Different Perspectives on Managing Patients on Conditional Release

Treatment Team Perspective

For treatment providers, challenges abound when working with patients on conditional release. Not only do almost all these patients have severe mental illness, many have treatment refractory illness that has warranted numerous medication trials or complex regimens to achieve stability. This patient description makes many psychiatric providers uneasy, but knowing that these individuals have often committed serious violent offenses when ill heightens anxiety further. Most of the patients are in residential placements with psychiatric rehabilitation programs for daytime structure. Some might have substance use services as well. The burden of coordinating care between the providers associated with these programs is a huge challenge. Coordination with the state monitoring agency is a necessary aspect of this care as well. This close collaboration is often welcomed. Despite the additional time needed, having the influence of the state monitoring group to ensure that a patient stays on medication is very useful. Despite years of inpatient treatment, many patients continue to lack insight and want to stop medications. Oversight from the monitoring agency reduces nonadherence, decompensation, and potential return to serious symptoms and dangerous behaviors.

One question that emerges from the perspective of the treatment providers is understanding the limits of the monitoring agency’s oversight. The fact that the patient is on state monitoring for conditional release must not hinder the relationship that needs to be established between the psychiatric provider and the patient, but realistically, the presence is felt. One notable example occurs in decisions about medication changes. Often, patients who are being monitored have had extensive hospital stays with fine-tuned medication regimens. Upon release, it is not uncommon for patients to make requests for medication changes now that they are living in the community. Sometimes these requests are driven by ongoing poor insight into their mental illness and the severity of symptoms that arise when the individual is acutely ill. There are other times when a patient makes an understandable request for a change because of the burden of the psychiatric regimen or its side effects. The community psychiatric provider must weigh the risk of decompensation of a high-risk patient with respecting the patient’s request and autonomy.

Looming in the background is the monitoring team that also plays a role when a regimen change is being considered. The monitoring team might have more extensive details about the course of treatment while in the hospital or strong opinions about the need for various medications. Their input can pose a dilemma for the psychiatric provider. Individuals under state monitoring after release for committing serious offenses when ill should have conditions that ensure that they adhere to treatment. But those conditions should have some reasonable limits that allow the patient and treatment provider to negotiate some aspects of care.

On the opposite end of the spectrum are occasions when the treatment team requests additional support from the monitoring team. It is not uncommon that patients remain marginally adherent to aspects of care to meet the conditions of their release, thus remaining stable, but have little commitment to the care that they are receiving. The community treatment provider might appreciate that dynamic yet, despite making attempts to intervene, is unable to improve the patient’s insight. In these instances, especially with impending termination of court-ordered monitoring, a treatment team might appeal to the monitoring group for an intervention, such as pursuing an extension of the monitoring. Even if such requests are in the best interest of the patient and society, this approach might be considered to violate the rights of the patient and undermine the treatment relationship. Such requests may also push the monitoring team beyond their role into a potentially unethical position that exceeds their duty.

Monitor Team Perspective

Maryland’s Community Forensic Aftercare Program has been in existence for over 40 years. Yet there is no specific statutory mandate that requires the health department to actively monitor individuals for whom the court has ordered a conditional release to the community. Instead, among other things, the law requires that the department must report alleged violations of conditional release to the court and the state’s attorney. After consideration, the court can continue, modify, revoke, or extend a conditional release.²

Although limited in scope, this mandate resulted in the establishment of a formal system to monitor this population and ensure compliance with statutory reporting obligations. All CFAP monitors are licensed social workers whose background involves working with individuals with chronic and persistent mental illness; forensic experience is preferred, but not required. Training and experience are desirable, as they inform a monitor’s perspective and approach to a task focused on an individual’s functioning and psychiatric stability.³ This background and expertise can create challenges for the monitors: they are both qualified and accustomed to serving as active members of a treatment team, yet their job description, strictly interpreted, seems to imply that they police a patient’s adherence to conditions. If implemented within this restricted framework, monitoring may only entail administrative duties, such as recording missed therapy sessions or documenting address changes for the purpose of reporting infractions.

Patients are frequently conditionally discharged following extended hospital stays marked by several medication regimens, episodes of both progress and recurrence, unpredictable behavior, and intervals of relative behavioral stability. Either because of the burden of their symptoms, limited insight, or omission of historical details, patients cannot be solely relied upon to communicate this information to community providers. Release monitors typically are familiar with or have access to this information. When a provider makes a change in treatment that, based on history, is likely to result in dangerous behavior, the monitor has a responsibility, as a clinician, to intervene. Some monitors are uncomfortable with this heightened degree of clinical responsibility; however, clinical expertise is inherent to the position and cannot be disregarded solely based on the monitoring role. This approach seems to approximate the judiciary’s expectations for oversight: mental health professionals are placed in this role to use their training and experience.

There are also times when the monitoring team advocates for therapeutic changes. Five years is the maximum length of time court-ordered conditions can remain in place without the state or health department petitioning for an extension.⁴ The decision to extend or terminate conditional release has significant implications for community safety and for the patient, as without the oversight of the court, a patient’s autonomy increases exponentially. As an individual nears the end of the period of conditional release, monitors are looking for evidence that the person is capable of independently and safely functioning. Factors such as insight into the person’s condition and need for treatment, psychiatric stability, independent living skills, stable employment, and decreasing levels of residential supervision are indications that court-ordered conditions are no longer needed to ensure that the person is not a danger to self or others.

To ensure that patients are progressing toward independence, monitors may recommend therapeutic advancement before it is proposed by providers. The monitoring team might have to encourage treatment providers to consider reduced levels of supervision, such as self-administration of medication and scheduling mental health appointments, or increased community involvement. Because of concerns about liability and the risk of relapse, treatment teams might hesitate to implement these changes, or there may simply be a lack of urgency. The monitoring team is then put in the position of recommending and, in some cases, insisting upon more assertive advancement despite this hesitancy. Realizing that conditional release is not endless and extensions are not indefinite, the goal of progress toward functionality without monitoring must always be kept in mind.

The schism between providers and monitors described above reflects differing duties. This basic concept fuels the disparate approaches of the two teams, despite their common goal of patient wellness and safety. The treatment team has an ultimate duty to the patient in ensuring the individual’s wellness; by extension, this protects society at large. In contrast, the monitoring team’s primary responsibility is to see that a patient adheres to the terms of the conditional release, thus fulfilling a duty to the judiciary that serves society. The challenge for each of these teams when working independently and collaboratively is constantly assessing these relationships to ensure that the best interest of the patient and society are being met at the same time. When both groups are aligned, patients maintain clinical stability, adhere to the conditions of their release, and make progress in their psychiatric recovery.

To make the collaboration between the teams work well, key components are required. First, it is crucial that all members of each team are clinicians who understand the various facets of patient care. The need to assess one’s role and how one might be too strict or expansive is best accomplished by clinicians who are trained to examine such treatment dynamics. Secondly, open communication ensures that all parties are on the same page and that patients receive the same message from the treatment and monitoring teams. Regularly scheduled collaborative meetings are needed. In addition, in between these meetings, teams must be responsive to one another for ad hoc discussion to address urgent matters. Each instance presents an opportunity for the teams to support one another. Finally, all must keep in mind that at times the questions are complex and, inevitably, opinions will differ. Using clinical skills to understand problems from different vantage points is highly useful and allows for more rapid resolution when disagreements arise.

Despite efforts at collaboration, it is certain that gaps will remain in our current model. To move the concept of conditional release toward a better coordinated and comprehensive system of care, all states should consider the implementation of Forensic Assertive Community Treatment (FACT) teams. FACT is a service delivery model intended for individuals with serious mental illness who are involved with the criminal justice system. FACT builds on the assertive community treatment (ACT) model, but unlike ACT, FACT is purposefully designed to prevent arrest and incarceration among people with severe mental illness who have histories of involvement with the criminal justice system. FACT teams should not only meet ACT fidelity but also utilize forensic liaisons to serve as a single point of contact when collaborating with criminal justice partners.⁵

Another, admittedly debatable, option to enhance monitoring of this group would be the utilization of assisted outpatient treatment (AOT) as an option for treatment after termination of conditional release.¹ If patients could be transitioned from higher intensity conditional release monitoring to AOT, trepidation about the possibility of relapse postconditional release might lessen. Regardless of the strategy, it is apparent that ongoing investment into optimizing care for this vulnerable but high-risk population is necessary.