Sentenced to treatment: early experience of drug treatment and testing orders in England

Drug Treatment and Testing Orders (DTTOs) were introduced in the 1998 Crime and Disorder Bill and were piloted in three areas in England over the subsequent 18 months. The orders, funded by the Home Office, allow drug using offenders to be coerced into attending for treatment, to have regular urine tests and to be reviewed by the courts. In Croydon an equal partnership was set up between probation, a local statutory provider of drug services and a voluntary sector agency. Treatment plans were individualised and included a variety of treatment options. Forty-eight orders were imposed mainly for persistent shoplifting. Sixty-three percent of individuals had used heroin and 54% crack cocaine in the 30 days before the order was imposed. Ethical issues raised in coerced treatment were important for the individuals providing treatment although the clients all had to consent to treatment. The pilot programme raised issues about the nature of treatment, clinical responsibility, the selection of clients for orders and the objectives of treatment. Frequent urine testing was problematic but in the vast majority of cases clients were not breached just because of positive tests. The provision of DTTOs in an area created unacceptable inequalities in access to treatment. The paper concludes that partnership working and clear objectives are vital for treatment programmes to operate effectively. More research is needed to explore the most optimum way to deliver treatment in the context of a DTTO.

Research, policy, and the federal role in prevention initiatives for children

With the ability and the funds to implement programs on a national level, federal policy is a potentially potent tool in primary prevention. Despite the U.S. government's history of ambivalence toward intervening in child rearing and limited national support for primary prevention, several initiatives have been implemented for children and families with some measure of success. The successes, however, are mitigated by limitations of the initiatives themselves and by the inconclusive nature of much of the evaluation data. This review of 5 federal policy-based initiatives for children and families provides the backdrop for discussing aspects of federal prevention program design, implementation, policy, and research.

Emerging issues, policy changes, and the future of treating children with sexual behavior problems

Children and adolescents with sexual behavior problems are a growing national concern. While the field continues to make advances, we have much more work to do. We are working in a difficult and trying period for juvenile justice. It is a time when many are willing to give up on adolescents or punish them as we do adults. We have reached a point where many in our society do not know about, or care to understand, the complex issues that are the roots of violence and sexual violence in youth. Certainly their faith in the resiliency of youth has been tarnished. Nine critical areas that need to be taken into account when working with youth with sexual behavior problems are addressed. These areas include the unfortunate but continued trickle-down and use of adult-based treatment models to treat youth with sexual behavior problems, changes in juvenile law that have an impact on our ability to treat these youths effectively, the need for continued research in developing typologies for youths with sexual behavior problems and valid and reliable risk assessment scales, continued work with understanding and developing dynamic risk factors for sexually abusive youth, the need to develop better treatments for special populations of youth with sexual behavior problems, the need for a continuum of care, what constitutes best practice in treating youths with sexual behavior problems, the need for developing and refining standards of care, and the need for continued public education that supports prevention efforts to reduce sexual abuse by youth.

Sex offender reentry courts: a cost effective proposal for managing sex offender risk in the community

Recently enacted legal strategies to protect society from dangerous sex offenders generally use two very different approaches: Long-term incapacitation or outright release. The first strategy relies on harsh criminal sentences or indeterminate sexual predator commitment laws. The second relies primarily on registration and notification laws. Both strategies rely on prediction models of dangerousness. Authorities determine at a single moment the likelihood that an offender will sexually "recidivate" and then choose the appropriate type of control for an extended period. This paper reviews the problems of predicting sexual recidivism in the context of both strategies. It then proposes special sex offender reentry courts to manage the risk that sexual offenders will reoffend. Risk management allows decision makers to adjust calculations of individual risk on an ongoing basis in light of new information and to adjust the level of control. Drawing on Therapeutic Jurisprudence-a belief that legal rules, procedures, and legal roles can have positive or negative psychological impact on participants in the legal system-these courts can impose, and then adjust control over sex ofenders in the community. In a sex offender reentry court, the judge is a member of an interdisciplinary team that uses a community containment approach; the offender, as a condition for release, enters into a behavioral contract to engage in treatment and submit to periodic polygraph testing. This therapeutic jurisprudence approach creates incentives for offenders to change their behavior and attitudes, thereby reducing their recidivism risk and earning more freedom. It can also monitor compliance and manage risk more effectively.

Sexual aggression: mad, bad, and mad

Legal institutions in the Western liberal tradition ordinarily rely primarily on the criminal justice system to address conduct by some individuals that deliberately harms other individuals. The mental health system provides an alternative institutional structure through which societies can address such harmful behavior. Those who deliberately engage in conduct that causes harm to others are traditionally addressed through either the criminal justice or mental health systems on the basis of their being categorized as either "bad or mad." This paper examines some of the relevant reasons for categorizing sexual aggression as bad or mad. It emphasizes the significance of such categorization for the broader set of legal institutions of coercive social control and for the manner in which we respond to persons within those institutions.

Reform of the Mental Health Act: its direction and impact

The legal framework which determines what doctors can do to their patients, under what circumstances and with what limitations is determined by Parliament (statute law), the courts (common law) and the General Medical Council (as arbiter of medical ethics). In a nutshell we must put the needs of our patients first, we must have the consent of those patients who are able to decide for themselves, we must act in the best interests of the patient if they lack capacity, we must not ignore advance refusals and we must not partake in euthanasia. Emergencies may preclude a full assessment of these issues. It is generally agreed that relying on common law does not give a satisfactory framework for the care and treatment of those who lack medical decision-making capacity. Scotland now has an Incapacity Act 2002 and the government has agreed to introduce a bill for England and Wales.

Psychiatrists' knowledge of the Human Rights Act and its relevance to mental health practice: a questionnaire survey

The recent implementation of the Human Rights Act 1998 has important implications for UK psychiatric practice but previous studies have demonstrated that psychiatrists generally have poor knowledge of mental health law. The aims of this study were to assess psychiatrists' knowledge of the Human Rights Act and to examine whether knowledge is related to seniority or experience. Questionnaires were sent to 154 psychiatrists in the Northern Region, testing both their factual knowledge of the Human Rights Act and their ability to apply it to clinical scenarios. Ninety-mix psychiatrists responded and they demonstrated good overall knowledge and ability to apply the Human Rights Act However, half of the respondents were not aware that the Act only imposes a duty on public authorities and that a lack of active treatment in itself does not constitute a breach of the Act Specialist registrars and consultants scored significantly higher than SHOs but there was no significant difference between the specialist registrars and consultants. The scores of psychiatrists who had detained at least one patient under the Mental Health Act 1983 over the last six months were significantly higher than those who had not. The implications of these findings are discussed. There is still a need for further training on relevant aspects of the Human Rights Act.

Estimating the impact of alcohol policies on youth suicides

BACKGROUND

Alcohol consumption has been identified as one of the most important risk factors for youth suicide. Previous research has shown a strong, empirical link between alcohol use and suicide. If alcohol use is a contributing factor in determining suicidal behaviors, then policies designed to reduce the alcohol consumption may succeed in reducing youth suicides as well.

AIMS OF THE STUDY

This paper looks at the role of alcohol-related policies in reducing completed suicides by American youths and young adults. This hypothesis comes from two well established relationships: i) the observed correlation between alcohol consumption and incidents of suicide, and ii) the negative relationship between the full price of alcohol and consumption. The alcohol policies examined are excise taxes on beer, measures of alcohol availability, and drunk driving laws.

METHODS

Data on completed suicides for each state in the United States are analyzed for the period 1976-1999. Negative binomial regressions are used to estimate a reduced form model of youth suicide. Suicides are analyzed by gender and age groups (ages 10-14, 15-19 and 20-24).

RESULTS

The results indicate that increases in the excise tax on beer are associated with a reduced number of male suicides. This tax, however, has no impact on female suicides. Suicides by males ages 20-24 are positively related to the availability of alcohol, and negatively related to the presence of a 0.08 BAC (blood alcohol concentration) law and a zero tolerance law for drunk driving. Female suicides are not impacted by the availability of alcohol, although the drunk driving laws may impact suicides by teenage females.

IMPLICATIONS FOR HEALTH POLICIES

Policies designed to reduce alcohol consumption may have the unintended benefit of reducing suicides, particularly among young males.

IMPLICATIONS FOR FURTHER RESEARCH

While this research shows that alcohol policies may be successful in reducing male suicides, such policies have little impact on female suicides. Future research should explore other potential types of policies and programs to reduce female suicides. Also, illegal drug use has been linked to suicides in a similar manner as alcohol consumption. Future research should consider the role of illegal drug consumption and related policies in determining youth suicides.

[Current problems of psychiatric health care--2002]

The paper is a presentation of the most important and actual psychiatric health care problems in Poland: the financial situation of hospitals, the risks faced by the outpatient psychiatric care, maintaining the legal issues of the psychiatric patients, the situation of forensic psychiatry and legal-psychiatric expertise, post-graduate training, the level of diagnosis and therapy, availability of psychotropic drugs. Attention is paid to the importance of giving the programme of psychiatric health protection a status of evident value and that this programme should become a government (national) programme.

The use of sections 2 and 3 of the Mental Health Act (1983) with older people: a prospective study

The use of the UK Mental Health Act (MHA) is under scrutiny with older people, especially in those with dementia and other organic mental disorder. Whilst research into use of the MHA with this group has been sparse, the small body of existing research suggests that the MHA is applied differently to older adults (i.e. those over 65 years). This multi-centre study identified all MHA assessments conducted over a prospective three-month period, and obtained detailed data on the circumstances behind assessment. The findings highlighted that older people assessed under the MHA tend to exhibit different behaviour patterns, circumstances and core characteristics to those under 65; older people were more likely to be detained because of self neglect and physical illness and also more often had a diagnosis of an organic mental disorder. Younger people were unlikely to have a diagnosis of organic mental disorder and were more likely to be judged as a risk to other people. Risk of suicide was particularly highlighted with the under 65 age group. Implications for legislative reform are discussed.

Prior Alcoholics Anonymous (AA) affiliation and the acceptability of the Twelve Steps to patients entering UK statutory addiction treatment

OBJECTIVE

The study investigates levels of affiliation with AA and beliefs about the organization and its philosophy among a cohort of alcoholics entering a UK (non-AA) alcohol treatment service.

METHOD

A total of 150 consecutive admissions (75% men) were interviewed by an independent researcher within 5 days of their entry into a residential alcohol treatment unit.

RESULTS

Although about three quarters of these patients had previously attended AA meetings, levels of affiliation were low, with only 16% having worked any of the Twelve Steps. Previous AA attenders were more likely to be older, drinking greater daily quantities prior to treatment and to have first sought alcohol treatment at a younger age. Roughly equal groups expressed "positive," "neutral" and "negative" current attitudes towards AA (38%, 36% and 26%, respectively). Each of these three AA-attitude groups expressed greater endorsement of "Personal Responsibility" steps than of "Higher Power mediated" steps.

CONCLUSIONS

Few participants were universally negative to AA or the Twelve Steps--most regarded some of the steps as positive, but many rejected those referring to a Higher Power. Most also regarded some aspects of the organization and its philosophy worthwhile, with attitudes spread across the continuum of opinion. As AA remains one of the most widely sought forms of help for alcohol problems, a clearer understanding is needed of its impact on patients and the appropriateness of its integration within substance misuse programs which are not explicitly Twelve Step in orientation.

Defining recovery: an interactionist analysis of mental health policy development, Wisconsin 1996-1999

The author examines how, as part of a reform of Wisconsin's public mental health system, a workgroup of system stakeholders defined and operationalized the concept of recovery. Based on participant observation, document analysis, and interviews, with an analytic framework drawn from symbolic interactionism, the author finds that although individual members held a range of definitions of recovery, the workgroup was able to reach consensus in its policy recommendations through processual means and by tacitly agreeing on a set of overarching values that were flexible enough to accommodate many definitions.

Making psychiatric epidemiology useful: the contribution of epidemiology to government policy

This paper aims to discuss the contribution of epidemiology to aspects of public policy that have either a direct influence on mental health and mental disorders, or an indirect effect by influencing environmental factors which influence mental health. Both kinds of public policy will need to be considered by governments wishing to protect, promote, and improve the mental health of their populations. The paper draws on information from both relatively wealthy and low-income countries. The paper defines epidemiology and mental health policy, sets out the range of government policies which may have an impact on mental health, and explores the ways in which epidemiology may contribute to mental health policy in relation to service inputs, processes and outcomes as well as to wider government policies. The paper also examines the advantages and disadvantages of different sources of data. There are a number of reasons to carry out large-scale surveys of psychiatric morbidity. First, effective policy should address the needs of the population, which can best be assessed by the epidemiology and the social and economic causes and consequences of psychiatric morbidity. Secondly, representative information in a defined geographic area can document the use of existing services and can estimate the extent of unmet needs and the services required meeting those needs. Thirdly, valid information on prevalence and associated risk factors of presumed causal importance allow aetiological hypotheses to be generated and tested and models developed for prevention. Finally, by repeating community surveys, it is possible to monitor the health of the population and trends. Epidemiological findings emphasize the importance of mental health policy addressing the key role of primary care, the social context and social consequences of disorder, the importance of addressing services for children, the need to reduce premature mortality from suicide and from physical illness. Epidemiological findings show that mental health and mental disorders are related to the environment both in its structural physical sense and in the sense of the social processes connected to and influenced by particular settings. Thus epidemiology can contribute to general policies on employment and unemployment, housing and homelessness, education, and women's issues. Mental health policy is increasingly recognized as an essential area for countries wishing to enhance their economic, social, and human capital. Epidemiological data are a basic prerequisite to informing such policies. Expert professional and epidemiological advice to ministries is essential if policy is to be rooted in the evidence for population needs, risk factors, effective treatments and services, and measurement of outcomes. It is therefore important to develop the capacity for policy work in the psychiatric profession by including public health, epidemiology, and policy placements for young psychiatrists.