Backsliding in the Bay State

Jonathan Dosick
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Some months ago, I wrote on this blog about the move toward overly-restrictive “risk management” policies in my home State of Massachusetts.1 At the time, I was guardedly hopeful that the avalanche of “risk management” policies coming from the State would reach a logical conclusion. At some point, someone would say “enough!” Or, maybe the duplication of risk management procedures would result in sheer chaos for providers.

Was I ever wrong on that one!

Unfortunately, the drumbeat for more “Risk Management” just gets louder. And nowhere is this so alarmingly evident as a new policy proposed by the Massachusetts Department of Mental Health (DMH) in November 2012.

The “Community Risk Mitigation” (CRM) policy, released in draft form on November 5, 2012, is a near-complete inversion of everything  ‘self-directed’ and ‘person-centered.’ The policy excludes peer/survivor involvement at every level, and does an end-run around the Constitution. If adopted as written, it will be a tremendous step backward.

DMH does deserve credit for an early commitment to a transformation to a ‘recovery-based’ system of care, and they continue to invest in it. My work and training as a Certified Peer Specialist is a proud testament to this. Hundreds of peer specialists have been trained across the Commonwealth and are now in the workforce at various positions, including at the Department itself.

It’s also important to note that risk management is, to some extent, necessary in health care settings. But as public conversation about ‘mental illness’ (sensationalized by the media and amplified by politics) continues to harp on the “link” between ‘mental illness’ and violence, Risk takes up a disproportionate amount of attention. And so begins a treacherous and slippery slide down the slope of curtailing civil liberties.

After the horrific tragedy in Connecticut, proponents for forced treatment and involuntary commitment laws have sprung into action. Their modus operandi is to push a tired and disproven myth: that violence and “mental illness” are intimately connected. Interestingly, they often state that ‘the mentally ill are no more violent than the general population,’ before launching into increasingly vitriolic accounts of violence that send a message that ‘mental illness = violence.’ This even applies to incidents so recent that no ‘conclusion’ can be reached.

In addition, many of these “advocates” are disparaging increased civil rights protections for peer/survivors. A recent New York Times Op-Ed lamented that there’s “too much concern…about the civil liberties of people who have horrifically distorted thinking.”2

Thus, fuel for the fire to pass ever more restrictive policies, like this one.

As I mentioned in the earlier post, doesn’t it make sense that with more “Risk Management” in place, wouldn’t the “Dignity of Risk” (taking healthy risks, an essential part of recovery) end up being smothered? The introduction to the proposed policy states, “Acknowledging risk that is inherent in living is a fundamental dimension of supporting persons in recovery.”3 But looking at the language of the rest of the policy, one would easily forget that point.

What is “Community Risk Mitigation?”

The CRM policy applies to people who have applied for and been approved for DMH services, and those receiving services in outpatient clinics, respite, crisis beds, and going for emergency screening.

The policy’s stated purpose is to “help identify and monitor public and personal safety related to Individuals in the community,” and to set up information-sharing protocols between the Department and other providers.

What Does “Risk” Look Like?

The language of the policy has an alarming number of logical mistakes. “Risk” is defined differently nearly every time it is mentioned. Here are some definitions of “risk” in the policy:

  • “Behavior, including, but not limited to, history of criminal involvement.”
  • “A relevant history of behaviors that pose serious risk of harm  to others, including a history of criminal involvement on charges of serious violence.” (Do “charges” by themselves merit the activation of intense risk monitoring? Also, what is “serious” violence?” Is there such thing as “casual violence?”)
  • “Risk of physical harm to self and others” (no mention of emotional harm.) “Inappropriate sexual aggression, exhibition or other sexually offensive behavior stemming from symptoms of major mental illness.” (Which symptoms; and what defines a “major” mental illness?)

The most comprehensive “definition” of what constitutes “risky” comes fairly late in the document, under “behaviors that raise concern about public safety.” (Whose concern?) These include:

  • Completion of an IFRA (Independent Forensic Risk Assessment) – a standard risk management evaluation for inpatients at DMH hospitals;
  • “Histories of criminal or delinquency charges and/or behaviors related to serious violence, stalking, or firesetting.”
  • Registered sex offenders;
  • “Problematic sexual behavior that has created public safety concerns.”
  • “Individuals with serious suicide or self destructive histories.”

…Is your head spinning yet?

An official policy should offer concrete definitions and details, but this is a motley hodgepodge. So, it’s not hard to imagine that many more people will be subject to unnecessary monitoring. Those who have been charged in, or simply accused of, criminal behavior would be monitored under this policy. People whose “risk” behaviors occurred in the distant past can be included. Even if the peer/survivors have worked hard on their own to lessen possible “risk,” these efforts are not taken into account. There is NOTHING “strengths-based” here.

Because more people will be labeled “high-risk” and subject to the heavy-handed results of this policy, they will face longer delays to placement in less restrictive, “community” settings, decreased housing and employment opportunities, and unnecessary stigmatization.

But shoddy definitions are just the tip of the iceberg…

Composition of Committees

In the recent past, peers have been given a “seat” on many DMH committees. Granted, not nearly enough seats, but some effort has been made towards inclusion. But the Committees the CRM policy would create, if implemented, would exclude entirely the people who would be discussed in them, unless an Area official or doctor believes it “appropriate” to invite them. Nor is any mention made of having peer workers in attendance.

There are two formal committees created by this policy, all at the Area level (there are three DMH “Areas” in the State.)

1.) The Critical Incident and Complaint Review Committee, which meets once or more weekly to review any critical “risk” incidents and create an ‘action plan.’ This can include human rights complaints, as well – but without peer/survivor involvement (detailed later).

2.) The Area Risk Review Committee, which, meeting an undefined amount of times, maintains a “tracking” system for persons deemed at risk; reviews individuals with “providers, case management or others” (specified as other agency representatives); and shares information relative to risk.

Keep in mind a guiding slogan of the Recovery Movement, “nothing about us without us,” when looking at the makeup of these two committees.

(Members can send a designee if they choose):

Critical Incident and Complaint Review Committee

  • Co-Chairs: Area Medical Director and Area Director;
  • Director of Community Services;
  • Child and Adolescent Director;
  • Area Child and Adolescent Psychiatrist;
  • Area Quality Management and/or Performance Improvement representative; and
  • Human Rights Coordinator.

Something seems to be missing here…oh, “other members” may attend with the approval of the Area Director (no mention is made of the peer/survivors being discussed, or peer workers).

Area Risk Review Committee (same as the above committee, with the same Co-Chairs), which adds four more members:

  • Area Forensic Director;
  • Area Site Director;
  • Director of Program Management;
  • Director of Mental Illness/Problematic Sexual Behavior (MIPSB) Program;

Still something missing here, even though Clinical Consultants and DMH Service Providers may be invited “as indicated,” and “others deemed appropriate by the Chairs.” Again, no mention of the person being reviewed.

Another structure written into the policy, the Clinical Review, is the most intimate of all meetings. One would think that any peer being discussed would always be invited…but think again.

The Clinical Review is “conducted by or with the Area Medical Director or Child Adolescent Psychiatrist or designees, along with relevant Area/Site Office staff and providers when indicated.”

Individuals and guardians “shall be invited to participate in discussions regarding their services…” At last! But two critical words complete this sentence:

“…as appropriate.”

No specifics as to WHO issues these invitations. How can it be inappropriate for a person served to participate in developing a risk plan?

I find it mind-boggling that after so many years of implementation of the ‘recovery-based,’ ‘person-centered’ system of care the Department prides itself upon, they have created a policy that completely leaves out the person! If this policy is implemented without changes, it will erase years of progress.

Lack of Informed Consent/Due Process

There are no provisions within the CRM policy that call for the “at risk” peer/survivors being discussed (and ‘tracked’) to be informed of these meetings – or even to be told the basic fact that they are being tracked. This is a clear violation of the principle of Informed Consent. There’s no language here that grants the “at-risk” people the opportunity to review or respond to the Committees’ work, no releases of information to sign, nothing. If they wish to challenge the Risk Committees’ findings (which they may not even know about), well, there’s nothing about that either.

It seems that Informed Consent and Due Process are viewed an unnecessary luxury for our population. Does any other branch of the medical field keep their work a secret, deny important information to those it serves, and then absolve itself from any legal challenge?

Information Sharing

The CRM policy would create more paperwork – lots of it. If a client is transferred from DMH to a private provider’s services, a lot of information would be shared. But with no provision for releases of information, personal information would be transferred quite freely – and there’s no telling who on the receiving end (the provider) could access this information – it’s not specified. Shouldn’t people know where their personal information goes?

How Long?

The CRM policy doesn’t have any timeframes attached to it – when the “risk” monitoring would start, or when it would end. And since a person can be “tracked” without being told of it, they could be followed for years without even knowing. An unpleasant hint of Big Brother there.

The language of the Community Risk Mitigation Policy is about as clinical and un-person centered as possible. But in addition, there are no words here that address cultural competency, and nothing about trauma.

Nothing About Us Without Us. This proposed policy is all about us, but completely without us. We have made progress in the struggle to be respected. However, regressive policies like this and the ongoing push to crack down on ‘the violently mentally ill’ are making a mockery of the humanity and strengths we all share.

The bright side (hopefully) of all this is that the policy as written was a draft. Many people and groups, including the State’s top public-interest law firms, have protested this policy loudly during a comment period, and hopefully, major changes will be made.

By not allowing the peer/survivor voice to be part of the “risk” discussion, are we lessening potential risks, or creating a much larger one by keeping a whole population utterly disempowered?

Citations

1Dosick, Jonathan. “Risk Management and the Dignity of Risk.” Blog post. Mad in America.com. 21 May 2012. Web. <https://www.madinamerica.com/2012/05/risk-management-vs-dignity-of-risk/>

2Steinberg, Paul. “Our Failed Approach to Schizophrenia.” New York Times, 25 December 2012. Web. <http://www.nytimes.com/2012/12/26/opinion/our-failed-approach-to-schizophrenia.html?_r=0>

3Commonwealth of Massachusetts, Department of Mental Health. DMH Policy: Community Risk Mitigation (Draft). 5 November 2012. Print.

9 COMMENTS

  1. Are the mentally ill a special group of violent offenders that require additional risk management for the protection of the community?

    It is an interesting question.

    The mentally ill may not be more likely to commit violent acts but they are apparently more likely to commit violent acts that trigger cognitive bias.

    That is to say the mentally ill seem to have a certain panache for acts that are more memorable because they are bizarre, against strangers, and in mass quantity – and thus attract more media attention and encoding into our memory banks via the avaialability heuristic.

    Thus the approximately 0.3% of people who were murdered in the USA this year in these acts (i.e., Aurora and Newtown) are given higher level of salience by the brain than the other 99.7% (14,000+) who were murdered – disproportionately by “normal” people who did so to their family members, lovers, frienemies, and “business associates” for understandable motivations such as money, drugs, religion, politics or sex . (By the way, people who assign inappropriate levels of salience to potential threats has a label in psychiatry, doesn’t it?)

    The appropriate policy response, therefore, is not to focus the risk management on the mentally ill, but on the non-mentally ill, as they pose a greater risk to the overall safety of society. However, no such government agency currently has a mandate to conduct this profiling and monitoring of the 4/5ths of Americans without psychiatric labels who, as a group, are statistically more likely to kill.

    As representatives of the mentally ill, who are statistically more likely to be victims of this violence, we have a moral obligation to stop this threat from “normal” people in the community, by ensuring they have all been carefully assessed for their risk of violence and are appropriately monitored by state authorities. Fortunately there is an agency in the progressive state of Massachusetts with a penchant for managing community risk, capable to take upon this noble cause. This may seem draconian to subject vast number of honest, law-abiding citizens to this type of dehumanizing treatment, but then again, there’s “too much concern…about the civil liberties of people who have horrifically distorted thinking.”

    Godspeed, comrade.

    -A

  2. Just another example of how the professionals are working for society and not for the patients. There is no other so called health problems a person can have where it becomes a societal issue. People get HIV and are free to keep it a secret and have all the sex they want even as they’re killing people because it’s considered a health problem and those, with the exception of mental illness, are considered totally private in our culture.

    It just proves everything that Thomas Szasz ever said. This is not real medicine. This is the inquisition all over again.

  3. I was born in Boston, grew up in Everett and then spent a decade in Lawrence. Massachusetts policies were so frustrating that it fueled a great deal of my motivation to leave the state. I often say that I wouldn’t move back there even if somebody paid me. The last time I checked, Mass population is not too far from 10 million people. The state has some real problems. In Everett, the unofficial symbol is a machete. I don’t know if the “urban legend” lives on today but that is just what it was.

    It seems to me that rather than targeting the individual for “risk management”, specific counties, cities and towns with known detriment should be the focus. If an entire environment is hostile and potent with threat, risk and danger, neglecting it is the same as fertilizing it. It makes no sense to target an individual if the greater collective is the real problem.