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

APNA 29th Annual Conference Session 4027: October 31, 2015 Image CreditgoestoBBCKS2Bitesize 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 ordered to treatment.  Identify factors that can interfere with therapeutic engagement Gentz 1

APNA 29th Annual Conference Session 4027: October 31, 2015  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 other criminal behavior  Breaking and entering/ larceny: for the sole purpose of 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 Gentz 2

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

APNA 29th Annual Conference Session 4027: October 31, 2015  What exactly happened? Why ATO/ MI Court/ S obriety 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)  ODD?  Conduct DO?  Ant isocial PD?  BAD?  S  ADHD? 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) Gentz 4

APNA 29th Annual Conference Session 4027: October 31, 2015  JOINING  We are in this together  “ Y our 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 on 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 of 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? Gentz 5

APNA 29th Annual Conference Session 4027: October 31, 2015  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 obriety Court: if the substance use is self-medication of or causing symptoms, treat accordingly.  S omet 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 obriety courts produce cost savings of $3000 - $13,000 per client, including prison costs, revolving door arrests and trials  S obriety 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 obriety court recidivism rate is 27% compared to over 60% for non-court clients.  (MI St at e Supreme Court Administration, 2012) Gentz 6