercion on help-seeking, sense of self, and the therapeutic alliance (Trochim et al., 1993). This was one of the first times that freedom and coercion were identified as important in assessing mental health outcomes. An expert panel of consumers working on mental health report cards have also recommended that any use of force or coercion in mental health services should be considered a failure of the system and quantified and used as a performance measure of service system effectiveness.

There have been some studies of the outcomes of perceived coercion, and scales to measure consumer perceived coercion have been developed and used in services research efforts (Lidz & Hoge, 1993; Gardner et al, 1993; Hiday et al, 1997). The consumer research project, The Well-Being Project (Campbell & Schraiber, 1989), found that 47% of mental health consumers had avoided seeking traditional mental health services for fear of involuntary commitment. In consumer testimony and qualitative research, consumers have also reported that involuntary interventions such as seclusion, use of restraints, in-patient and out-patient psychiatric commitment, and forced medication produce fear, anger, sadness, and confusion among consumers. Learned dependency is another identifiable outcome of coercion and psychiatric commitment according to research. It has been found that the attitudes and behaviors of professionals regarding mental health consumers mediates the use of coercion. For example, professionals consider it more legitimate to coerce those who they view as psychotic. "It is a common part of the professional discourse that psychotic conditions risk graver consequences for the patient and other people" (Rogers, 1993). For consumers, issues of voice, validation, respect, and information in the therapeutic alliance tend to moderate perceptions of coercion (Campbell & Schraiber, 1989).

The clinical criteria for use of coercion is not objective and there is much practice variation in service delivery. Treatment decisions regarding the level and appropriateness of coercion in psychiatric settings is also mediated by the consumer's race, gender and class. Early studies of help-seeking behaviors of people with mental illness indicate that there is significant variation in commitment by gender. Women are more likely to be committed that are men, and this is true for groups matched on sociodemographic characteristics and diagnosis. Men who are committed tend to enter the hospital after relatively brief periods of problematic behavior, while the opposite was true of women who are committed. Men who express fear that they might have a mental illness tend to enter the hospital on a voluntary basis, but eight out of 10 women who make such an interpretation are either committed at admission or shortly thereafter (Clausen et al, 1982). Race has also been found to be an important moderator of levels and types of coercion in service delivery. In a study of psychiatric emergency room visits (Klinkenberg & Calsyn, 1997), several risk factors predicted a return visit only for African Americans. In general, black males are institutionalized at much higher rates than other groups in the general population.

Ultimately, it is the public belief in the link between mental disorder and violence that tends to precipitate and justify the use of coercion in service delivery. Even though prior history of violence and current alcohol and drug abuse are much more accurate indications of the risk of violence, the public cannot seem to accept that the "absolute risk posed by mental illness is small, and only a small proportion of the violence in our society can be attributed to the mentally ill" (Mulvey, 1994).

Research findings have established that violence by persons with a psychiatric diagnosis is often grounded in contextual relationships rather than in isolated psychosis (Estroff et al, 1992). Consumers' lives are set apart by angry or indifferent communities that reject, shun, and sometimes attack them. Sometimes a person's symptoms can make other people annoyed or afraid, and, consequently, they may attempt to coerce or control that person in ways that spiral into violence. "The contextual nature of violence raises questions of shared culpability, and it challenges taken-for-granted prerogatives of family members, clinicians, and agents of community safety to name and manage 'the violent mentally ill'" (Campbell et al, 1994).

Anecdotal accounts of violence committed by sons or daughters who are mentally ill against their parents contributes to legislative pressure to increase involuntary interventions at the broadest public policy level in order to "protect the public, the family and the patient." Often in such public displays, issues get side-tracked into a balancing act where the rights of individuals for freedom are weighed against the rights of the community for safety. Coercive solutions are sought at the highest level of public policy (such as out-patient commitment) which also have the widest impact on individual citizen rights. Proxal solutions that would reduce the risk of violence by improving the delivery of mental health services at the local level are seldom explored when such discussions become polarized. If used at all, coercion should only be applied as a last resort with a broad assortment of services available that are not coercive that would necessarily precede any use of coercion.

Finally, it is troubling to note that services and treatments that promote consumer liberty and provide choice lag far behind coercive modalities at all treatment and system levels, and such proactive responses are often characterized as "alternatives" to traditional mental health systems of care. In fact, the concept of the "least restrictive setting" is predicated on the assumption that restrictive environments are the standard approach. Therefore, any dialogue regarding involuntary interventions is necessarily inadequate because it both reifies coercion, and it represses the possibility of consumer empowerment through the proactive embrace of systems of choice and rights.

Research and Statistics

1. Collection of Data

Providers and SMHAs appear to be reticent to collect data on the frequency of administration of coercive interventions or the undesired consequences from or side-effects to receiving coercive services. For example, 72% of the SMHAs do not measure the impact of involuntary commitment on consumers in both impatient and outpatient venues. Further, there is little information of the demographic profile of people subject to coercion (e.g., women, blacks, elderly),. In addition, there is a dearth of research data on the practices and protocols related to coercive interventions. With the introduction of managed care to public mental health populations, it is important to determine if coercive interventions are increasing, and, if so, to what effect on both treatment patterns and consumer outcomes.

2. Dissemination/Address of Information

Similarly, providers and SMHAs are also reticent to provide access to or distribute information on the frequency of administration or coercive interventions or the undesired outcomes from or side effects to receiving coercive services. This is not necessarily a conspiracy of silence, but often its the result of not prioritizing such data in the analysis of data in management information systems, or service system report cards.

3. Recommended Research

Besides the lack of data on coercive interventions and little effort to analyze and distribute available data, mental health services research has also failed to incorporate the consumer perspective on coercion in most research projects. Consumer input in studies of coercion could be facilitated through methods such as focus groups and concept-mapping or support provided for consumer generated research on coercive interventions. It is also important to insure access to consumer populations to study negative outcomes of coercion in mental health services, and to have management information systems collect data on the frequency of utilization of coercive practices. Some important areas that are under-researched are the attitudes and behaviors of mental health professionals and police, the positive outcomes of noncoercive interventions, and the impact of coercion on help seeking behaviors, empowerment, personhood, recovery quality of life, and consumer satisfaction with services.

Consumer, Family, Public and Special Populations

1. Attitudes towards Coercion

a. The role of stigma and prejudice The lives of consumers are set apart by angry or indifferent communities that reject, shun ,and sometimes attack them. False but pervasive stereotypes of consumers as dangerous, unpredictable, incompetent individuals who do not know what is in their own best interests persist in our popular culture while social isolation due to such stigma erodes social support and diminishes individual dignity. This has profound effects not only on the well-being of mental health consumers, but on their own sense of worth. Over 40% of consumers surveyed in the Well-Being Project reported that other people treat them like they are violent or dangerous when they find out they have mental illness. Consumers are not only social pariahs in the community, but in the mental health system the diagnosis of mental illness serves to separate the people delivering services from the people receiving services. Stigma subverts the therapeutic alliance by redefining consumer behavior as potentially dangerous, and such attitudes often lead to the use of coercion. In the Well-Being Project 25% of the respondents surveyed reported that they had the experience "always" or "a lot" of being angry and having a member of their family, a teacher, a mental health worker, or the police say that they were "mad," "crazy," or "mentally ill." A discordant picture of the treatment relationship emerges as the fears of consumers by mental health professionals grows. Because of a few incidents (such as when a mental health worker is killed or injured by a consumer) both OSHSA and mental health workers are worried that violence could strike them. Administrators have hidden alarms installed in outpatient clinics; staff attend seminars on "How to diffuse an explosive situation." In a newspaper interview published in the Los Angeles Times, workers said that they had to learn to treat each client with caution and speak of counseling with the door open, wear loose clothing, and stay alert to the patient's mental state, "because to relax and day dream can be dangerous" (Jones, 1989).

Coercive interventions and/or lack of choice in type of services are often justified by professionals and family members based on the assumption that consumers do not know what treatments are in their "best interests," that they lack "insight," 67% of consumers reported that "sometimes," "seldom," or "never" are they treated like they know what is in their own best interests; almost 70% of family members felt their relative did not know what was in his/her own best interests; 55% of professionals agreed.

b. Practices considered coercive and/or involuntary? The right to refuse treatment may be derived from the first amendment, the constitutional right to privacy, and the eighth amendment ban on cruel and unusual punishment. Countervailing governmental interests have in some cases been held to outweigh the patient's right to refuse, but the least restrictive alternative doctrine applies in this context, as well as the requirements of due process on decision-making related to the right to refuse.

There are certain treatment modalities that consumers have consistently indicated that they do not want or would not choose if there were other treatments available (Blanch et al, 1993; Campbell & Schraiber, 1989; Chamberlin, 1978; Colom, 1981). In response some states have begun to reduce the use of seclusion (52.2%), restraints (52.2%), forced medication (30.4%), and involuntary commitment (30.4%). Even though such initiatives have begun, very little outcome data is being collected to show the effectiveness of these efforts, with the exception of over 40% of the states that report that they are measuring physical harm caused by restraints.

Also lack of choice of treatment plan, primary staff person, medication type and dosage, and housing and supports all contribute to a coercive system that fails to give people with mental illness the type of services they need and want. In an analysis of the State Mental Health Authority (SMHA) Profiling System, I found that only half of the states surveyed reported that they offer consumer-directed individualized treatment/support plans. In psychiatric hospitals SMHAs only provide choice in selecting a primary staff person in 15.2% of the states, in clinical treatment 34.8% of the states, in medication type and dosage 26.1% housing type and location 26.1% and support services/program type and level 30.4%. On the other hand, community services offer greater choice in selection of primary staff, clinical treatment, and medication than psychiatric hospitals. However, choice in services is still quite rare for people with mental illness, particularly those in the public mental health system.

* civil commitment The denial of freedom inherent in involuntary commitment is problematic even if it is implemented in "the best interests" of the individual. While some people may be thankful they were committed and involuntarily treated, others find the experience both counter-therapeutic and humiliating. One consumer recounted, "My experience in the hospital was like a nightmare....They treated me bad in there, not nice. They locked me behind a closed door, and forgot about me" (Campbell & Schraiber, 1989). Further, the Well-Being Project found that 48% of those surveyed had avoided treatment for psychological or emotional problems due to fear of being involuntarily committed; the number went up to 55% for those who had been involuntarily committed in the past. Kopolow (1971) points out that, "this fear of being involuntarily committed to a mental hospital as a result of the opinions of a psychiatrist is a major factor in the distrust of many patients toward the organized mental health system. The fear of losing one's freedom, of being labeled mentally ill by society, by having medications forced down one's throat or injected into one's body had led patients to deny and attempt to conceal their problems rather than face the penalties that can be imposed on those exhibiting behavioral deviancy." The Well-Being Project showed that consumers surveyed are overwhelmingly against making it easier to commit an individual to a psychiatric facility while family members support the easing of commitment standards. 64% of family members report that they had involuntarily committed their son/daughter or relative.

Those who argue for involuntary psychiatry and easy commitment often recount horror stories such as "this man committed suicide", another "killed his wife," or a third "struck a nurse while on the psychiatric unit." These cases are provided as proof that "mental illness" is responsible for the crimes, and that they could have been predicted and prevented if the commitment laws were only less liberal. Family members often claim that patients' rights that prohibit force and coercion lead to situations where consumers are "dying with their rights on" since they can refuse needed treatment. Survey research and legal scholars point to evidence that shows that when some consumers recover from a psychotic episode that they support the use of coercion to force them to get needed services (Stone, 1982; Lucksted & Coursey, 1995; Psychiatric News, 1997). However regardless of the particular study, there exists a significant number of consumers who are angered and resentful when coerced, and qualitative data consistently shows consumers oppose involuntary services.

* outpatient commitment There is some debate as to whether outpatient commitment expands or reduces coercion in the mental health system. Consumers argue for the former, professionals and family members for the latter. For consumers, outpatient commitment is seen as an additional coercive intervention that uses involuntary hospitalization as a threat to force compliance to treatment regimes that may not be needed or wanted by the consumer. Further, the tenure of outpatient commitment can be excessive (up to 180 days in some states); terms can be much longer than if a person were involuntarily hospitalized. During that time monitoring and enforcement of the terms of the outpatient commitment can intrude on the most intimate details of a person's life while residing in the community. On the other hand, family members and professionals see outpatient commitment as a way to prevent hospitalization by breaking the pattern of noncompliance and thus preventing psychotic episodes. Even if this were the case, prior history as a criteria for outpatient commitment literally expands in statute the right to use additional coercion on consumers to induce desired behaviors. It also could be argued that this intervention could produce negative outcomes, and that the availability of quality services with appropriate access (both traditional services and consumer-generated services) is a better approach. Finally, many consumers would rather have an occasional crisis resulting in a brief hospitalization than to be tracked and monitored for compliance to treatments they may not want for extended periods of time. The threat of outpatient commitment can loom as a constant threat over their lives and can drive people into isolation when they most need help.

* seclusion and restraints Seclusion and restraints are utilized as mental health treatments "to control behavior that is physically harmful to the patient or to someone else, or when the patients' behavior is disruptive to the extent that it presents a danger to the facility" (California Code of Regulation). McCoy and Garritson (1983) wrote that "The potentially therapeutic as well as potentially punitive use of forced human separation and isolation from others has long been recognized. Yet, the effectiveness of seclusion remains based on conceptualizations, not reliable research findings." Many consumers view seclusion and restraints as punishment rather than treatment. Even though the use of a seclusion room my help protect an individual while being restrained, the use of restraints in common dormitories have been reported and vulnerable consumers have experienced retraumatizing effects of the use and abuse of seclusion and restraints of consumers that have experienced sexual and physical abuse in the past.

When Soliday (1985) conducted a study to compare directly the attitudes of patients and staff members towards seclusion, the results showed that consumers had much more negative attitudes toward seclusion than staff. Consumers felt more than staff that seclusion "felt like punishment" and that it "humiliates people." Over half the consumers surveyed said that being secluded made them dislike staff. Chamberlin, a mental health consumer/survivor, wrote that "...it is widely acknowledged that sensory deprivation can cause hallucinations and other forms of bizarre behavior. Mental health professionals do not seem to have looked at this phenomenon in relation to the use of seclusion on psychiatric patients. Yet it is not uncommon for a patient placed into solitary confinement to become agitated the longer he or she remains isolated (leading, of course, to justification for further isolation). It is possible that the 'treatment' itself is producing more symptoms, more pathology" (1985).

* forced psychiatric medications There are good reasons why some consumers refuse psychiatric medications of particular kinds of psychiatric medications, besides lack of insight--a claim by psychiatrists to justify forced medication. The saga of dramatic and debilitating side-effects to psycho tropic drugs is told by many consumers. One person related that "they kept pumping pills into me that weren't working. My legs shook like hell and I couldn't stop them; my whole body just followed my legs and I couldn't stop shaking" (Campbell & Schraiber, 1989). On the other hand, survey data in the Well Being Project presents a mixed picture regarding consumer experiences with psychiatric medications. For some drugs are helpful, but for others it can produce mild to severe side-effects, and even irreversible neurological damage that may preclude ever getting off the medication. Psychiatry erred when it claims drug therapy was an effective treatment rather than a means of controlling patients (Conley, 1985). Anderson (1984) writes that "patients often improve, but sometimes they don't improve--and sometimes they get worse. ...All too often, chemicals serve either as a total control (enabling hospital personnel to deal with troublesome patients) or as a bureaucratic lubricant (making it impossible to move patients briskly through the system without actually doing anything for them." 58% of mental health professionals surveyed in the Well Being Project said that clients should have the right to refuse or stop taking medications. However, only 25% of family members agreed (Campbell & Schraiber, 1989). In most cases the issue is not about refusing, however, but reflects the desire of consumers to receive information, and to participate with their psychiatrist in determining what works best. Consumers respond better to treatment when doctors support the consumer's wishes rather than the "patient's best interests" as seen by the psychiatrist. Although there are many jurisdictional variations, two major legal themes regarding the right to refuse antipsychotic medication are reflected in Rogers and Rennie cases. In Rennie the Third Circuit found that involuntarily committed patients may be given medications according to the judgment of the treating physician whenever there is a danger to the patient or others. In Rogers the Massachusetts Supreme Judicial Court held that in the absence of an emergency any person who has not been adjudicated incompetent may refuse antipsychotic medication, and no institutionalized person may be administered such medication without informed consent.

Legal, Legislative, Advocacy Issues

The reliance of hospital care for psychiatric crisis has persisted despite the fact that there has been a growing literature which suggests that people with severe mental illness can avoid hospitalization during acute crisis, without adverse effects, often at a cost savings, and without imposing additional burdens on families and others (Kiesler, 1982; Stroul, 1987; Anthony & Blanch, 1989). In particular, a research demonstration called the Crisis Alternatives Project (CAP) was undertaken in Harris County Texas (1996) to expand knowledge about crisis care alternatives by addressing some unanswered questions and untested assumptions. The project demonstrated the feasibility of treating individuals experiencing severe psychiatric crises, who met criteria for involuntary hospitalization, in alternative settings and compared this with standard hospitalization. The two major program components of the alternative care interventions were "brief hospitalization" and "respite care." It also compared the different types of alternative crisis care and determined characteristics of these services which were associated with enhanced outcomes and cost savings. Overall it was found that there were few significant differences between the experimental and control groups at the various post-crisis points, indicating that there were no notable differences in recompensation. In fact, there was a trend on some measures (e.g., role functioning, self-care) suggesting somewhat slower recompensation in the standard hospitalization group. The data also suggested that brief hospitalization plus respite care was more cost effective than standard hospitalization, and respite care alone was equally effective and less costly. Differences between in-home and crisis apartment groups were compared and no differences in outcomes by setting were found. Finally, the standard hospitalization group was less satisfied with their services than the alternative care groups. This study clearly showed that individuals who receive alternative care do just as well, if not better, clinically than do those who receive the usual involuntary hospital stay, and that alternative crisis care services can meet the needs of the community.

1. Alternatives to involuntary interventions

* advance directives There is a growing awareness of the potential benefits of advance directives (a legal document created during a time when a consumer's symptoms are not severe enough to impair capacity to make informed treatment choices)(Sherman, 1994). In the SMHA profiling data, almost one-third of the states indicated that they support advance directives, but only one state reported that it collects data on the number of consumers who have advance directives on file. Therefore, it is difficult to determine the extent of consumer utilization of such directives. Further, little is ongoing to address the programmatic issues involved in using advance directives for involuntary psychiatric care. This is problematic for a number of reasons. Foremost is that the way advance directives will be used will reflect the bias of the entities that may choose to promote and help consumers create their directives. Sherman has pointed out that legal people will shy away from issues involving legal conundrums, providers will favor "Ulysses Wills," and consumers will favor the directives in a different direction entirely. Everyone needs to be educated about the advantages and drawbacks in their use, and consumers will especially require assistance in actually creating viable directives. Good data collection is needed to determine (1) the likelihood that a consumer would countermand/rescind a directive at the time of commitment; (2) if having a directive on file increases or decreases the possibility that one's wishes will be followed once the commitment occurs; (3) if the willingness to execute a directive varies as a function of whether consumers are given an opportunity to discuss the pros and cons of what they think they want to happen with the professionals who will treat them if they were to be committed; (4) given a choice of various mechanisms for creating directives, which ones consumers prefer; and (5) the perceptions of directives by attending physicians and the courts. Certainly, federal leadership that can bring a broad view of the intervention to these and other important questions is needed to maximize the benefits of using advance directives to reform the involuntary treatment system.

* mediation Mental health consumerism asserts that people with mental illness should have the right to speak for themselves regardless of diagnosis or severity of symptoms, Consumers have argued that by pathologizing their behavior and dismissing their input, legitimate differences between consumes and other parties escalate into coercive treatment and often involuntary commitment. Therefore, use of mediation as a means to resolve such conflicts could reduce the use of coercion in the mental health system. Mediation is a process by which a neutral third party assists disputants in negotiating a mutually acceptable resolution to their differences. Mediation may provide a way to resolve difficult problems in a manner that is empowering to individuals with mental illness without diminishing the opportunity of other stakeholders to have their view influence the ultimate outcome. It could be effective in unclogging a system burdened by coercive regulations and procedures. Mediation techniques have the potential to influence in a positive way the daily interactions of mental health professionals and administrators with recipients and lead to improved understanding. However, before mediation could be used to reduce coercion in the mental health system, the assumption that persons with serious mental illness lack the capacity to engage in a mediation process would have to be overcome by research and training.

* consumer-run crisis services "Ex-patients need a place where involuntary commitment is not a threat, where we can be ourselves, where we can be 'crazy' but not 'ill' and still find a sense of safety, affirmation, and trust" (Budd, 1987). Many crisis residences can be effective (Stroul, 1989), but in general, we know little about what community support services work for whom (Anthone, 1984), and under what conditions. For more than a decade consumers have asserted that help is best received when the recipient has direct control over the help and there is reciprocity between helper and recipient (Chamberlin, 1978; Zinman, 1982). Many mental health professionals and researchers are arriving at similar conclusions (Jacobs & Goodman, 1989; Reissman, 1990). Recent research by Durmont has contributed to the development of a theory and practice of helpfulness about an alternative crisis response that is consumer-driven called the Crisis Hostel Project. The project operated an alternative to psychiatric hospitalization with both research and program components. It provided training in strategies for dealing with crisis that included self/peer advocacy skills and self-directed crisis-management skills, and it operated a residence where people who defined themselves as in crisis and at risk of psychiatric hospitalization could be supported through a crisis up to 14 days. The results of the research, including the relationship of the program to key outcomes such as the incidence of psychiatric hospitalization, individual empowerment, and satisfaction with services is currently being reported to CMHS.

* last resort clause Currently, coercion is part of standard clinical practices with some laws and court decisions that protect consumer rights under specified conditions. While many consumer advocates argue for the elimination of all involuntary interventions, another approach would be to limit coercive interventions to extremely rare occurrences. Therefore, the scope of coercion could be drastically reduced without equivocation of many legal procedures and statutes. As a best practice intervention or part of clinical guidelines, consumers would have to be provided with a series of program alternatives (such as the ones discussed above), and only if these failed to resolve the crisis could involuntary interventions be imposed as a last resort. In such cases, providers would have to document that alternatives were provided and with what consequences before coercion could be imposed. There procedures and documentation could be assured through accreditation review, patients' rights advocates, and the filing of grievances.

2. Training and information

Since the belief in a strong link between violence and mental illness is firmly rooted in the minds of many citizens, the routine practice of sensationalizing movies and newspapers must be addressed through education of people that perpetuate the cultural stereotype of the violent mental patient. On the other hand, attempts to change public views by anti-stigma campaigns often fail, and in fact may increase public fears. One reason perhaps, is that they tend to focus the text and images of the materials on people with mental illness rather than addressing the prejudicial and discriminatory behaviors of the public. The contextual nature of violence is not recognized as people with mental illness continue to fulfill the social need to situate violence outside "normal" human agency.

Therefore, the most important training and information dissemination efforts that relate to the use of involuntary interventions need to address the issues of stigma and perception of threat of violence. Such efforts are best done in partnership with mental health consumers. Also, people in all roles in society should be provided with resources that would enable them to begin to interrogate their own biases and assumptions regarding people with mental illness. It is only by creating an atmosphere where people do not engage in polemics that the contextual nature of violence and coercion can be understood and remedies sought that reflect a true collaboration of all stakeholders.

Violence toward mental healthcare workers has only recently begun to be addressed as an occupational health issue. In part this is due to a perception that assaults of workers are part of the job and are not predicable or preventable (Lipacomb, 1992). Most new approaches being developed by labor and management are heavily weighted toward a clinical patient management approach rather than one in which the emphasis is placed on staff/consumer interactions. A model training program for workplace security and consumer safety should encompass preventing violence by identifying, evaluating and controlling environmental, organizational, and patient management factors that lead to violent incidents and subsequent coercion. A safety training for mental health workers in the community was developed by the New York State Office of Mental Health and the Bureau of Forensic Services suggests that violence can often be prevented by focusing on consumer needs. A part of the equation that leads to violence is related to the unmet needs of the individual, including meeting basic needs (food, shelter, clothing, medical care) and the needs for treatment, rehabilitation and social support. In addition, individuals with a history of violence are at relatively higher risk for future episodes and should be provided with skills to avoid future violent behavior. It is also essential to focus on staff interaction since potentially violent episodes may be inadvertently escalated into actual violence by the lack of early recognition and the inappropriate intervention on overreaction of the part of staff.

3. Informed Consent

Consent is contingent on the consumer receiving information on the risks and benefits of the use, and making an informed decision. Such protocols allow consumers to weigh not only the risks, but the benefits to consumers. In order for consent to be truly informed, three factors must be considered; the quality of the information provided, the competence of the consumer to give consent, and the level of coercion to induce consent. Since informed consent protocols are usually written by providers or administrators, this produces conflicts of interest between the needs of the system and the needs of the individual consumer. To the clinician, the consent is sometimes viewed as an obstacle to convincing the consumer to agree to the data collection or use. Information in consent forms may be biased or inadequate. Surrogate consent may be appropriate depending on the competence and conservatorship status of the consumer. However, competence is not a precise legal term. In some states the courts have ruled that involuntary patients in a psychiatric hospital are considered competent to refuse treatment.

The concept of informed consent is the key to refusing treatment and is a concept which should be applied in the same way to people with mental illness as to other people. Instead, mental health consumers are discriminated against due to their status and are governed by legal distinctions that depend more on where a person resides than on actual constitutional considerations (Swartz, 1985). There is a significant minority of states that do not require consent for various treatment modalities such as administration or ECT (37%) and prescription of psycho tropic drugs (52.2%).

General Clinical Protocols and Practices

From a consumer perspective, the following core competencies should be promoted and monitored in the provision of services and care in order to promote a system of empowerment, choice, freedom, and recovery, rather than one based on dependence, illness, chronicity, control and coercion.

EMPOWERMENT

* Encourage the consumer's independent thinking. * Treat the consumer like they believe (s)he can shape his/her own future. * Give the consumer freedom to make his/her own mistakes. * Support choice-making and risk-taking as leading to growth. * Understand and support the consumer's need to regain "critical consciousness" of self-awareness. * Learn how to provide choice and avoid controlling behaviors.

COMMUNICATION SKILLS

* Listen to the consumer and believe what (s)he says. * Learn to practice the strengths model. * Look at and recognize the consumer's abilities. * Learn to compliment consumer respectfully on their abilities. * Learn to listen to consumers and consider what they say to be valid and important. * Learn how to talk to the consumer when they need to talk to someone.

SELF-MANAGEMENT

* Learn how consumers live with and manage their disorders. * Learn about and support consumer self-control of psychotic symptoms. * Learn and support the coping strategies of consumers, as well as recognize stressors. * Learn how to accept consumers' feelings of sorrow, despair, anger, frustration, joy excitement, etc. without pathologizing.

RECOVERY ATTITUDES

* Treat the consumer in a way that helps the recovery process. * Learn recovery triggers and structure settings so recovery triggers are present. * Believe in the consumer's ability to recover. * Learn to foster a sense of hope. * Shift from a stance of demoralizing pessimism to rational optimism. * Learn to break the cycle of disempowerment, despair and learned dependency.

STIGMA

* Learn to respect people's dignity by taking into account their status as survivors of the mental health system and of physical and sexual violence, as well as their cultural and ethnic diversity, including sexual orientation. * Learn about how much psychiatric labels and language can stigmatize and diminish people. * Learn not to treat consumers as children. * Learn to avoid stigmatizing language. * Learn that recovery from the consequences of the illness are sometimes more difficult than recovering from the illness itself. Issues of dysfunction, disability, and disadvantage are often more difficult than impairment issues. * Learn methods to support community interaction with consumers. * Learn that an inability to perform valued tasks and roles, and the resultant loss of self-esteem, are significant barriers to recovery.

IATROGENIC EFFECTS

* Understand the negative outcomes of coercion in treatment settings. * Learn to mitigate the negative consequences of coercion by attending more closely to procedural justice issues (fair decision-making process) and supporting consumer voice, validation, respect, and information.

VIOLENCE

* Learn the statistics related to mental illness and violence and recognize that people with mental illness are not usually dangerous. * Learn non-violence responses to consumer threats and violence. * Learn alternatives to seclusion and restraints, including mediation. * Learn ways to avoid involuntary commitment by addressing problems before they escalate.

TRAUMA

* Learn the signs and impacts of sexual and physical trauma. * Recognize the trauma induced by the mental health system with particular attention to retraumatizing effects of over-medication, and the use and abuse of seclusion and restraints.

RECOVERY TECHNIQUES

* Learn how to reduce symptoms and distress according to the perceptions of the consumer. Explore and understand feelings, thoughts, values, goals and roles that enhance recovery throughout treatment. * Learn to assist people to be successful and satisfied in chosen roles and settings. Minimize reliance on crisis intervention. * Learn to access services that facilitate recovery through case management. * Learn shared decision-making techniques and models of clinician-client partnership. This is particularly important in maintaining mediation schedules.

SERVICE PLANNING

* Coordinate and structure services to enhance the total well-being of the consumer, rather than offer isolated programs that address individual' deficits, or programs that specialize in only a segment of one's well being. * Learn how to build choice into service planning. * Treat the consumer as an equal in planning his/her services. * Training and support for consumers to become real participants in developing individual service plans. Work with the consumer to find the resources (s)he needs. * Assess if consumer problems and needs are consumer identified/defined or professionally identified/defined. * Resource allocation to "black box" programs need to be minimized and replaced with individualized services that contribute to a consumer's progress toward recovery.

VOCATIONAL SKILLS

* Learn to provide prevocational and vocational skills training. Learn the "choose-find-keep" model of job placement--job development and placement should be based on the expressed need and demonstrated interest of consumers.

RELAPSE AND CRISIS

* Learn not to penalize consumers for relapses. * Learn that the episodic nature of severe mental illness does not prevent recovery. * Learn how recovery changes the frequency and duration of symptoms. * Learn that recovery is not a linear process, but involves growth and setbacks, periods of rapid change and little change. * Learn nonthreatening crisis response techniques.

MEDICATIONS

* Teach the consumer about the medications (s)he is taking. * Learn to use the consumer as the expert on what medications work and do not work. * Learn to recognize the subtle and severe side-effects of medications. * Rather than support a program of medication compliance, support informed judgment of consumers by enabling them to learn what they are really like off medications.

EDUCATION

* Educate consumers about their diagnosis, prognosis, medications, and treatment. * Set up training programs to teach consumers how to work with the local mental health board and the mental health system. * Learn and teach consumers about advance directives. * Learn and then provide training for consumers in how to work effectively with human service systems, and how to access benefits.

SELF-HELP

* Support for self-help groups and enable consumers to access alternative supports. * Support consumers helping other consumers recover. * Learn about spiritual alternatives. * Learn about and then educate consumers on the history and organization of the consumer movement.

RIGHTS

* Learn about consumer rights. * Learn all protocols regarding privacy and confidentiality of consumer data. * Learn the provisions of the ADA and the manifestations of discrimination. * Learn about informed consent protocols, and how to provide informed consent for all treatment and data collection activities.