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THE WEST HUDSON PSYCHIATRIC SOCIETY VIRTUAL NEWSLETTER

Published bimonthly in conjunction with the printed newsletter

January-February 1998 Edition

Robert N Sobel, MD, Editor & Syed Abdullah, MD, Co-Editor

Leslie Citrome, MD, MPH, Virtual Editor

The President's Desk: The Winter Months

Psychiatry and the Law: The Double Agent - Managed Care & Ethics

Public Affairs: West Hudson & Coalition Continue Outreach Projects

Psychiatric Update: Alternative Psychotherapy

Private Practice: "Formation of an IPA" or "Lunch with Bert Pepper"

Outpatient Update: Outpatient Commitment Program

The President's Desk: The Winter Months

The change of seasons is a bitter time of year. Leaves fall, vegetation dies and the landscape turns gray and inhospitable. The hours of natural light become fewer and its intensity more pale until it reaches its nadir at the winter solstice. Then there is the new year. The unavoidable symbol of the end and the beginning. During this critical period, the human spirit can either diminish as the winter nights become longer, or it can rise above its surroundings and search for rebirth.

One solution that cultures have developed to ease the burden of this period is the festival of lights. Christmas and Chanukah are celebrations that cut against the grain of the darkening season, with its tradition of charity and gift giving. Perhaps Mental Illness Awareness Week is Psychiatry's contribution to that celebration. A reaching out to the public at a time when they need it the most, from Axis I through V. It is our seasonal message of hope at a time when exacerbations of biologic disorders can reach their peak. It puts us in the mind of the public during the most challenging time of the year.

As usual, our district branch, although small in numbers of members by national standards, managed to pull off a disproportionately large number of events. These included depression screenings at the Nanuet Mall, a public forum on "Breaking the Silence" at Town Hall in New City, school gigs by Rockland players on destigmatization, radio call-in shows on mental illness, a multidisciplinary conference at Rockland Psychiatric Center and a variety of speakers at commercial and civic locations. This casual listing of events cannot express the amount of energy, hard work and creativity that the membership squeezed out of their busy schedules to make MIAW a success. They were all very well received and well attended. I would like to personally thank all those who participated and express the hope that even more of us get involved next year.

The change of seasons has another special meaning for psychiatry. Unfortunately, it is an unsettling one. This is a point in our history where our identity as physicians is being sorely challenged. What the profession will look like in ten to fifteen years is anyone's guess. Will we be replaced by a more efficient breed of doctors, unified in their belief that less is better and that quality means adherence to the latest edition of an HMO manual. Who will these new doctors be, who have grown up in a residency that has been saturated with managed care. Will we look like dinosaurs to them, plodding and anachronistic. Will our current version of a physician find a quiet death or will there be a subtle rebirth, as the traditions we have nurtured so carefully during our professional lives refuse to go away. I would hope the latter. But each year, each change of season, brings us closer to that answer. In their dark period, it is encumbent upon us to hold onto those intangible skills, which has made us such a valuable resource to society.

Psychiatry and the Law: The Double Agent - Managed Care & Ethics

In the area of the "Cold War", we often heard of CIA operatives who were actually "double agents" for the Soviets or some other country. The double agent is an individual beholden to two masters, but betraying one for the other. Some years ago, The Hastings Center published a paper on the Double Agent in Psychiatry. These were individuals who worked for one entity (e.g., a prison system) and were treating patients (inmates) in the facility. Their conflict occurred when an inmate advised their therapist, presumably within the confidential doctor-patient relationship that a prison riot (or similar event) was imminent, and the psychiatrist was faced with the dilemma of advising the prison administration of the impending riot, betraying his/her patient's confidences, or withholding the information thus, possibly betraying his/her obligation to the employer (the prison) with the attendant risk of potentially preventable injuries. There are no easy answers to these ethical dilemmas. But with careful planning and foresight, some can be minimized or avoided.

It seems to me that we, as psychiatrists and physicians, have been placed in the position of Double Agent, vis-a-vis our patients and the Managed Care companies which are paying us to treat them. In reality, we may have joined the Managed Care companies in betraying our patients and breaching our ethical obligations. Some examples:

a)In order to be viewed as "good" providers, worthy of referrals from the company, we are routinely cutting down on the number of sessions we offer to patients, possibly providing less than adequate care.

b) Some Managed Care companies have requested us to describe to them one or more recent cases we have treated, including the type of treatment and number of sessions utilized. To be "good" providers, we submit cases with a small number of sessions utilized. We certainly don't submit a description of a complex case requiring 18 months of treatment and multiple medications as well as three hospitalizations and a dubious outcome. We do this so they think well of us and send us cases. They then use our own examples against us and our patients, by defining these short treatments as the usual duration of treatment and disallowing requests for longer treatment.

c)Patients are seen by social workers on the panel for many months, then referred to us for a single session and medication evaluation, possibly with 20 minute medication maintenance sessions every 1-3 months. We know little about the therapist's training, experience or skills, and are in collusion to have the patient treated by someone who may have terrible skills and experience while we assume medical responsibility. The patient receives second-rate care, with our approval.

d)A "case manager", possibly with no professional degree or experience, is allowed to ask for detailed information about the patient and then questions our treatment plan, negotiating for fewer sessions, and even a change in medication to a less expensive alternative. We comply because we want the case manager to think we are "on the team " or " one of the good guys".

These are just a few of the examples we've all seen and experienced since the onset of managed care. Who are we actually serving, our patients or the Managed Care company? And do we ever really fully disclose to the patient what we are doing to stay on the panel? Do we even admit it to ourselves? Is this what we took the Hippocratic Oath for? Is this not some of the most egregious breaches of our ethical guidelines? Will we one day be accused of participating with or going to bed with Managed Care companies in their (and our) grand scheme to make money for themselves (ourselves), while undermining good medical care? (Is this the Nuremburg trial's "good soldier" concept in another form?)

As with all ethical questions, there are no easy answers, but I certainly believe these must be addressed by each of us individually and jointly, as an organization.

Public Affairs: West Hudson & Coalition Continue Outreach Projects

Mental Illness Awareness Week was a tremendous success. The public forum "Breaking the Silence-People with Mental Illness Speak Out" which was held on October 15, 1997 was attended by over 200 people. The stories of the three consumers who spoke (Leslie Boyd, Susan Tracy, and Gerry Trautz) were inspirational and heartwarming. They each spoke about their recoveries from mental illness and spoke so eloquently that one person in the audience expressed the wish that everyone who treats people with mental illness could hear their inspiring stories. They gave us all a tremendous feeling of hope as well as feeling gratified for being in the mental health field. I must admit that in my professional years as a psychiatrist that night will always stand out as one of the special ones. A special thank you to Rena Finkelstein, Co-President of FAMILYA-AMI and Carol Olori, CSW (who works for the Rockland County Department of Mental Health) who chaired this event. In addition, County Executive Scott Vanderhoef and Commissioner of Mental Health Maryanne Walsh added so much to this special evening with their introductory remarks. Dr. Les Citrome and I served as representative psychiatrists and answered questions on medications and diagnosis. A special thanks to Les for his support.

I must admit that despite the fact that there were many community leaders present (politicians, hospital leadership and other representatives), I was disappointed that Dr. Citrome and I were the only psychiatrists . I feel strongly that if we want to be leaders in our community, we need to be visible in our community. I hope that many of you will not only attend the next forum, but will also attend the coalition's meetings. I must state that I am concerned by the lack of psychiatric participation. When other professions take over the role that should be psychiatry's, we will have no one to blame but ourselves, if we fail to perform as community leaders.

On the brighter side, I would like to report that the coalition's project at Link Elementary School in New City was another tremendous success. The Rockland Players, a volunteer improvisation group from the Mental Health Association, and the professionals from the Mental Health Coalition did a great job. The principal, the school psychologist, and the fifth grade teachers were all enthused by the presentation. We were all particularly touched when one fifth grade student remarked that "this program really helped me to realize that my parent's divorce is not my fault". The children were indeed the "stars of the show". Their enthusiasm and questions were inspiring! My son Evan, a fifth grader at Link later said to me "Mom, that day you did that mental health program at Link was the day I was proudest of you." Moments like that make me proudest to be a psychiatrist.

The coalition is already planning for May (which is mental health month). Events planned include a special event with the clergy. If you would like to participate, please contact me at 914-364-2428.

I would also like to thank Rick Brand, MD and Scott Lawrence, MD who did a great job at Barnes and Noble in Nanuet. Dr. Brand spoke about Seasonal Depression and Dr. Lawrence spoke about the holiday blues. Both sessions were well attended and another great service to the community.

The Mental Health Coalition participated in depression screening at Dominican College in Orangeburg. The turn out of people was overwhelming. Thanks to all the coalition members who helped out and especially to Roz Fields (Education Coordinator of the Mental Health Association) for organizing the event.

The presence of Alternative Psychotherapy is a well known, if not a well recognized phenomenon in psychiatry. In fact the root of this form of psychotherapy is typically American and predates the psychoanalytic movement by several decades. From 1830 to 1855 a group of nineteenth Century writers, poets, philosophers and psychologists of New England became loosely linked to an idealistic concept of the unity of all creation, and the belief in the essential goodness of man. They championed such causes as suffrage for women, better conditions for workers, temperance and other social concerns. Insight and intuition were rated higher than the logical, linear approach to knowledge. German transcendentalism, Neoplatonism, the Indian and Chinese writings of the ancients as well as the writings of mystics like Emanuel Swendenborg and Jakob Bohme were freely incorporated in the system of philosophy/psychology propounded by the American transcendentalists. They included such diverse thinkers like Ralph Waldo Emerson, Henry David Thoreau, Margaret Fuller and others. In 1840, Emerson and Margaret Fuller founded the magazine The Dial wherein some of the provocative writings of the transcendentalists appeared. William James, M.D. and John Dewey were heavily influenced in their thinking and formulations by the transcendentalists.

Despite this rich heritage, these American thinkers did not produce a coherent system of psychotherapy. Their impact in the field of psychotherapy was further undermined by the emergence of the psychoanalytic movement in Europe. The sheer brilliance and almost evangelical force of the psychoanalytical crusade swept aside the impact of the transcen-dentalists of America. Jung attempted to bridge the gap between these two bodies of knowledge, but his voice was drowned in the disputes that went on within the psychoanalytic movement. The writings of Walt Whitman, Herman Melville, and Nathaniel Hawthorne, who were influenced by the transcendentalists, led to the flowering of the American artists and the evolution of the American Renaissance in literature, but they did not result in a system of psychotherapy that could compete with the burgeoning psychoanalytic avalanche.

In the context of the scientific/ technological breakthroughs of the late 19th century, there was little attention paid to alternative psychology that talked about the Soul of man, and his higher potentials in the realms of love, altruism and other spiritual matters. Although the transcendentalist relied mainly on their Christian beliefs and the writings of the Christian mystics, they incorporated the spiritual ideas and practices of the Eastern and Middle Eastern religions. Meditation, retreats, communion with nature, and spiritual awakening were their core message. William James book The Varieties of Religious Experience was a landmark publication which talked about the levels of consciousness: ...our normal waking consciousness, rational consciousness as we call it, is but a special type of consciousness, while all about it, parted from it by the filmiest of screens, there lie potential forms of consciousness entirely different. ..No account of the universe in its totality can be final which leaves these other forms of consciousness quite disregarded...they forbid a premature closing of our accounts with reality. Despite all this, the development of a system of treatment, based on these ideals remained an unfulfilled goal.

In recent times there has been a renewal of interest in issues pertaining to the soul, that immaterial aspect of a human being which confers individuality and humanity to a person. The undeniable success of the AA movement and other 12 Step programs, is an example of the relevance of the spiritual factor in psychotherapy. Two recent publications, in the tradition of the transcendentalists, are worth mentioning here. One by Thomas Moore, titled: Care Of The Soul, is an attempt at cultivating depth and sacredness in daily life. Thomas Moore is a New England psychotherapist who has written several books including The Planets Within, Rituals of the Imagination, and Dark Eros. Besides being influenced by the transcendentalists, Moore also lived as a monk for twelve years and has a Ph.D. in religious studies. He is an exponent of archetypal and Jungian psychology, mythology and the arts. He blends these in his psychotherapy. His thrust is to reach the depths of the person's psychological turmoil, to dredge out the connections between spirituality and the problems of the individual and society.

The other recent addition on this subject is the book The Five Stages of the Soul by Harry Moody, Ph.D., and David Carroll. A beautifully written book, it might prove to be a landmark publication. Just published this fall, it has already been translated and published in a German edition, and a French version is underway. The book deals with the enduring cravings of the soul to find meaning and purpose in life. This craving persists even after the individual has achieved his/her material, emotional and career goals. A Professor of Philosophy, Dr. Moody has had extensive experience in Gerontology. He has spoken and written on the phenomena of aging and the psycho-spiritual fulfillments of life. Perusal of his book will be gratifying to those who are engaged in innovative forms of in-depth psycho-therapy, where the spiritual aspects of the clients are seriously considered.

In conclusion, the basic premise in alternative psychotherapy, is that deep in the essence of every human being there is a Divine spark, an incorruptible Spirit, which is the repository of strength and goodness in that person- a nidus har-boring the attributes of love, forgiveness, creativity, generosity, kindness and intuitive wisdom. The farther removed a person is from that center within him, the more overwhelmed he becomes with the stresses of life leading to depression, neurosis, psychosis and a host of maladaptive maneuvers like alcoholism and substance abuse. It is the task of the therapist to explore with the patient his true self, and discover his capacity to love and be loved, and to give and receive from life what is his legitimate share.

Private Practice: "Formation of an IPA" or "Lunch with Bert Pepper"

On Friday, November 21, about a dozen of your fellow members had the privilege of spending an hour and a half with Bert Pepper discussing the merits, ethical complications, logistics, history and purpose of creating an Independent Practice Association (IPA). Bert Pepper is a member of your local district branch and is also the Director of the American Psychiatric Association Consultation Service. He flew in from Washington to join any members who wished to participate in the discussion.

Let me first reiterate, that your executive council has debated the creation of an IPA on several occasions. After considerable discussion, we took a central role in defeating the effort of NYSPAA to create a New York State IPA because we felt it would create a conflict of interest for a professional society to operate a non-profit business that might exclude some members from participation and that might compromise other efforts to restrict or regulate for-profit competitors. I personally remain vociferous in my opposition to any professional society creating an IPA or using it's resources to create an IPA. I am also not interested in participating in a privately created IPA. I've tried to make it clear in previous articles in SYNAPSE that I'm disinterested in managed care participation and troubled by the ethical and business implications. Nevertheless, I find the issues very interesting and timely.

Dr. Pepper reviewed the history of the Consultation Service and it's role in organizational consultation, especially to groups of psychiatrists trying to form an IPA. He described how an IPA is organized, it's relationship to a Managed Services Organization (MSO) and how it must market itself to survive. He reviewed in some detail the controversial and successful creation of an IPA in Connecticut. He informed us of some of the little known details and relationships which cast that conflict in a somewhat different light from that portrayed in our press.

Many of us left the meeting with the impression that attempting this kind of venture is extremely time consuming, quite costly with no guarantee of financial success and also very complicated. Dr. Pepper reiterated that those of us in solo private practice should think about having "outriggers" on our career "canoe" in this time of practice uncertainty. and that an IPA could be an "outrigger" for some. There are a variety "outriggers" which don't present the difficulties of an IPA and he detailed a few he is pursuing.

It was such a lively and interesting discussion that we asked him to return to finish it. Any member who wishes to join your executive council, other interested members and Dr. Pepper for a 90 minute lunch meeting to discuss IPA's and related issues should plan on coming to the Dellwood Country Club at 12 Noon on January 9. Please call Dr. Marc Tarle (639-9650) to reserve your spot.

BACKGROUND

In 1993 New York State adopted the Community Mental Health Resources Act,more commonly known as the Community Reinvestment Law. This legislation continued New York's longstanding policy of reducing beds at state psychiatric centers, but required that the money saved be invested into a wide array of community-based services for individuals with serious and persistent mental illness.

Soon thereafter the New York State Legislature conducted hearings which concluded that some individuals who require mental health treatment and services to survive safely in the community frequently reject the care and treatment offered to them on a voluntary basis and decompensate to the point of requiring repeated psychiatric hospitalizations." The Legislature also found that a number of other jurisdictions permit court-ordered outpatient mental health treatment (also known as "outpatient commitment.")

Chapter 560 of the New York State Laws of 1994 amended both the Judiciary and Mental Hygiene Laws to allow the establishment of a three year pilot program to provide for "involuntary outpatient treatment of mentally in persons."Additionally, it called for a study to determine the effectiveness of the program"in assisting participants to live and function in the community" and "in preventing relapse or deterioration that may result in the need for hospitalization." The legislation also required that the study assess"participant satisfaction with such pilot project."

Bellevue Hospital Center was chosen to implement the pilot program in late1994. It was chosen because of its long commitment to treating individuals with psychiatric disabilities, its wide scope of mental health programs and its experience in handling mental health legal issues.

A request for proposals to conduct the research study was issued in early1995. The contract was awarded to Policy Research Associates (PRA), an independent firm that specializes in mental health policy research.

THE BELLEVUE OUTPATIENT COMMITMENT PROGRAM

The Bellevue Hospital Center Department of Psychiatry began its Outpatient Commitment Program (OCP) on July 1, 1995. The OCP operates through a Coordinating Team which has its offices in the Psychiatric Ambulatory Care Clinic. The Coordinating Team serves as a medico-legal consultation service, and is responsible for implementing the clinical program in full accordance with Section9.61 of the New York State Mental Hygiene Law. The Coordinating Team is also responsible for collaborating with PRA to implement the research study.

In order to be eligible for the OCP, individuals must meet all of the criteria as set forth in the legislation. These criteria include that: (I) the patient is eighteen years of age or older; and (II) the patient is suffering from a mental illness; and III) the patient is incapable of surviving safely in the community without supervision, based on a clinical determination; and (IV) the patient is hospitalized at [Bellevue]...or in the case of an application for an additional period of treatment, the patient is currently receiving involuntary outpatient treatment; and (V) the patient has a history of lack of compliance with treatment that has necessitated involuntary hospitalization at least twice within the last eighteen months; and( VI) the patient is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment pursuant to the treatment plan; and (VII) in view of the patient's treatment history and current behavior, the patient is in need of involuntary outpatient treatment in order to prevent a relapse or deterioration which would be likely to result in serious harm to the patient or others...; and (VIII) it is likely that the patient will benefit from involuntary outpatient treatment...."

Any psychiatrist attending at the Bellevue Comprehensive Psychiatric Emergency Program (CPEP) or on the Bellevue inpatient service may refer a patient to the OCP. Staff of the OCP Coordinating Team then screen the referred patients and enroll those appropriate as candidates for the OCP.

Candidates for the OCP are required to have housing, case management and psychiatric treatment services included in their discharge plans. The candidate's inpatient treatment team is responsible for developing the comprehensive discharge plan, as is the case for any other psychiatric inpatient. Staff of the OCP Coordinating Team are available for ongoing consultation to assist in developing optimal outpatient plans.

A discharge plan is complete when providers have been identified for each and every service required by the patient in the community. Providers must formally accept patients in order to be included in completed discharge plans.

During the first six months of operation, all patients enrolled as OCP candidates were brought to court for outpatient commitment orders if and when comprehensive discharge plans were completed.

The PRA research study formally began in January 1996. The outcome study compares patients who receive court orders with those who receive enhanced,coordinated clinical services without court orders. The goal of the study is to determine the specific effect of the court order on community tenure of significantly noncompliant mentally ill individuals.

As of January 1996 all patients who become candidates for the OCP are referred to PRA staff. They then explain to the patients that the study involves being interviewed a number of times over a period of one year. The PRA team attempts to gain each patient's informed consent to participate in the study.

Patients who consent to participate in the study have discharge plans developed as described above. At the time that the discharge plan is completed,patients are randomized into two groups: 50% are brought to court for outpatient commitment orders and 50% do not go to court, and thus serve as "controls" in the study. Therefore both groups receive comprehensive, enhanced discharge plans.

Outpatient commitment orders are requested for all patients who do not consent to participate in the research study.

The court may order a patient to comply with outpatient mental health services for a period of 180 days. Additional court orders for 180 days at a time may subsequently be requested.

Section 9.61 of the Mental Hygiene Law defines "involuntary outpatient treatment" as any of the folloWing categories of service which have been ordered by the court:

1) medication; 2) individual or group therapy; 3) day or partial day programming activities; 4) services and training, including education and vocational activities; 5) supervision of living arrangements; 6) intensive case management services; 7) and "any other services within the local plan prescribed to treat the person's mental illness and to assist the person in living and functioning in the community, or to attempt to prevent a relapse or deterioration that may reasonably be predicted to result in the need for hospitalization."

Two specific additional categories of service have been included in outpatient commitment orders as per item 7 above. These are supportive case management and assertive community treatment. The latter provides both case management and psychiatric treatment services in the community.

An outpatient commitment order requires a patient to comply with categories of service, not with individual providers. Thus, the formal court order states only the categories of service, not the names of the individual providers.

It is important to note that a discharge plan is not complete until a specific provider has been identified for each and every category of service being requested. Patients may not be ordered by the court to comply with a category of service unless the provider identified for that category has formally accepted the patient for community care.

Changes of providers within a category of service do not require court hearings. Therefore, an outpatient care plan may be changed at any time as long as there are providers for each category of service in the order. It is possible to alter outpatient commitment orders once they are in effect. However, additions or deletions of categories of service from an outpatient commitment order require court hearings.

MEDICATION

The court may order medication as a category of service only if specific criteria are met. In addition to demonstrating the patient's eligibility for outpatient commitment, the hospital must show by clear and convincing evidence that:

1) "the patient lacks the capacity to make a treatment decision as a result of mental illness" and 2) "the proposed treatment is narrowly tailored to give substantive effect to the patient's liberty interest in refusing medication, taking into consideration all relevant circumstances, including the patient's best interest, the benefits to be gained from the treatment, the adverse side effects associated with the treatment and any less intrusive alternative treatment."

OUTPATIENT CARE

After the court issues an outpatient commitment order, the patient may be discharged to the care of the outpatient providers included in the discharge plan. Patients in the control group of the study are also discharged to the care of the outpatient providers included in their discharge plans. Both groups are monitored by the OCP Coordinating Team. Patients with 9.61 court orders are followed as long as an order is in effect. Control patients are followed for one year after discharge from the referring inpatient hospitalization.

Outpatient providers have responsibility for providing ongoing treatment and services to their patients in the OCP. They provide treatment and services to OCP patients according to the standards of care of their organizations and agencies.

The OCP Coordinating Team is available to assist with any and all aspects of patient care. The OCP Coordinating Team hopes that patients will benefit from their participation in the program with improved clinical outcomes.

NONCOMPLIANCE

Outpatient providers are responsible for assessing compliance with treatment and services for their OCP patients. The OCP Coordinating Team is available to provide assistance in evaluating compliance and re-assessing outpatient care plans.

Noncompliance is not, in and of itself grounds for hospital re-admission. Patients may only be admitted to a hospital if they meet the standard legal criteria for admission, i.e., danger to self or others. Section 9.61 does,however, have a mechanism for evaluating this situation. If an examining psychiatrist determines that a patient under court order has been noncompliant and may meet admission criteria, that psychiatrist may contact the OCP Director or a designated psychiatrist at the Bellevue Comprehensive Psychiatric Emergency Program. The Bellevue psychiatrist may then direct the police to remove the patient to Bellevue for evaluation for admission.

An outpatient who is court ordered to receive medication as a category of service is required to take medication according to the specifics of the order. If an examining psychiatrist determines that a patient is noncompliant with medication, and efforts have been made to solicit compliance, medication may be administered over the patient's objection. This may be done according to a set of guidelines which have been issued by the President of the New York City Health and Hospitals Corporation. A copy of these guidelines may be obtained by contacting the OCP Coordinating Team.

It is important to note that Section 9.61 explicitly states that "failure to comply with an order of involuntary outpatient commitment shall not be grounds for involuntary civil commitment or a finding of contempt of court."

FURTHER INFORMATION

The OCP Coordinating Team would be happy to provide further information or assistance. You may contact the Director, Howard Telson, M.D. at: Bellevue Hospital Center, 462 First Avenue, C&D Building, 2nd floor, New York, N.Y. 10016

Dr. Telson's telephone number is (212) 562-4073. The OCP fax number is (212)562-4556. PRA staff are available to answer any questions regarding the research study. The Field Supervisor, Kostas Gounis, Ph,D. may be reached by telephone or fax at (212)562-4071.