Behavioral Health Laws & Managing Aggressive Behaviors
Patient s Rights Persons with mental illness have the same legal rights and responsibilities guaranteed all others, including, but not limited to: The right to treatment; in ways that are least restrictive The right to dignity, privacy and humane care The right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse or neglect The right to prompt medical care and treatment
Denial of Rights Only when good cause exists That the exercise of the specific right would be injurious to the patient That there is evidence that the specific right, if exercised would seriously infringe on the rights of others That the institution or facility would suffer serious damage if the specific right is not denied That there is no less restrictive way of protecting the interests specified in the above
Voluntary Patient is willing to accept treatment on a voluntary basis The right to discharge themselves from a facility at any time The right to refuse anti-psychotic medication The right not to be placed in seclusion and/or restraint, absent an emergency situation
Involuntary Detention Purpose of involuntary treatment is to provide evaluation, proper treatment, and legal protection for mentally disabled individuals, not to limit patient s rights Use of 1:1 sitters for supervising of DTS/DTO on medical floors At end of 72 hours 5250 vs Voluntary vs Discharge
5150 72 hour legal hold DTS danger to himself/herself DTO danger to others GD gravely disabled Unable to provide for his/her basic personal needs such as food, clothing or shelter An advisement must be provided
5250 Notice of Certification Up to an additional 14 days Right to contest by means of habeas corpus or writ hearing Superior court judge will hold a hearing within two judicial days Right to be represented by an attorney or public defender Judge can release patient against medical advice At end of 14 days Continue Hold vs Voluntary vs Discharge
Extensions of Holds 5260 Second Notice of Certification Continues DTS Up to an additional 14 day extension (max 31 days) 5300 Post Certification Continues DTO (max 180 days)
T-CON (Temporary Conservatorship) Only for those who remain GD after completion of a 5250 30 days A person is appointed by the court to serve as conservator acts in the interests of a gravely disabled person May or may not include right to refuse medications
P-CON (Permanent Conservatorship) Only for those who remain GD after completion of a T-CON 1 year term which is renewable for one year periods May or may not include right to refuse medications
Riese Hearing Eleanor Riese vs St. Mary s Patient s have the right to exercise informed consent to take psychotropics, absent an emergency Should they reject medication, a judge shall determine whether they should be treated Psychiatrist will write/dictate. Psych nurse to process.
Tarasoff Tatiana Tarasoff vs UC Berkeley Psychotherapists bear a duty to use reasonable care to give threatened persons such warnings as are essential to avert foreseeable danger arising from a patient s condition Call SFPD to file a report. Notify SFPD when patient is discharged Social workers can help facilitate
Risks for Assault Mentally ill, particularly those who are off meds, with a weapon, drugs or alcohol on board Patients with a diagnosis of Bipolar disorder who are manic Those with a history of assaultive behavior Young males age 18-22, lower socioeconomic group with substance abuse
Knowing Yourself and Your Effect on the Patients You become a safety risk if you do not have yourself in control Most assaultive incidents, patients to staff, occur when the staff loses control Employee attitudes influence client behavior
Self Control Self control enables critical thinking Fight or Flight Avoid power struggles Over-reacting situation can escalate Under-reacting safety compromised
Assault Cycle Baseline Triggering event Escalating warning signs Crisis/Assault violence Recovery can re-escalate Most patients fall asleep Post crisis patient feels ashamed or embarrassed Not a time to talk to the patient Remember: Relaxed muscles to not fight; busy hands do not hit!
4 Reasons for Assault FEAR: feels threatened, trapped or their basic well-being compromised Threat reduction for perceived safety Medications can change the internal environment Relaxed posture with open hands, slow gestures, speak in soft and low tones using brief phrases, avoid physical contact
4 Reasons for Assault FRUSTRATION: an expression of destructive rage from pent-up frustration Lend control to help patient gain self control Stand with back straight with square shoulders, nod for emphasis, speak in low tones with clear and action oriented directives, give direct eye contact, avoid physical contact
4 Reasons for Assault MANIPULATION: an indirect attempt to obtain or avoid something Examples: temper tantrum- yelling, banging, stomping, etc. playing the numbers staff splitting, asking multiple staff members promoting confusion brings in related, but irrelevant matters to cause confusion Detachment for healthy re-engagement and/or requests Relaxed muscles, closed posture (arms folded or behind back), subtle gestures of disinterest or disapproval, speak in monotone or low volume, avoid eye contact and physical contact
4 Reasons for Assault INTIMIDATION: calculated attempt to get something by threatening physical injury Example: Antisocial lack empathy, believes they are not responsible for their own behavior Identify consequences for patient to make safe choices Poised and ready to move/react quickly, but not defensive; use few gestures, stand with back towards an exit or using furniture between you and the patient, be matter-offact and emotionless, avoid physical contact
Communication Verbal communication Empathetic listening Tone, volume, cadence Rule of 5 (use five words that are less than 5 letters) loud, simple and direct Jane! Stop that now! Setting limits pick your battles Simple, clear, reasonable and enforceable
Assault Prevention Exercises Personal space What is too close for you? Body space out of arms reach Body posture and motion Avoid crossing arms and looking away Moving away without turning your back Blocking punches and kicks Getting out of pinches, grabs and choke holds
The End!