Introduction

Trauma is inherent in the life of a person with serious mental illness. Salyer, et al, in a report for the Indiana Division of Mental Health cited research estimating lifetime prevalence of trauma ranging from 85% to 97% Posttraumatic stress disorder (PTSD), one of the primary effects of trauma, is also prevalent. Compared to the general population where lifetime estimates of PTSD range from 8% to 12%, 29% to 43% of people with SMI meet criteria for current PTSD . They find, however, that PTSD is not systematically diagnosed or treated in this population.

Trauma is so prevalent in the SMI population for three reasons.

Trauma has a causative effect. Post Traumatic Stress Disorder is, obviously, a result of trauma. However, childhood or adult abuse or neglect or other traumas can initiate or exacerbate other mental illnesses.
Mental illness creates a population vulnerable to victimization. The current emphasis on studying why people with severe mental illness are potentially violent has overlooked the effect of violence committed against these individuals. (See article by Marley, James A; Buila, Sarah)
Treatment itself and the communities response to the illness can be traumatic. It is this trauma that will be the concern of this document.
1. Coercive Care. For the sake of argument, we can consider that coercive care falls into three general areas.

i. Inpatient Commitments. This is the stripping of a person’s civil liberties for the sake of their treatment, their safety and the safety of others. In Nebraska, this always begins with an “Emergency Protective Custody” order.

ii. Outpatient Commitments and other legal coercions to treatment.

iii. Extra-Legal coercion. Bernice Pescosolido et al report that almost a third of people entering mental health services through an emergency room, that is not brought by police, report being their through coercion.

Restraint. For adults with mental illness, restraint and seclusion both are limited to inpatient settings, with one major exception. During crisis, in Nebraska, a police officer can take a subject into “Emergency Protective Custody”, and the person is transported to a hospital in a police car, and in handcuffs. EPC Statute Extract:
Seclusion. Seclusion, as the term is generally used, occurs during hospitalization when a patient’s actions have escalated to the point that staff feel seclusion is the only alternative.

This is graphically represented in Figure 1 Coercion and Trauma

Coercion is described in different words in the summary of SAMHSA's 2001 Involuntary Treatment Meeting.

Involuntary commitment is the most frequently mentioned example of coercion in mental health practice. However, consumers may experience coercion in many other situations, such as:

seclusion,

restraints,

involuntary medication,

outpatient commitment

persuasion by family members, friends, or practitioners to enter the hospital,

inducements if one agrees to enter the hospital,

threats of loss of services or other supports (e.g., housing, income) by family members, friends, or practitioners unless one enters the hospital,

pressure to give informed consent without viable alternatives,

highly assertive community case management,

lack of alternatives to psychopharmacological treatment, and

being told that one has a mental illness and should give up hopes of being employed or fulfilling other major life roles.

Our challenge is to reduce trauma caused by that coercion. Whenever possible, trauma inducing events should be eliminated. When not possible, they should be implemented so as to minimize the trauma.

There are three areas of intervention.

Inpatient Commitment process including emergency situations.
Outpatient Commitments
Seclusion and Restraint (generally considered together in terms of interventions for reduction.)

For use in discussion, an un-official copy of the Nebraska Mental Health Commitment Act is available. This is annotated and reformatted to hopefully ease reading.

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DRAFT DOCUMENT