The least restrictive alternative in the postinstitutional era

Area of Science:

• Psychiatric care
• Mental health law
• Healthcare policy

Background:

• The legal principle of least restrictive alternative is applied to psychiatric patient treatment.
• Current application often equates 'least restrictive' with any setting other than a state hospital.
• This has led to an uncertain role for state hospitals and challenges in staffing.

Purpose of the Study:

• To critically evaluate the application of the least restrictive alternative in psychiatric care.
• To advocate for an expanded interpretation of the concept.
• To address the negative impact on state psychiatric institutions and patient care.

Main Methods:

• Analysis of the legal concept and its practical implementation in two large communities (Ohio and Massachusetts).
• Review of how treatment settings are used as the sole measure of restrictiveness.
• Examination of the consequences of this approach on patient needs and institutional roles.

Main Results:

• The application of the least restrictive alternative has been oversimplified, focusing solely on the treatment setting.
• Patient characteristics and individual needs are frequently overlooked.
• Program quality variations within different facility types are not adequately considered.

Conclusions:

• The current interpretation of the least restrictive alternative is inadequate and potentially harmful.
• An expanded view incorporating patient needs and characteristics is essential for effective treatment.
• State hospitals should not be automatically excluded from consideration for patient admission based solely on the 'least restrictive' principle.