1. The Least Restrictive Alternative – is it too Restrictive?
Presenters:
Judy Clisby
Marilyn Starr
Introduce myself and Maz – as community visitors and Maz as community member of the Darwin Panel

2. Presentation Outline
Background to the Least Restrictive Alternative (LRA)
Case Examples
Discussion
LRA is the lynchpin of mental health policy in Australia – but there’s no generalised interpretation of the term, and at times can be used as justification for what are arguable fairly restrictive practices even at times with the best intentions. We’re going to unpick that a little using case examples – in terms of what these practices may mean to the person who is receiving treatment.
We’re going to ask Krieg,s question – who decides the LRA – patient, Physician, board or court?
We’re also going to restrict the presentation to individual rather than policy considerations – it’s too broad for this half hour.

3. Origins of the LRA Perlin (2000)
The LRA found “constitutional life” in the USA in
Lessard v Schmidt The Wisconsin Federal Court held that even where dangerousness and mental illness are present, a person can be involuntarily hospitalised only as a last resort. A person could not be deprived of their liberty, if there were less drastic means of achieving the same goal (p1013).
The burden for exploring alternatives was placed on the person recommending the full time involuntary hospitalisation – these alternatives included family and other community supports available and what had been investigated, along with other less restrictive alternatives eg night hospital only, day hospital only, involuntary outpatient treatment…
This was the beginning of the development of the doctrine, there were court challenges on the Right to Receive Treatment, the Right to Refuse Treatment,. Perlin cites Keilitz as outlining factors to include the risks and benefits of treatment alternatives, consumer co-operation, restrictiveness of the medication and also to define restrictiveness in termes of the persons physical, social and biological liberties.
UN Principles for the Protection of People with Mental Illness and the Improvement of Mental Health Care – incorporate the LRA. Passed in 1991 and then adopted in Australia’s National Mental Health Policy and Plan. Is now incorporated into most Australian Mental Health Legislation. However, as we said before, its definition remains problematic.

4. LRA – A Definition
Least restrictive or intrusive treatment in the least restrictive environment
2 variables, environment and voluntariness
How do we define restrictive/intrusive treatment?

5. Hierarchy of Restrictiveness
Involuntary, Seclusion Restraint
Involuntary admission, secure ward
Involuntary admission, open ward
Voluntary admission, open ward
Involuntary treatment, community
Voluntary treatment, community

6. Case Examplars
There are times when consumers, who feel that they are unsafe, attend a mental health facility seeking a safe place to be. In this situation, a consumer may feel safer if they are involuntary patients in a locked facility, because in this situation they know they are unable to harm themselves..

7. Case Exemplars
Using the hierarchy outlined above, people in this situation would be seen as receiving the most restrictive care – that is, involuntary treatment in a locked ward.
From the consumer’s perspective being involuntary and in the locked ward is less restrictive because the consumer feels safe.

8. Case Examplar 2
There may be other occasions when the consumer’s status on the ward is ambiguous. The consumer may have been admitted as a voluntary patient, but knows that refusal of treatment or an attempt to leave the facility will in fact mean that their status will change to involuntary. They are voluntary, but they are de facto involuntary.
On these occasions, consumers may prefer to retain their involuntary status because this would mean at least that their status would be reviewed by a body such as the Mental Health Review Tribunal. Of course at the same time, even with the restrictions, the consumer may feel better about the admission because they are “voluntary”.

9. Case Examplar 2
Using the hierarchy outlined above, consumers who are involuntary, even in an open ward, would have been considered to have been at the highly restrictive end of the continuum. Service providers may argue that by admitting consumers as voluntary patients whenever possible, they are acting in accordance with the least restrictive alternative.
From the consumer’s perspective, involuntary status may in fact be preferable because it would mean access to Tribunal review and so would be, from their perspective, more restrictive. Other consumers may in fact find it less restrictive to be admitted voluntarily. The key variable in this example is consumer choice.

10. Case Examplar 3
Imagine a situation where there are severe side effects to the medication. The side effects may be impotence, or tiredness, or tremor, or restlessness to name just a few. Sometimes, the case manager may not understand the impact the side effects are having on the consumer’s life. Even if the treating team does know that the consumer is experiencing side effects to the medication, they may believe that the consumer must be treated involuntarily in the community because the consumer may be a danger to self or others when unwell.

11. Case Exemplar 3
Using the hierarchy with voluntariness and environment as two measures of restrictiveness, it would seem that in this example, the consumer is receiving a service that is less restrictive than either of the examples above, as treatment is being provided in the community, even though this is involuntary.
Yet the consumer may consider the treatment to be highly restrictive because the medication affects the ability to live a normal life. The consumer may also believe that concerns that are expressed about medication are not being heard.

12. Case examplars - conclusion
In all case examples, the consumer viewed the restrictivity of their experience in a different way from the hierarchy of restrictiveness. The determinants of restriction were different for consumers, and were far broader than environment and voluntariness. These examplars demonstrate that the most important determinants of restriction are consultation and choice.

13. Autonomy
The aim of mental health intervention is promotion of the autonomy of the individual.
The LRA is a mechanism for preserving autonomy.
For this reason, the hierarchy of restrictiveness must wherever possible respect the choices of the person receiving treatment.