Transcript Mental Health Matter - Asia Pacific Coroners Society

Mental Health Matters
Dr Anthony Duncan
A good time to talk.
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There is a potential for Coroners and Mental
Health Professionals to talk past each other.
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As “risk” is assuming such a high profile this
could become more and more of a problem
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This potential can be minimized if we better
understand each others roles and work closer
together.
Mr David BYRNE
European Commissioner for Health and
Consumer Protection
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“Risk versus benefit”
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European Voice Conference “Farm to Fork”
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Brussels, 22 November 2001
Are we in danger of being overcome
by "risk paranoia"?
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Do we suffer from "risk dyslexia"? Are we
weighed down by "risk overload"?
We can't have a risk free society.
Yet we cannot have a free for all especially in
areas touching on public health considerations.
We need deep reflection on these questions.
Perhaps they are not capable of satisfactory
resolution in a neat package.
Today’s Tasks
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Talk about risk and risk management.
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Talk about the different working models of coroners
and psychiatrists and the potential for talking past each
other
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Comment on the role of the Coroner’s hearing for
families and health professionals in achieving closure
after a death.
And then………
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Talk about concepts of Mental Disorder and
Illness, and how they are related.
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Managing severe personality disorders.
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And then any other topics of interest!
What is risk?
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The change of something happening that will have
an impact on objectives.
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It is measured in terms of consequences and
likelihood.
We live in an era where there is a great distrust
of professionals and institutions.
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A quick scan of the Sunday paper finds stories about alleged
misspending of public monies by a number of government
departments.
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The risks of GE.
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The risks of aerial spraying to control pests.
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The risk of lahars on Mt Ruapehu.
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Poor practice by a variety of professionals.
The Tipping Point
by Malcolm Gladwell
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‘How little things suddenly can make a big
difference.
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Hush Puppy Shoes.
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The folding of paper, and epidemics.
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Risk assessment and management.
Managing Risk
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Since the mid 1950’s a more formal approach to
managing risk has evolved out of the
manufacturing and insurance industry.
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Healthcare risk management approaches have
developed since the 1960’s.
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They originated in the USA.
Australia and New Zealand are in the
early stages of acceptance and
implementation.
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Accountability for health care outcomes is an
area of recent focus.
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Learning how to manage risk effectively enables
managers and health care providers to achieve
improved outcomes by identifying and analyzing
the wider range of issues and providing a
systemic way to make informed decisions.
Risk perception.
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Technical expert looks at probability and
consequences.
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Lay person’s perception determined by factors
including
Degree of familiarity with the activity
 Degree of personal control that cab be exercised
over the activity
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Degree to which exposure to risk is voluntary
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The distribution of the risks or benefits
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The potential of an event to result in catastrophic
consequences
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Whether the consequences are dreaded.
Risk thermostats.
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We are all set a little different.
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Has an impact on career choice.
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Has an impact on how the past is seen to
influence future decision making.
Same information different response.
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Individualists.
Stress market forces and individual responsibility
Egalitarian
Our group knows best, we plan and act accordingly
Hierarchists
Expect protocols to work, trust the experts, do more
research.
Fatalists
Why bother things just happen
We are the first generation of
practitioners in the risk management
society.
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Risk is to a large extent socially constructed.
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Most people will fly and drive
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Many won’t have cell phone towers near their
homes
As living has become less dangerous we focus
more on risks!
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Especially on those we are exposed to, but have
no control over
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Perceived to be caused by others.
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More powerful than us.
We focus on risks out of our control
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Much more public concern about dioxin that
diabetes
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Much more concern about environmental
carcinogens than diet.
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Agent Orange compensation meeting held in
smoky RSL clubs.
Emerald Pools fall.
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12 year old falls to his death in a national park in Utah
in the USA.
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Parents sued the park authority for inadequate warning
signs.
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Attorney Kathryn Collard had argued in the appeal that
several warning signs posted in the vicinity of the pools
were not specific enough to warn of the danger
The case failed.
 "The Middle Emerald Pools could be made perfectly safe by installing
around it a 10-foot-high chain link fence with spikes on top," said Tuesday's
decision. "But few would want to visit such a site. Zion officials have to
decide the extent of safety precautions that can be justified in a scenic park.“
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Collard was not available for immediate comment Tuesday. Even if the signs
posted had warned of algae, as Collard had suggested they should have, the
10th Circuit questioned whether park officials would then be required to add
signs explaining how to identify algae or warning of the hazards of rocks not
covered by algae.
It is a risky world out there
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If risks were better quantified and managed.
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Nothing would ever go wrong.
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So if anything goes wrong
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Somebody should or could have prevented it.
Professional actions as assessed
socially as well as objectively.
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Suicide and homicide are terrifying.
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Media portrayals tend to be polarized between then being
inexplicable or inevitable.
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They could happen in any family.
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They must not and should not.
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They will not if mental health professionals do their jobs right.
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And Coroners are in the ideal place to make sure they do.
Changes in Mental Health Services.
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A move to more community service provision,
and a reduction in the number of institutional
beds.
Working in a society where there have been
major changes.
Dramatic increases in life choices for people.
Increasing drug abuse and markers of family
breakdown.
Roles
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Psychiatrists bring their general knowledge to
the specific, to guide their actions in the face of
considerable uncertainties.
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Coroners use information obtained from a
certain and specific case to make more general
recommendations.
PART 4 — INQUESTS
Section 15
Purpose of Inquests.
1) A coroner holds an inquest for the purpose of—
(a) Establishing, so far as is possible,—
 (i) That a person has died; and
 (ii) The person's identity; and
 (iii) When and where the person died; and
 (iv) The causes of the death; and
 (v) The circumstances of the death; and
b)
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Making any recommendations or comments on
the avoidance of circumstances similar to those
in which the death occurred, or on the manner
in which any persons should act in such
circumstances, that, in the opinion of the
coroner, may if drawn to public attention reduce
the chances of the occurrence of other deaths in
such circumstances.
What is the Coroner’s Task.
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Or what should it be.
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Micro
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Macro
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Alone
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With others
Psychiatric Training.
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Taught how to extrapolate from minimal information,
ie see patterns, establish and check out hypotheses.
Learn the art of formulation, which tries to establish
some order on chaos.
Learn how to do risk assessments, and how to weigh
risks.
Learn to feel confident to take decisions, in a situation
of under resourcing, in a system not configured the way
you would want it configured.
Clinical Accountability
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Somebody must be held accountable!
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For the outcome?
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I can only be responsible for my decision making
process not the outcome.
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Reviews should concentrate on the decision making
process!
Systemic Accountability
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Clinical practice occurs in a system.
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Built by others
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With particular ideologies.
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Community focused
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Funder provider split, and private provision of
residential care.
Social Accountability
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Welfare provisions
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State role in employment market
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Drug and alcohol Policy
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Gambling policy
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Family values.
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The technologically disenfranchised.
The role of the Coroners Court in
Guilt and Expiation.
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One function of the hearing is to allow closure
on a death.
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Often by this stage a considerable reworking of
“the truth”
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We do not speak ill of the dead.
Lots of mixed feelings
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Ambivalence.
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Guilt
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Relief
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Anger
By the time it comes to the
Coroner’s Court.
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We as a family are pure as the driven snow.
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The deceased never had any problems until
he/she went to the Mental Health Service.
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If only they had done what they should have
done (and we told them what to do) he or she
would still be alive.
What might the health
professionals say?
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We could not hospitalize him because he did not
meet the criteria of the Mental Health Act.
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And doing so would have prevented the
outcome.
It is not my fault.
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I am as pure as the driven snow.
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Of course I would have detained him is I could.
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It is the fault of the Mental Health Act.
What do these two series of
statements have in common?.
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An assumption that in an ideal world all dangers
should be predictable and manageable.
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“It would not have happened if……”
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The real world is not a safe and friendly place!
What was the family’s thinking in the
time immediately around the death?
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He really was difficult
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If only he had / had not…….
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If only we had / had not
What was the health professional
thinking at the time of the last
assessment?
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At the time, based on past experience I felt the
best course of action was……..
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I really did not think he was a risk to much of a
risk.
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And I judged the risk of other courses of action
to be greater.
How did they weigh the risks before
deciding what to do.
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To the individual
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To significant others
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To the system as a whole.
The medicalisation of
suffering
My son has been diagnosed as
having a mental disorder.
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And there is no service for him.
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If nothing his done he will kill somebody
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The Doctor has diagnosed an Antisocial
Personality Disorder
Mental Disorder (DSM IV)
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A clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual.
And that is associated with
Present distress (painful symptom) or
Disability (impairment in one or more important areas
of functioning) or
With a significantly increased risk of suffering death,
pain, disability or an important loss of freedom.
Cautionary Statement
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The purpose of DSM-IV is to provide clear
descriptions of diagnostic categories in order to enable
clinicians and investigators to diagnose, communicate
about, study and treat people with various mental
disorders.
The clinical and scientific considerations involved in
categorization of these conditions as mental disorders
may not be wholly relevant to legal judgments, for
example, that take into account such issues as individual
responsibility, disability, determination and competency
Mental Disorder.
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An abnormal state of mind
Of continuous or intermittent nature
characterized by
Delusions, or by disorders of mood, perception
or volition or cognition
Of such a degree that it
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Poses a serious danger to the health or safety of
that person or of others or
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Seriously diminishes the ability of that person to
take care of himself or herself.
Are Mental Health Service there to
manage Mental Illness?
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Words like illness, disease and sickness have
been defined in various ways.
You can have a disease without feeling sick or
being ill.
One essential feature of illness and disease is the
assumption (from physical medicine) that they
are biological conditions afflicting the “person”,
and can be potentially be “fixed”.
The medical model fits for some
mental disorders
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Especially “Mental Illnesses’
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Ie “Diseases” that can be seen as an affliction which
can potentially be “fixed” so the person returns to
normal.
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Schizophrenia
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Manic depressive illness, Unipolar affective disorder,
Anxiety disorders.
Medical model
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Symptoms are epiphenomena the doctor needs to
decipher to get to the diagnosis.
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The doctor prescribes treatment for the disorder.
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The patient takes the treatment, and gets better.
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And thanks the Doctor and the rest of the team.
Allows you access the sick role
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It is not your fault.
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It is out of your control.
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We have the therapy to get you better.
Most of these illnesses can be treated
reasonably well
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If
The person accepts the sick role
Takes the medications
Comes to terms with the illness
Avoids substance abuse.
Treating these conditions remains
the core business of Psychiatrists
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The further away from this core one gets the
less relevant medical training and “being a
Doctor” is
However
There are understandable societal expectations
that we can “fix” everyone and everything
“He must be mad, look at the way he acts”
And when we can’t, we have failed!
How near to core psychiatry was this
case?
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The further away (both in time and scope), the
less we can be expected to be responsible for.
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We are not society’s fix it squad!
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Changes is suicide rate are largely socially
determined, and intervention needs to be
societal to change the rate.
Welcome to the mind of a
Psychiatrist.
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I do as much assessment as I think is need to allow me to feel I
can reach an understanding of the person, and make a diagnosis.
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Weigh the risks and decide on a course of action.
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I then wait and see how things pan out and if necessary have
another crack.
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There is never enough time to cover all the bases, and the law of
diminishing returns means near enough is good enough!
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Most the moves I make are good ones!
It is a risky world out there!
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I am never dealing in situations where there is a choice
between a course with no risk and one with lots.
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I decided on a course of action light of clinical
experience, a gut feeling, knowledge of the literature,
social supports and resource constraints.
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I fill out risk assessment forms and other parts of the
paper trail under great duress.
An inpatient goes AWOL
•Goes
to parents house.
•They
ring the ward, and say “he is OK, says he
is not suicidal and his friend will bring him back
later in the afternoon.”
•Staff
have concerns, as he has been suicidal, but
parents say no please don’t come, this is the first
time he has accepted he needs help.
The friend decides to take him for a
drive before returning him.
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He jumps out and kills himself!
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What does the inquiring Coroner need to consider?
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What were the risks of other actions such as going out,
and putting him under the Act, without parents
consent.
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Were they appropriately weighed up ?
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What should happen in the next 10 similar cases?
Importance of not invalidating
good practice.
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What were the alternative possible courses of action?
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What might one usually be expected to weigh up in such a
situation.
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How often are practitioners called on to make a decision in
similar circumstances?
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What would be the usual expected outcomes of the various
options.
How close to core psychiatry was
this?
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What is the appropriate level of
recommendation
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Whose subsequent decision making needs
to be targeted
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What are the resource implications of
recommendations, and does that need to be
commented on.
Management of Borderline
Personality Disorder.
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Therapeutic risk taking.
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There is a high chance this condition will be
fatal if we do nothing or contain, so lets try to
do something positive.
Aetiology
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Possible genetic predisposition.
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Usually terrible childhood experiences.
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These leading to problems sense of self and self worth.
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Problems with affect control, affect regulation,
tolerance of negative affect and impulse control.
These people do not have a
treatable illness
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But they are distressed and distressing.
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Very low self esteem
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Chronically empty
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Chronically suicidal
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Very impulsive
What helps
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Treat any superimposed illnesses
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Establish a good working alliance, and at first take no
risks until you can be sure there is no superimposed
illness.
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Containment is often counter productive as it leads to
increased regression, feelings of powerlessness and
increases the already very high chance of suicide.
The long term prognosis with
treatment is quite good.
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As long as they do not kill themselves in the
meantime.
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Theraepeutic risk taking is appropriate.
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BUT
Only in the well selected patient
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Acutely if you don’t know the patient, and there
is no management plan admit them.
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However
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For carefully selected cases it is an appropriate
management approach.
To feel confident to work in this way
clinicians need to feel supported.
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These people have a disorder in part caused by
others, via neglect and or abuse.
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People can help fix them, but cannot be
responsible for them except in crisis.
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These conditions are often fatal, and we have to
accept that!