SB 686 (2021 Session)
OREGON LEGISLATIVE ASSEMBLY--2021 Regular Session Senate Bill 686
Sponsored by Senator FREDERICK (at
The following summary is not prepared by the sponsors of the measure and is not a part of the body thereof subject to consideration by the Legislative Assembly.
It is an editor’s brief statement of the essential features of the measure as introduced.
Establishes right to receive inpatient psychiatric care in person and on-site. Requires hospital,state hospital and secure intensive community inpatient facility to inform patients or residents of right to in-person and on-site care and to offer patient or resident choice to receive psychiatric care in person and on-site.
A BILL FOR AN ACT
Relating to mental health care.Be It Enacted by the People of the State of Oregon:
(1) An individual receiving inpatient psychiatric care described in subsection
(2) of this section in a hospital licensed under ORS (Oregon State Statute) 441.015, a state hospital or a secure intensive community inpatient facility has the right to have the psychiatric care provided to the individual in person and on-site and to refuse to receive psychiatric care through electronic means from a psychiatrist or other mental health care provider who is not on the premises.
(2) A hospital licensed under ORS (Oregon State Statute) 441.015, a state hospital and a secure intensive community inpatient facility shall inform an individual, verbally and in writing, of the individual’s rights under subsection
(1) of this section and offer the individual the choice to receive in-person and on-site care from a psychiatrist or other mental health care provider for:
(a) The initial evaluation and ongoing treatment;
(b) Prescribing medications; and
(c) Conducting assessments or evaluations under ORS (Oregon State Statute) 137.464 or ORS 161.315, in civil commitment proceedings or in any other circumstances requiring the evaluation of the individual’s mental competence.
Click to see the bill on the State of Oregon website here.
Patient choice heals the entire community. Everything about us with us.
Bill of Choice
In Oregon, in some inpatient hospitals, inpatient patients are only allowed to be treated by psychiatrists and prescribers online through a video screen. Theses sessions are usually held in small rooms, and the patient has no privacy with the psychiatrist because there is a hospital assistant (sometimes a new stranger to the patient) sitting there to guard the telehealth equipment. Many of these doctors are not even located in Oregon.
This bill requires that the hospitals must provide the patient choice for quality in-person onsite psychiatric care and not only inpatient care done on a video screen, or telehealth, if that is a method the inpatients units use.
This bill states that if hospitals offer inpatient telehealth psychiatry, the hospitals must offer patients choice for telehealth care or in-person psychiatric care verbally and in written form.
We would like your stories of inpatient telehealth care. We believe you. Writing stories in Spanish is fine. You deserve choice. You deserve the best care. You deserve healing.
El resumen siguiente no fue preparado por los patrocinadores de la medida y no es parte del cuerpo sujeto a consideración por la Asamblea Legislativa. Es una breve declaración del editor de las características esenciales de la medida como fue introducida.
Establece el derecho a recibir cuidado psiquiátrico con hospitalización e in situ. Requiere que hospitales, hospitales estatales, e instalaciones de hospitalización comunitaria intensivas seguras informen a pacientes o residentes del derecho al cuidado en persona e in situ, y ofrezcan a pacientes o residentes la opción de recibir cuidado psiquiátrico en persona e in situ.
PROYECTO DE LEY PARA UNA ACTA
Con relación al cuidado de salud mental.
Que Sea Promulgado por el Pueblo del Estado de Oregon:
SECCIÓN 1. (1) Un individuo recibiendo cuidado psiquiátrico hospitalizado como descrito en subsección
(2) de esta sección en un hospital licenciado bajo ORS 441.015, un hospital estatal, o
una instalación de hospitalización comunitaria intensiva segura tiene el derecho a recibir el cuidado psiquiátrico provisto
al individuo en persona e in situ y a negarse a recibir cuidado psiquiátrico mediante medios
electrónicos de un psiquiatra u otro proveedor de cuidado de salud mental que no esté en las premisas.
(2) Un hospital licenciado bajo ORS 441.015, un hospital estatal, o una instalación de hospitalización
comunitaria intensiva segura deberá informar a un individuo, verbalmente y por escrito, de los derechos
del individuo bajo la subsección (1) de esta sección y ofrecer al individuo la opción de recibir cuidado en persona e in situ de un psiquiatra u otro proveedor de cuidado para:
(a) La evaluación inicial y el tratamiento en curso;
(b) La prescripción de medicamentos; y
(c) La conducción de valoraciones o evaluaciones bajo ORS 137.464 o ORS 161.315, en procedimientos
de compromiso civil o en cualquier otra circunstancia requiriendo la evaluación de la competencia mental del individuo.
A recent article, published in Psychiatric Services in Advance, explores the use of digital technologies and how they can be misused and employed coercively in psychiatry. The author highlights steps that can be taken to reduce coercion and misuse of digital technologies in psychiatric settings.
The author, psychiatrist Nathaniel Morris of the University of California San Francisco, writes:
“Coercion is just one possible outcome among many, including loss of privacy, distress for patients and families, the transmission of stigmatizing information, and exacerbation of racial and socioeconomic disparities, related to digital technology use and misuse in psychiatry. At the same time, these technologies bring new opportunities for reconsidering and studying coercive practices to support the well-being of and respect for patients in psychiatric settings.“
While the use of digital technologies in psychiatry was already on the rise pre-pandemic, its use has dramatically increased throughout the COVID-19 pandemic. Although such technologies, including but not limited to telepsychiatry and mobile mental health apps, have been beneficial in that they have increased client access to mental healthcare and information, they bring with them a number of concerns regarding how they might infringe upon clients’ rights and be employed in coercive tactics.
Given that psychiatric clients are already at high risk for coercion, we must attend to how digital technologies may be used to further add to the problem.
Morris begins by addressing potential concerns associated with electronic medical record (EMR) flags, which can note high suicide or violence risk. The digitization of client records allows mental health professionals to easily access clients’ information and gain awareness of potential risks or concerns, enabling them to adequately address and assist those who might have a history of suicidal ideation or attempts. Such flags about histories of violence can also enable clinicians to take necessary safety precautions.
However, while beneficial in some ways, flagging clients’ records could be used in the service of coercion. Morris highlights, for example, how the attention is drawn to clients’ risk for suicide or violence might lead to biased treatment, wherein the physician may solely focus on the client’s mental health while potentially ignoring a broader medical understanding of the client—which could result in them missing medical issues.
Increased attention to mental health concerns may also lead clinicians to pursue coercive interventions, such as involuntary psychiatric hospitalization, that may not be necessary or helpful to the client. Further, EMR flags could be used to deny clients access to treatment or pressure clients into treatment that is not congruent with their own preferences.
For example, at the Veteran’s Health Administration, clients flagged with histories of violence may be required to follow certain treatment conditions, like needing a police escort or to be screened by a metal detector before entering the facility. Critics of EMR flags have also noted that most flagged behaviors are verbal, with some suggesting that flags are a way to punish individuals who express concerns or complaints about their treatment.
Morris also draws attention to the use of surveillance cameras in psychiatric units. While the use of surveillance cameras on psychiatric units is often justified as being in the service of the safety of the clients, research evidence does not support this claim and, in fact, suggests that surveillance can contribute to psychological harm. Other concerns associated with video surveillance include: “privacy, consent, dignity, data protection, and potential exacerbation of psychiatric symptoms.”
In addition to concerns about privacy and clients’ dignity, video surveillance in psychiatric settings can be used coercively. Clinicians could use client behaviors that occurred on camera, when the client presumed no one else was present, against them in civil commitment hearings that could potentially keep clients institutionalized. Along similar lines, clients may be monitored covertly without their knowledge, which raises privacy concerns in addition to potentially causing ruptures in clients’ trust.
Moreover, although videoconferencing in psychiatric settings has been beneficial, especially during the COVID-19 pandemic—increasing access to care, allowing clients to connect with their loved ones, and facilitating legal proceedings—several concerns accompany this technology. Morris suggests that poor sound and video quality could potentially impact the client’s ability to be fully present for and understand civil commitment hearings, with clients typically already struggling to understand why they remain in the hospital following such hearings with or without the use of videoconferencing.
Additionally, clients in forensic settings struggling with mental health and/or substance addiction issues might not feel comfortable sharing personal or sensitive information in a videoconference with strangers or may not feel as if they have the same ability to access and confide in their legal counsel.
While video conferencing may allow family and friends to visit their loved ones in psychiatric settings, Morris also raises concerns that such access may lead to loved ones choosing tele-visitation over in-person visits. Televisitation may not allow for the same sense of connection as in-person visits, wherein loved ones are more clearly able to see the impact of involuntary hospitalization on those they care about, which allows them to better advocate for their institutionalized friends or family members.
Lastly, risk assessment tools, which allow clinicians to assess for the likelihood of things like suicide or violence, are discussed as potentially problematic and coercive. Although risk assessment tools have been employed in psychiatric settings prior to the use of digital technologies, digital technologies are transforming these tools.
Risk assessment algorithms have been employed to assess for suicide, violence, and other negative events. While accurate predictions of such adverse outcomes could be useful, the reality is that these tools are imperfect and not as accurate as they may appear.
Social media companies, like Facebook, have also developed suicide risk assessment algorithms to detect concerning social media posts—which raises significant ethical concerns and questions about how valid such algorithms are. The lack of accuracy of these algorithms has real-life implications for those involuntarily hospitalized, potentially on false grounds.
Not only may these algorithms be inaccurate, but they also might contribute to systemic inequalities of individuals belonging to marginalized racial, gender, socioeconomic, and other disenfranchised groups, such as children, who tend to be particularly at risk for coercion in psychiatric settings.
“In a recent example, researchers found racial bias in a widely used algorithm for stratifying patients’ health risks and targeting high-risk patients for additional care management. Because less money often is spent on Black patients than on White patients with similar needs, and the algorithm stratified risk on the basis of costs rather than illness, the algorithm perpetuated less attention to the health needs of Black patients.”
In addition, risk assessment tools also leave room open for interpretation. If clinicians are not properly trained or do not know how to interpret or use certain risk assessment tools, this could also contribute to the coercion of psychiatric clients.
Morris identifies steps that can be taken to reduce the abuse of digital technologies in psychiatric settings, such as disclosing the technologies being used in treatment to clients. He also suggests that clients be provided with the opportunity to “opt-out” of certain technologies when appropriate, providing the example of allowing clients to choose in-person rather than video observation when available.
Clients should also be given the ability to change or erase digital information, like requesting the removal of EMR flags or erasing video surveillance records. However, Morris suggests that while such requests will likely not, and in some instances, should not be granted, having formal procedures available could allow for open discussion between clients and clinicians about the purpose of flags and other surveillance measures.
Morris also advocates for further guidelines, training, and support for clinicians to know how to properly use and employ digital technologies and so they are aware of potential risks related to coercion so those can be avoided at all costs.
Morris concludes by pushing for a balanced approach to the use of digital technologies in psychiatric settings, one that is aware of the potential benefits and possibilities for such technologies, in addition to being aware of and avoiding misuse and abuse of these technologies.
Morris, N. P. (2021). Digital technologies and coercion in psychiatry. Psychiatric Services in Advance, 1-9. (Link)
Ashley Bobak is a PsyD student in Clinical-Community Psychology at Point Park University and has a Master’s degree in Counseling Psychology. She is interested in the intersections of philosophy, history, and psychology and is using this intersection as a lens to examine substance addiction. She hopes to develop and promote alternative approaches to conceptualizing and treating psychopathology that maintain and revere human dignity.
Choice heals, force does other things
May the healing be with you!