POSITION STATEMENT: Mandatory Outpatient Treatment (MOT) Introduction The psychiatric nursing profession provides treatment by adhering to the American Nurses Association (ANA) Code of Ethics with Interpretive Statements (2001) and the ANA Scope and Standards of Psychiatric-Mental Health Nursing Practice (2000). Both of these documents guide professional nursing practice. These guidelines provided a basis for discussion and development of a position on MOT. The right to self-determination in the ANA Code of Ethics with Interpretive Statements (ANA, 2001) states: Respect for human dignity requires the recognition of specific patient rights, particularly, self-determination. Self-determination, also known as autonomy, is the philosophical basis for informed consent in health care. Patients have the moral and legal right to determine what will be done with their own person; to be given accurate information in a manner that they can understand and all the information necessary to make an informed judgment; to be assisted with weighing the benefits, burdens and available options in their treatment, including the choice of no treatment; to accept, refuse or terminate treatment without undue influence, duress, coercion or penalty; and to be given necessary support throughout the decision-making and treatment process. Such support would include the opportunity to make decisions with family and significant others and the provision of advice and support from knowledgeable nurses and other health professionals. Patients should be involved in planning their own health care to the extent they are able and choose to participate The nurse recognizes that there are situations in which the right to individual selfdetermination may be outweighed or limited by the rights, health and welfare of others, particularly in relation to public health considerations. Notwithstanding, the modification of individual rights must always be considered a serious deviation from the standard of care, justified only when there are no less restrictive means available to preserve the rights of others and the demands of justice. (pp. 8-9) Background Mandatory Outpatient Treatment (MOT) refers to court-ordered outpatient treatment for patients suffering from mental illness who may not participate in treatment without a court order. Prior to the 1960's, involuntary treatment of the patient with a psychiatric illness was provided in hospitals. No effective treatment was available on the outpatient basis. With available treatment modalities and the introduction of treatment with psychotropic medications, the community mental health movement and advocates for the mentally ill worked to de-institutionalize as many patients as possible and provide treatment in a "least restrictive environment". As the years passed, more stringent commitment laws demanded that the client be treated in the least restrictive environment possible. These stricter laws led to a decrease in the total numbers of involuntary inpatient commitments. The development of "dangerousness" standards prevented involuntary hospitalization of those patients who were in need of treatment but did not meet the standard of dangerousness. When the "dangerousness standard" is used, present
danger to self or others must be apparent. These individuals were to receive outpatient treatment. However, as a result of mental illness, individuals may lack insight or judgment regarding their need for treatment. Following through with medications and aftercare treatment does not always occur, and may lead to relapse. Historically, the lack of both available services and continuity of treatment in the community were obstacles preventing the mentally ill person from receiving services. Involuntary outpatient commitment laws were passed not only in response to the absence of effective and available outpatient treatment but also to promote adherence to the prescribed treatment regimen. The laws attempted to guarantee treatment and protect society from harm that may occur due to violent acts from some persons with mental illness. Overtime, a conceptual shift in the assessment of dangerousness has occurred. Historically, the focus on predicting violence in an individual as a measure of dangerousness changed to the use of risk assessment. Risk assessment is based on a patient's past history of violence rather than the actual presence of danger and is an important aspect in determining need for mandatory outpatient treatment. Based on the risk assessment standard, MOT will provide the necessary treatment (Borum, Swartz and Swanson, 1996; Harris and Rice, 1997; Tardiff, 1998; Doyle, 1998; Applebaum, Robbins, and Monahan, 2000; Monahan, et al. 2000). Numerous studies, (Policy Research Associates, 1998, Telson, Glickstein, and Trujillo, 1999, Rohland, Rohrer and Richards, 2000; Swanson, J.W., Swartz, M.S., Borum, R. Hiday, V., Wagner, H., and Burns, B., 2000) demonstrate the efficacy of MOT. Outcome measures and methodology used vary from study to study. Different state programs also vary. Generalization of results is therefore difficult. However, none of the early studies report negative results from MOT, and when considered as a whole, suggest that MOT does provide favorable outcome measures, e.g., reduced re-hospitalization, and improved treatment compliance (American Psychiatric Association, 1999). The inherent conflict between the patients right of self-determination and society's decisions as to who requires treatment needs to be explored carefully. (Levy and Rubenstein, 1996). Advocating for mental health treatment and maintaining patient rights is nursing's priority. Balancing the need to safeguard patient rights and provide mandatory outpatient treatment is the challenge facing the psychiatric community. Both can be done, but not one without the other. Position APNA believes that mandatory outpatient commitment (MOT) does have a place in the mental health treatment continuum. MOT is an appropriate response for some persons with serious and persistent mental illnesses, who are treatment resistant, meet risk assessment standards and have not benefited from voluntary participation in mental health services. 2
APNA believes: All patients have the right to make their own decisions and MOT should be used as a last resort. MOT is implemented as a means of protecting the public, and provides treatment to severely ill patients who can benefit from psychiatric treatment. If MOT needs to be implemented, measures must be taken to ensure that each patient is treated with respect and dignity, and that full consideration is given to the patient's rights, civil liberties, and confidentiality issues. The psychiatric advanced directive allows patients to provide their treatment preferences in writing so that if and when they relapse, their wishes and rights are respected. The psychiatric advanced directive can include the patient's preferences for psychotropic medications, ECT, hospital preference, selection of a psychiatrist/psychotherapist, attorney and any other preferences. Wishes regarding mandatory outpatient treatment can be expressed. The advanced psychiatric directive allows patients to voice their self-determination wishes, so when they are ill, these directives can be honored. If MOT is indicated patient rights are maintained, despite the fact that at the present time they are unable to contribute in the decision making process. The patient can change/revoke the document when he/she is not experiencing acute symptoms. (Geller, 2000; Mental Health Treatment Preference Declaration Act, 1990). If a person is mandated to receive outpatient treatment, it is imperative that services are available, provided and follows a comprehensive treatment plan. A treatment team must be responsible to provide and oversee the treatment. Treating practitioners and family members must be subject to oversight by independent panels in order to protect the rights of the patient receiving MOT. Independent panels need to be available for continual review of the administrative and clinical process. Medication is often an important intervention in the treatment of mental illness. Mandatory medication administration is very controversial. Establishing therapeutic alliances to promote compliance with treatment including medication adherence should be the preferred clinical approach. However, each case needs to be evaluated individually. It is stigmatizing for any court ordered outpatient treatment laws to be named after a person who was the victim of an unfortunate or violent act committed by person with a mental illness. By referring or naming a law after the victim only continues to stigmatize mental illness and should be discontinued. January, 2003 3
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