Risk, Medication, and Compulsory Treatment: Ethical and Practical Issues Notes

Risk, Medication, and Compulsory Treatment: Ethical and Practical Issues

Overview

This lecture discusses risk assessment, engagement with medication, and compulsory treatment within the context of professional ethics and practice. It emphasizes the importance of evidence-based practice, client-focused risk management, and ethical considerations in psychological interventions.

Last Week's Review

  • The lecture shifted from discussing the construction of mental disorder ideas to emphasizing critical evaluation of evidence.
  • Evidence-based practice is central to the scientist-practitioner model.
  • Practice decisions should be driven by evidence, considering factors like dosage, intensity, timing, readiness, motivation, coercion, trans-diagnostic responsibilities and therapist factors.

This Week's Topics

  • Risk Assessment:
    • Background to risk assessment.
    • Risk assessment sites, codes, guidelines, and the three generations of risk assessment.
    • Pathways: compulsory treatment, child protection.
  • Medication Engagement:
    • Potential roles with clients in relation to pharmacotherapy.
    • Liaising with clients regarding medication-related issues.
    • Medication terminology and abbreviations.
    • Liaising with prescribing doctors.
  • Ethical and practical issues are discussed throughout.

Risk Management

  • Guidelines on competence, consent, confidentiality, documentation, and consultation are often directed at risk management, primarily focusing on risk to the psychologist.
  • Emerging PsyBA documents emphasize a client-focused approach.
  • Psychological contexts with client-focused risk:
    • Family court, access, custody, parenting orders.
    • Risk and family violence (as a subject or offender).
    • Risk of lapse or relapse.
    • Child protection.
    • TOSH (Threat of Self Harm).
    • TOHO (Threat of Harm to Others).
    • Rehabilitative potential.
    • Risk of reoffending.
    • Form and length of sentence.

Types of Risk

  • Most often refers to the risk of self-harm, suicide, violence, or harm to others.
  • Focus is on 'self-harming', 'suicidal', and 'life-endangering' patients.
  • Risk assessment for potential harm to others differs from other psychological approaches because the client's welfare is not the primary focus.

Ethical Considerations in Risk Assessment

  • Violence risk assessment by mental health professionals has faced ethical criticism due to potential harm to clients without corresponding benefits (Nonmaleficence).
  • Clinical work involves 'protecting the public'.
  • Ongoing risk assessment and management are essential in the day-to-day treatment of many clients.

The Code of Ethics

  • The code permits disclosure of confidential information when there is a 'clear risk' to others.
  • The guidelines indicate circumstances when psychologists may/must disclose potential harm to third parties.
  • Confidentiality can be breached in such cases.
  • Psychologists who fail to warn identifiable third parties of serious harm may face professional sanctions or civil action.
  • Over 50% of psychologists in counseling and/or clinical intervention will encounter at least one 'dangerous' patient.

APS Code A.5.2

  • Psychologists disclose confidential information only under specific circumstances:
    • With client consent or legal authority.
    • Legal obligation.
    • Immediate and specified risk of harm to an identifiable person that can be averted only by disclosure.
    • When consulting, supervising, or in professional training, ensuring client anonymity.

Guidelines for Serious Harm to Others

  • Serious harm includes physical, sexual, or psychological harm, such as violence, sexual assault, stalking, intimidation, bullying, and harassment.
  • Psychologists must weigh the likelihood of harm and their responsibility towards potential victims against the client's confidentiality, potential harm to the client, and the capacity to manage the risk within the professional relationship.
  • These guidelines address ethical professional conduct but do not provide practice advice on predicting, preventing, or containing harmful behavior.
  • No advice or action by psychologists can fully prevent or protect against serious harmful behavior.

Violence and Mental Illness

  • Despite early beliefs, mental illness makes a relatively small contribution to violence risk compared to substance use, history of violence, being male, etc.
  • There is a modest but significant increase in violent behavior among the mentally ill, with certain subgroups being greater contributors (e.g. Schizophrenia).
  • Suicides or homicides by mentally disordered clients often lead to a disproportionate media, social, and governmental response.
  • The visibility and impact of this violence are greater.

Predicting Risk: The Three Generations

1. Clinical Methods

  • 'Unstructured clinical judgment' relies on a purely clinical opinion without a set structure.
  • Approaches vary among clinicians and clients.
  • Advantages: flexible, quick, individual/idiographic ('case study style').
  • Traditional risk assessment method.
  • Accuracy: widely variable, around 30% or higher.
  • Commonly used in practice.

2. Actuarial Methods

  • Similar to those used by the insurance industry.
  • Based on statistical relationships between measurable predictor and outcome variables.
  • Outcomes determined by fixed rules; statistical correlation is key.
  • Tools like the Violence Risk Appraisal Guide (VRAG) combine static predictors (historical, no clinical judgment needed) with dynamic factors (changeable, require clinical judgment).
  • Total score reflects risk, providing probabilistic statements.
  • Enhances reliability and statistical predictive validity over unstructured judgment.
  • Accuracy depends on the validity of predictor factors.

3. Structured Clinical/Professional Judgment

  • Considers both historical/static and dynamic risk items.
  • Considers nomothetic and idiographic factors.
  • Relevance of each item to future risk can be rated.
  • Case-specific items can be considered (not part of the core tool but relevant).
  • Unlike actuarial tools, multiple scenarios can be considered.
  • Risk is summarized as low, medium, or high, guiding the development of a risk management plan.

Violence Against Others - Risk Factors

  • Distinctions: reactive and instrumental violence, static and dynamic factors.
  • Risk factors include:
    • Being male
    • Exposure to abuse/violence
    • Prior violence
    • Age under 40
    • Substance use issues
    • Low SES
    • Low education level
    • Poor social problem-solving skills
    • Poor emotional identification/insight

Risk Assessment Questions

  • Does the false positive rate make it unethical?
  • What happens if a client is deemed a high risk for violence/harm and authorities are notified?

Mental Health Acts (Victoria Example)

  • Purpose of a Treatment Order:
    • Enables authorized psychiatrists to provide compulsory treatment.
    • Allows patients to be treated in the community or detained and treated in a designated mental health service.

Treatment Orders - Criteria

  • The Tribunal must be satisfied that all criteria apply:
    • The person has a mental illness.
    • Due to the mental illness, the person needs immediate treatment to prevent:
      • Serious deterioration in mental or physical health.
      • Serious harm to themselves or others.
    • Immediate treatment will be provided if the person is subject to a Treatment Order.
    • No less restrictive means are reasonably available.
    • Services must be available to enable treatment.

Child Protection Context

  • Risk assessment is a familiar consideration in child protection work.
  • It occurs when:
    • Deciding whether to make a notification.
    • In case planning.
    • Decisions on whether to remove a child from their home.
    • Determining whether an application should be made for the child to be placed in the care of the state, and in 'access and custody' decisions in Family Court.

Mandatory Reporting to Child Protection in Victoria

  • Mandatory reporting to child protection/DHHS is the legal requirement for certain professionals to report a reasonable belief of child physical or sexual abuse.
  • The Royal Commission into Institutional Responses to Child Sexual Abuse recommended national consistency in mandatory reporting and identified a minimum set of professional groups that should be mandated.

Mandatory Reporting in Victoria

  • From March 1, 2019, registered psychologists in Victoria are mandated to report a reasonable belief of child physical or sexual abuse.
  • Children, Youth and Families Act 2005 (Vic) applies.
  • Requirements apply to all registered psychologists, regardless of their work setting.
  • Reports must be made as soon as possible after forming the belief and after each occasion of becoming aware of further grounds.
  • DHHS in Victoria provides FAQs and contacts for psychologists.

Example Questions

  • Are psychologists mandatory reporters in Victoria? Under what Act?
  • Cite the section of the APS Code that discusses expectations in relation to a potentially violent client.
  • What is actuarial risk assessment for violence?
  • Provide three examples of a static risk factor.
  • List three likely presentations of a woman experiencing intimate partner violence.

Liaising with Clients About Medication

  • Clients often have limited consultation time with medical professionals.
  • The average GP sees 24-28 patients in a full day.
  • As 'non-prescribing clinicians', psychologists are often asked about medication.
  • It is within our remit to engage with this content.

Client Reluctance to Take Medication

  • Clients may be reluctant due to:
    • Stigma
    • Medical narrative
    • Severity narrative
    • Observational/personal experience
  • Psychologists can:
    • Educate about debates, pros and cons, side effects, timelines, and rebound effects.
    • Advise them to do their own research and be informed consumers.
    • Open dialogue about the limited efficacy of mono-therapy in some cases.
  • Use Solution-Focused approaches and positive psychology.
  • Frame medication in terms of how it may help the client make progress towards their personal goals (ACT, CBT, Solution Focused, etc.).

Medication Information for Psychologists

  • Psychologists need to know the medication and dosage.
  • Have clients bring medication or scripts if they are vague.
  • Given the relationship and time spent with clients:
    • Medication may be contributing to suicidal ideation.
    • The client may report ideation for other reasons but being prescribed a medication that they can overdose on should be taken into consideration.
  • Psychiatric medications, particularly benzodiazepines, new antidepressants, and antipsychotics, are relatively safe in self-poisoning.
  • Under-treating mental illness leads to a higher risk of suicide than providing medication.

Monitoring Medication

  • Psychologists can note when relational, social, transitional, or adjustment issues may require a medication review.
  • Monitor functional changes, side effects, and compliance.
  • Provide useful research-informed (nomothetic) likelihoods.

Medication Terminology

  • YES signs of overmedication (antidepressants):
    • Yawning
    • Expression/word finding challenges
    • Silly mistakes
  • Serotonin Syndrome: Overdose of serotonin, often due to mixing medications or increasing SSRI dosage.
  • Off-Label Prescribing: Prescribing a drug for an unapproved indication, administration route, or patient group.

Medication Abbreviations

  • qd – once daily; bd – twice daily, PRN – on demand
  • XR or ER – extended release
  • SEs – side effects; TEs – treatment effects
  • FGAs and SGAs

Antidepressant Side Effects

  • Side effects vary highly and are individual. The chart provided represents a risk of side effects in the general population. Common side effects:
    • Sexual Dysfunction
    • Gastrointestinal Discomfort
    • Weight Gain
    • QTc Prolongation
    • Hypotension
    • Insomnia
    • Drowsiness
  • Gastrointestinal side effects from SSRIs and SNRIs commonly subside within the first few weeks of treatment.
  • Starting any antidepressant may initially increase the risk of suicidal ideations and behavior in children, adolescents, and young adults.

Liaising with the Treating Doctor

  • In most referral cases, you are authorized to mutually share information with the referrer. Check and seek authorization if unclear.
  • Share the minimum required information.
  • Share no information about other parties (i.e., telling the doctor about the client's recent separation breaches the partner's privacy).
  • Outline relevant observed information.
  • Perhaps suggest a medication ('with respect', 'I seek your counsel on this').
  • See prescribed and additional readings for more detail.

Stigma

  • Many psychological conditions remain stigmatized.
  • Acknowledge and discuss this in sessions.
  • Taking the step towards medication can feel like another level for clients.
  • It may activate the 'medical'/organic narrative ('Am I that unwell?').
  • Psycho-education about organic bases or the diathesis-stress model helps.
  • Use analogies like 'rest and eating well can do a lot to aid recovery, but sometimes an antibiotic or other med is needed.'

Pharmacotherapy as an Obstacle

  • Some medications may impede the therapeutic process.
  • Anxiety medications like Amitriptyline (Elavil), often prescribed for depression/anxiety, can impair cognitive abilities, negatively affecting therapy engagement, especially in older clients.
  • Side effects of Amitriptyline can mimic signs of aging.
  • Drugs like methadone, buvidal, and suboxone (harm minimization for addiction) can cause cognitive issues, sleep difficulties, and physical discomfort, impeding therapy.
  • Many medications affect sleep – and 'sleep affects everything'.

The Victorian Mental Health and Wellbeing Act 2022

  • Prioritizes client autonomy/rights, with conditions and safeguards.
  • Less focus on compulsory treatment, new names for options, and tighter protections.

Factors in Assessing Appropriateness for Admission

  • Nature and acuity of the presenting clinical syndrome.
  • Age of the consumer and appropriateness of admission to an adult Acute Mental Health Inpatient Unit.
  • Functional impact of the current condition.
  • Availability of community services and family supports.
  • Clinical risk assessment.
  • The Acute Mental Health Inpatient Unit's ability to safely manage the clinical presentation.
  • Potential treatment responsiveness.

Summary

  • Role in client medication information provision and monitoring.
  • Basic concepts/terminology.
  • Liaising with client and Dr.
  • Refer to: The Mental Health and Wellbeing Act 2022 (Vic) (or your jurisdiction's relevant Act).
    • Context
    • Ethos
    • Part 3.7+ re restrictive interventions
    • Part 5.2+ re mental health crises and response types.

Example Questions

  • Discuss your views on whether it’s ethical/advised to discuss medication-related issues with a client.
  • Identify three issues that the treating psychologist might provide information on for the referring doctor in relation to client medication.
  • Identify some steps the psychologist should take to make this communication as ethical as possible.