Policies and Politics of Mental Health: Criminalization, Ethics and Advocacy (PDF)

Policies and Politics of Mental Health: Criminalization, Ethics and Advocacy: Class 11: PPN 303 Promoting Mental Health Course Checking-in PPN 303 – Promoting Mental Health Parking Lot & Making Space Topics of Mental Health and Substance Use can be triggering Please make space to acknowledge yo...

Policies and Politics of Mental Health: Criminalization, Ethics and Advocacy: Class 11: PPN 303 Promoting Mental Health Course Checking-in PPN 303 – Promoting Mental Health Parking Lot & Making Space Topics of Mental Health and Substance Use can be triggering Please make space to acknowledge your needs and if feeling triggered remember to pause and connect to supports. TMU Student Support Resources https://www.torontomu.ca/student-wellbeing/counselling/ Land Acknowledgment "Toronto is in the 'Dish With One Spoon Territory’. The Dish With One Spoon is a treaty between the Anishinaabe, Mississaugas and Haudenosaunee that bound them to share the territory and protect the land. Subsequent Indigenous Nations and peoples, Europeans and all newcomers have been invited into this treaty in the spirit of peace, friendship and respect." The "Dish", or sometimes it is called the "Bowl", represents what is now southern Ontario, from the Great Lakes to Quebec and from Lake Simcoe into the United States. *We all eat out of the Dish, all of us that share this territory, with only one spoon. That means we have to share the responsibility of ensuring the dish is never empty, which includes taking care of the land and the creatures we share it with. Importantly, there are no knives at the table, representing that we must keep the peace. The dish is graphically represented by the wampum pictured below. This was a treaty made between the Anishinaabe and Haudenosaunee after the French and Indian War. Newcomers were then incorporated into it over the years, notably in 1764 with The Royal Proclamation/The Treaty of Niagara. Objectives Describe The historical evolution and impact of policies and politics associated with institutionalization and criminalization of mental illness. Introduce Considerations relevant to mental health policy, legislation, ethics and advocacy Examine The rights of the individual and informed decision making in the context of mental health Explore How societal shifts and views of mental illness have shaped policies and approaches to care. Question What does “criminalization of mental Illness” mean? “Criminalization of Mental Illness” The over-representation of people with mental illness in the criminal justice system is often referred to as the “criminalization” of mental illness. 8 https://www.thestar.com/opinion/commentary/2017/04/27/judge-exposes-how-we-criminalizemental-illness-opinion.html 9 Background 36% of federal offenders were identified at admission as needing psychiatric follow-up. 25% of male federal inmates have an identified mental health need Over 50% of female federal inmates have an identified mental health need In an Ontario study, 80% of youth in detention met the criteria for at least one mental disorder as per DSM-5 Persons with mental illness more likely to be arrested for minor offenses than non-ill person – directly or indirectly related to mental illness (mischief, failure to appear, disturbance) Between 15% to 40% of convicted people currently incarcerated have mental illness – this is disproportionately higher than mental illness prevalence in the general population. 10 Transforming the Criminal Justice System: Mental Health and Addictions https://youtu.be/s8c6ME VXxFc Police Police officers are the gatekeepers of the criminal justice system. They have also increasingly become first responders in situations involving people with mental illness. First responders in a system where there are little options and supports for the most severely and chronically ill Individuals with mental health issues are more likely to be arrested in a police interaction, even when related to minor offences 12 While the vast majority of people with substance use or mental health conditions rarely come into contact with the criminal justice system ~ Question Why is there an over-representation of people with serious mental health issues in Canadian courts and correctional/remand facilities ? Several Factors Contribute Lack of Access to timely and appropriate treatment and supports. Lack of Sufficient supports & resources in the community Lack of early intervention, mental health promotion and prevention services Compounding risks and vulnerability that negatively impact equitable access to mental health supports – poverty, racism, stigma, discrimination When people with mental illness are incarcerated, symptoms can become more severe. Incarceration further disconnects people from supports making it more difficult to access services upon release. Involvement in the criminal justice system further stigmatizes 14 Cook County Jail USA https://pbswisconsin.org/ watch/mysteriesmental-illness/cookcounty-jail-syialh But How did we Get Here? Social Change and Mental Health Treatment • Depends on a community’s views and fears as well as availability of effective treatments and access to supports Historically: • Periods of social stability • • Less fear, more tolerance for diverse behavior Easier and safer for people with mental illness • Periods of rapid change • • Anxiety and fear toward mental illness Often treated inhumanely Policy and Historical Context of Mental Health Care Asylums •1500’s-1800s •“Mad Houses” •Poor Houses •Jails Early Forms of Institutional Care •19th and 20th century •Large Lunatic Asylums •Separated from society •Treatments limited •Over-crowded •Often poor conditions •20th – 21st Century •Shift in mental health policy •Advances in treatments pharmacotherapeutics •Downsizing of large provincial psychiatric hospitals •Closures of psychiatric hospitals •Communities ill prepared and underfunded to support needs of people discharged De-instituationalization 18 Early Forms of Institutional Care (Pre-1700s) • • • • • • Very few and small scale – run by citizen groups (non-medical) or religious charitable groups. Managed like guesthouses/poor houses Otherwise, many people lived with their families or communities No public or state involvement Extremely poor conditions in “mad houses” Alternatively, many people with mental illness in jails where gross abuses and neglect occurred Figure 1.1 Interior of Bethlehem Asylum (“Bedlam”), London, as depicted by William Hogarth in his series A Rake’s Progress. (From U.S. National Library of Medicine. Images from the history of medicine. National Institutes of Health, Department of Health 19 and Human Services.) Beliefs & Approaches to Mental Illness • Diverse beliefs and approaches to mental illness and attempts to treat have been employed over history and must be understood from that context. • Spiritual, biological, and social explanations commonly intertwined with popular perceptions of causes affect policy and ways society responds to the care of people with mental illness. • Evil spirits, sin, demonic possession, fears, contagious environments, or brain disturbances have figured in explanations of mental health conditions and shaped people’s responses, community resources, and medical treatment. 20 Humane Treatment (late 1700s – Early 1800s) Definition: • A moral, compassionate, and pleasant environment for people with illness • Based on the enlightenment ideas that “mentally ill” people were sick patients deserving of treatment that is humane and not abusive 18th century • Philippe Pinel: removed chains at Bicetre (France) • William Tuke: established the York Retreat (England) 19th century • Quaker Friends Asylum: kind and humane treatment toward patients • Care of the mentally ill became a public responsibility in the United States and Canada Canadian Asylums Established in each province. Late 19th and early 20th centuries. Replaced older forms of familial care and Poor Law–based approaches. Gender differences were reflective of the social situation of the time. Figure 1.2 Canada’s first hospital for mentally ill people, Saint John, New Brunswick, ca. 1885. (From Provincial Archives of New Brunswick, Saint John Stereographs—P86-67.) 22 The Legal Basis for Mental Health Care • Each province developed its own legislation. • In 20th century, the Insanity Act renamed Mental Health Act. • Patients are admitted to an institutional facility on either a voluntary or a certified basis. Dorothea Dix (1802–1887) Was responsible for mental health care system reform in the United States, Canada, and Great Britain Diligently investigated the conditions of jails and the plight of mentally ill people Promoted the building of mental hospitals Was instrumental in Canada in advocating for mental institutions in Halifax and St. John’s Figure 1.3 Dorothea Lynde Dix. (From U.S. National Library of Medicine Digital Collections. National Institutes of Health, Department of Health and Human Services.) 24 Kirkbride Asylum: Example of Moral Treatment https://www.pbs.org/vide o/kirkbride-asylumqnzvh2/ Early Institutional Life: Its Reality Despite the good intentions of early reformers, the approach inside the institution was one of custodial care and practical management, and treatment rarely occurred. Major concern was management of a large number of people who were forced to live together. Overcrowding and resource shortages created rowdy, dangerous, and often unbearable situations. Men and women were often abused. Quiet patients were involved in work as institutions grew into self-contained communities that produced their own food and made their own clothing. The Asylum Hill Project https://www.pbs.org/vide o/asylum-hill-projecty3hndx/ Canadian Developments in Mental Health Care • Universal health insurance for hospital care and medical services developed in the 1950s and 1960s. • Psychiatric departments established in general hospitals. • The Canadian Mental Health Association (CMHA) influenced policy development to integrate hospital care and community care, which led to deinstitutionalization. • Across North America, movement towards rapid de-centralization of mental health care and de-institutionalization 28 Un-Intended Consequences of Rapid De-Institutionalization • People with mental illnesses were discharged to communities that were illprepared to provide community-based programs and supports, housing, or employment opportunities • Stigma and discrimination widespread in the community • “revolving door” of in and out of acute care hospitalizations • Interconnectedness of severe mental illness and substance use disorders and inadequate community resources, and lack of housing resulting in growing numbers of homelessness and incarceration. • Fragmented system • Compounded systemic inequities for indigenous and black people 29 Deinstitutionalization without resources https://www.pbs.org/vide o/mass-incarcerationmentally-ill-8uizxd/ 2000’s ~New Era of Health Care Reform • Emphasis on community-based care for people with mental illness. • Large networks of public and private organizations share responsibility for mental health care. • Regional discrepancy has been blamed on the lack of a nationwide mental health strategy. • The need to develop a national mental health strategy became the impetus for the establishment in 2007 of the Mental Health Commission of Canada. 31 The Need for a National Mental Health Strategy Impetus: Lack of national strategy Inconsistency across provinces https://mentalhealthcommission.ca/about/ 32 Changing Directions, Changing Lives: The Mental Health Strategy for Canada (May 2012) • The Strategy translates this vision into 26 priorities and 109 recommendations for action, grouped under the following 6 Strategic Directions: • • • • • • Promote mental health across the lifespan in homes, schools, and workplaces, and prevent mental illness and suicide wherever possible. Foster recovery and well-being for people of all ages living with mental health problems and illnesses, and uphold their rights. Provide access to the right combination of services, treatments and supports, when and where people need them. Reduce disparities in risk factors and access to mental health services, and strengthen the response to the needs of diverse communities and Northerners. Work with First Nations, Inuit, and Métis to address their mental health needs, acknowledging their distinct circumstances, rights and cultures. Mobilize leadership, improve knowledge, and foster collaboration at all levels 33 Today ~ 2022 Public awareness growing that diverse cultural populations have distinctive mental health needs and experience inequity ~ Especially Black and Indigenous people Mental health services are still fragmented and not sufficiently developed to meet the needs of diverse populations. Financial and social barriers continue to affect the overall funding for mental health and substance use services Lack of investments into mental health promotion 34 Question? So, What about now in 2022? What are some of the beliefs around mental illness that affect society’s response to care? What’s Your Normal? https://www.pbs.org/vide o/whats-your-normaly0pjdf/ Legal & Ethical Aspects of Practice Law and Psychiatric Mental Health Care • Human rights and mental health legislation • Mental health legislation in Canada • Each province and territory is guided by its own mental health act to provide a framework for mental health care services, rules, and procedures (Table 7.2). • It is the responsibility of nurses to understand the Mental Health Act of their province/territory. Nurses need to be able to explain the Act's basic provisions to people with mental illness and their families. 38 Rights of a Person with Mental Illness (UN, 1991) Right to Medical Care Right to be treated with humanity and respect Equal protection right Right to be cared for in the community Right to provide informed consent before receiving treatment Right to privacy Freedom of communication Freedom of religion Right to voluntary admission Right to judicial guarantees 39 UN Convention on the rights of persons with disabilities • 2010 Canada ratified as a signatory, committed to: • Ensuring the promotion and protection of the human rights of all persons with disabilities • Disability in the CRPD is understood from a social perspective as arising from the way in which the environment interacts with a person’s condition rather than the condition itself. • Provides a basis for legislation, policies, and regulations for eliminating barriers to the societal participation of those with mental illness. 40 Mental Health Acts Across Provinces Allows Involuntary admission of a person to a designated facility The conditions that must be met are usually that an examination by a physician indicates that the person has a mental disorder, is likely to cause harm to self or others or to suffer substantial mental or physical deterioration or serious physical impairment, and not suitable for admission to a facility other than as a “formal patient” Admission certificate allows the person to be conveyed to a mental health facility and to be detained and cared for during a 24-hr period. Within that time, the person must be assessed by a physician. Legal Terms Related to Mental Health Acts • • • • • • Involuntary admission Formal patient Admission certificate Renewal certificate Competency Substitute decision maker • Best interests • Capable wishes • Modified best interests 42 Mandatory Outpatient Treatment (MOT) • Conditional leave • Community treatment order (CTO) • Review panels 43 Ethics Defined Ethics is the consideration of the way a person should act in order to live a good life with and for others. Learning to reach our potential as human beings: Values Relationships Principles Duties Rights Responsibilities Legal Domain of Ethics Law and ethics are separate domains. Nurses are required to know the legal context of mental health care in Canada. Health ethics is described by Somerville (2000) as the need to protect the profound respect for life and commitment to human spirit. Ethical Nurse Nurses have a fiduciary relationship with the public. Nurses are trusted to be ethical. Professionally, nurses are moral agents. Nurses require the commitment to the well-being of others in their care. Code of Ethics The CNA Code of Ethics Values for RNs is framed by seven values with related ethical responsibilities. The guide provides ethical standards of practice for nurses and informs other disciplines and the public of the profession’s commitment. Ethics in practice developed by the CNA. Deontology Postulates duty or obligation as the basis of doing right. • Also termed Kantian ethics Using reason alone to determine how to act in a given situation. Moral worth of the person’s action is determined by the intent of the person and not the effects of the action. One should treat others always as an end and never as a means. Utilitarianism The principle of utility: actions are right in proportion to their tendency to promote happiness. What is right to do is what gives the best consequences for the greatest number of people. Rule utilitarianism: once the decision is made on the best rules, then they should be followed even if happiness is not maximized. Principlism Four principles: 1. Nonmaleficence: that one should do no harm 2. Beneficence: one should do or attempt to do good and make things better for others when we can 3. Respect for autonomy: an obligation to respect a person’s right to be self-governing 4. Justice: fairness in the distribution of benefits and risk Casuistry Case-based ethics. The focus in casuistry is on agreement about cases, not necessarily principles or theories, and precedents are central to this approach. Past decisions about what was right or wrong in significant cases serve to inform decisions about the new case. Steps include: Identify the main ethical values and concerns. Identify the main alternative courses of action. Identify the casuistic factors. Compare the case with relevant paradigm cases. Ethics of Care and Feminist Ethics Ethics of care • Care based • Connection/responsibility for others • Emotional responsiveness Feminist ethics • Addresses power inequities, dominance, and oppression Relational Ethics Core elements of relational ethics are: • • • • Mutual respect, engagement Embodied knowledge Attention to the interdependent environment Uncertainty/vulnerability A relational ethics decision-making framework • Box 7.4 Ethical Practice Environments • Practice is grounded in compassion, empathy, and professionalism. • Interprofessional communication, collaboration, and conflicts are critical factors in the ethical climate. • Institutional policies, demands, and supports also play a role. • Relationships are a key issue. 54 Human Rights The central assumption of human rights is that every person has claims or entitlements because he or she is a human. The rights can be positive: Rights are obligations of the state or others to provide a right. Or negative: Usually civil or political in nature Question What About MAID for Mental Illness? Medical Assistance in Dying (MAiD) for people whose sole medical condition is mental illness is set to become legal in Canada in March 2023. MAiD – Mental Illness inclusion 2022 March https://youtu.be/DAOlzEr 4WSQ Medical Assistance in Dying • The administrating by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death • The prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may selfadminister the substance and in doing so cause their own death • Four criteria to meet to be eligible for MAID 58 Current MAiD Criteria At this time, to receive MAiD a person must meet all of the following criteria: 1. Be eligible for health insurance in Canada; 2. Be at least 18 years old and capable of making health care decisions; 3. Have a grievous and irremediable medical condition; 4. Make a voluntary request free from external pressure; and 5. Give informed consent after being informed of all other available treatments and care. 59 Current MAiD Criteria A person is considered to have a grievous and irremediable medical condition if they meet all of the following criteria: 1. They have a serious and incurable illness, disease or disability (excluding mental illness until March 2023); 2. They are in an advanced state of irreversible decline; and 3. Their illness, disease or disability or state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable • A person’s death does not need to be reasonably foreseeable for MAiD eligibility (i.e., a person does not need to be at the end of life). 60 Current MAiD Criteria • There are also procedural safeguards that must be met before a person can access MAiD. • These safeguards include undergoing medical assessments; submitting a written request that is observed by an independent witness; being informed of the right to withdraw the request for MAiD at any time; and providing final consent immediately before receiving MAiD. 61 MAiD – Poverty & Disability Example https://youtu.be/Up5k2Lx 5SPI Moral Dilemma and Moral Distress Moral dilemma is a conflict in which one feels a moral obligation to act but must choose between incompatible alternatives. Moral distress occurs when one is unable to act on one’s moral choices because of internal or external constraints. Identify the source of distress. Refer to one’s code of ethics and other documents for guidance. Seek support. Some Ethical Issues in Psychiatric Settings • • • • • • • • • Threats to dignity Behaviour control, seclusion, and restraint Psychiatric advance directives Relational engagement: “boundaries” Confidentiality and privacy Advances in neurotechnology Advances in genetics Social justice Research ethics 64 Threats to Dignity -> kindness and respect • Violated dignity can lead to suffering. • Nurses and other health care professionals must consistently ask: • What is it like to use our mental health services? 65 Behaviour Control, Seclusion, and Restraint Individuals who are at risk due to mental illness need to be protected and supported. The least intrusive and restrictive interventions are used in reducing such risk. Individual rights, dignity, and autonomy are respected. Psychiatric Advance Directives • A legal resource for people to use for times when their decision-making ability is compromised by a mental illness • Allow for designation of a surrogate decision maker • Are a useful tool in communicating with physicians, avoiding side effects by identifying specific medications that an individual wishes to avoid, and preventing involuntary treatment • Best practice 67 Relational Engagement • Boundaries are used to describe the limits of relationships; implies clear borders that should not be crossed where in actual practice it is more complicated. • Most serious type of boundary violation is sexual harassment and abuse of patients. 68 Confidentiality and Privacy • Consent is a central factor in decisions related to privacy and confidentiality, which becomes more complicated when the person involved has an illness that affects his or her ability to give consent. • Nurses should inform the patients in their care that the information will be shared with the team. • Advances in technology threaten privacy. 69 Social Justice • Justice, a principle of fair treatment of individuals and groups within society, is a core value underpinning the CNA Code of Ethics. • The social injustices related to mental illness due to stigma and discrimination exist worldwide. 70 Research Ethics in Psychiatric and Mental Health Nursing • • • • • • Tainted history. Adequate support for mental health and addictions research. Vulnerable population. Risks need to be evaluated. Social injustices related to mental health exist worldwide. Canadian nurses have an ethical responsibility to address the social, economic, and political issues that affect health and well-being. 71