Inpatient and Outpatient Treatment

The presentation from Mark Heyrman: "Why the Legal Standard for Involuntary Commitment to Mental Hospitals Doesn't Matter" is worth an hour of your time to listen to a very short but comprehensive history of involuntary commitment laws in the United States since the 1950's. Mark Heyrman is Clinical Professor of Law at the University of Chicago Law School and his talk was recorded on November 6, 2007 as part of the Chicago's Best Ideas Series.

Unfortunately though, he limits his talk to inpatient involuntary commitment treatment in hospitals and the difficulties faced by hospitals, both state and private, due to cost of treatment for those with a severe mental illness, as well as the reduction in the availability of psychiatric hospital beds, which have decreased from 55,000 in 1952 to approximately 1,400 now (or a reduction of approximately 95% in all 50 states). He does not mention the positive effects that assisted outpatient treatment (AOT) laws, such as the outcomes from New York's Kendra's Law. And obviously, since it had not yet been released at the time of his talk, he did not refer to the outcomes from the Treatment Advocacy Center's report, "The Shortage of Public Hospital Beds for Mentally Ill Persons."

I do not agree with all of Prof. Heyman's solutions because he does not mention the effects of lack of insight or anosognosia for those who receive (or I should say do not request or accept) mental health services outside of a hospital. His suggestion that increased intensive services in the community alone will solve the problems that the reduction of beds available for those with a severe mental illness has caused does not address the difficulty of providing services to individuals who do not think they have an illness, due to lack of insight.

One of the most important experts on anosognosia, Dr. Xavior Amador, provides a method called LEAP (which stands for listen, empathize, agree, and partner) in his book, "I Am Not Sick, I Don't Need Help!" However, Dr. Amador has also stated and given me permission to post on my blog site that, "AOT is a vital tool that we need to help people who have anosognosia, or lack of insight, for mental illness."

Only a very small minority of people with a severe mental illness and lack of insight need this AOT "tool" that provides court-ordered assisted outpatient treatment, but they are often the very individuals whose lives are devastated when treatment isn't provided. Sensible treatment laws, like NY's Kendra's Law, and PA's proposed AOT law, SB 226, will ensure that those individuals are given the compassionate, timely treatment they deserve.

Avoiding Victimization

I started advocated several years ago for changes to the Mental Health Procedures Act in our state that currently requires someone to be a danger to self or others before treatment is provided. Having experienced the heartache and tragedy of watching my family member go through numerous crisis situations followed by involuntary hospitalizations, I knew something had to change.

From the perspective of law enforcement, who often become involved when someone with a mental illness is in crisis, Dr. Laurence Miller has written an article that appeared on PoliceOne.Com news on May 12, 2008, P1 Exclusive Series: Dealing with mentally ill citizens on patrol.

The part that hit home for me and my main reason for my assisted outpatient treatment (AOT) advocacy efforts is the last sentence in the first paragraph under "Law enforcement response to the mentally ill," which states "However, the mentally ill are far more often the victims of crime than the perpetrators, and are three times as likely to be crime victims as ordinary citizens."

I think that people who have symptoms of severe mental illness and are not able to remain in treatment because they lack the insight to understand the need to take prescribed medications fall into the category of being "three times as likely to be crime victims." Helping someone remain in treatment, even if that requires court ordered assisted outpatient treatment, can help individuals avoid dangerous situations that can lead to victimization.

Involuntary commitment laws based on need for help

I read an article today that appeared in the BN Village, Mentally ill man dies a lonely death on L.A.'s streets . Another very sad, tragic, preventable event occurred in California because someone, Troy Green, who was in desperate need of treatment for his mental illness, did not receive help.

As stated in the article, "Across the country, Los Angeles County sheriff's homicide Det. Robert Harris was also not surprised when he learned the details of his newest case. He said he has seen similar cases again and again: mentally ill people, adrift in gang-populated neighborhoods, falling victim to homicide."

A friend of mine has been trying desperately to keep her daughter safe and able to receive consistent treatment. But, each time her daughter is released from a short stay in a hospital (and one time from a jail), her daughter wanders off and puts herself in a precarious situation that could potentially cause her harm. My friend doesn't want to see her daughter, who has a mental illness and wanders off and sleeps in parks at night, become one of the homeless statistics. But the mental health system only responds when she is a "clear and present danger to herself or someone else." A history of an individuals repeated hospitalizations and/or incarcerations is not considered if it is beyond the previous 30 days for an involuntary commitment.

The next time you see someone who is living on the streets, remember that they may have had a family that tried to get them help but that our mental health system didn't provide that assistance, because, by our outdated treatment laws, they weren't required to help.

Troy Green's sister, Lillian Green, "condemns a system that she said left her with few options to keep her brother safe." She further states, "she understands involuntary commitment laws. But, she says, "It shouldn't be that way. It should be based on whether they need help."

We need to change our commitment laws in all of our states to ones that provide timely help for those with severe mental illnesses who are not able to ask for that help themselves. A decent society would do no less.

Idaho passes important bill

As recently posted on the Treatment Advocacy Center's web site, Idaho has passed legislation that will help those with a severe mental illness who are often most vulnerable. The law will go into effect in July 2008.

I take heart and encouragement from knowing that common-sense approaches to helping those with severe mental illness who lack the insight to seek and remain in treatment do exist, and, that through education and advocacy, states such as Pennsylvania that require "clear and present danger to self or others" can also change their outdated laws.

I know that my friend whose daughter has been hospitalized four times and incarcerated once over the last six months hopes that we will soon have such a supportive, timely law in this state. Families who need to wait for their loved ones to receive consistent, sustained inpatient and/or outpatient treatment for their loves ones worry that their family members will not survive the constant months of cycling in and out between crisis situations and then hospitals and/or jails. I think of this form of mental health services as following the Russian roulette model of treatment. If you're lucky, your loved one will survive this trial period that is used to prove that someone is really, truly, undeniably in need of sustained treatment.

My friend's daughter was recently missing (again) and thankfully was found two days ago by a caring police officer who observed that she was in need of some help. The officer kindly took the time to take her to a hospital and was able to ensure that she could receive the treatment she needed through an involuntary commitment. Hopefully, the scary game of Russian roulette has ended and my friend's daughter now qualifies for sustained intervention.

SB 226, which would have allowed my friend's daughter the opportunity to access timely sustained assisted outpatient treatment after her second hospitalization or time spent in jail, could have helped to cut her time spent in hospitals and jails over the last six months in half.

If Idaho can take this common sense approach to treatment, certainly we can do the same in Pennsylvania.

Importance of inpatient and outpatient services

As Virginia puts into place the mental health bills that were recently passed, questions continue to arise as to the effects of more inpatient hospitalizations due to a change in their commitment criteria that now allows that there "exists a substantial likelihood” a person might cause serious physical harm to themselves or others as a result of mental illness for an involuntary commitment to be issued. However, there was no increase for the funds for state hospitals.

Meanwhile, their laws affecting outpatient treatment weren't raised to the standards of Kendra's Law, as their proposed SB 177 would have accomplished and that assisted outpatient treatment (AOT) model has outcomes that include a reduction in hospitalizations and incarcerations.

As stated by Robert Johnson, executive director of the Region 10 Community Service Board in Charlottesville in the article Number Crunch in The News Virginian, "“There really hasn’t been an increase [in funds for state hospitals] to meet our needs,” Johnson said. “And that’s because of a policy that [patients] should be integrated back into the community as soon as possible. And it’s a great policy. The problem is, when you do need a bed, it may not be there anymore.”

Reliving the experience

I've been in touch with a new friend who is going through a very similar experience that I had when my daughter's mental illness included a lack of insight that prescribed medications could help her. Because of non-compliance with treatment, she cycled in and out of hospitals, each time becoming more symptomatic, and endangering her life as she wandered off at all times of the day and night. Eventually, after reaching the required level of "clear and present danger to self or others" required by law, she would be hospitalized through an involuntary commitment.

My friend's daughter's journey has also included a month and a half period spent in jail, because while off medications and not thinking too clearly, she attempted to rob a store. This woman is not a criminal and, she had never tried to do anything like that before. Eventually, charges were dropped, after my friend had posted bail. Even the authorities understood that this woman was not well and was acting irrationally. Untreated mental illness does unfortunately, lead some people to listen to voices in their head and/or not listen to the common sense instincts that would have prevented her from attempting to break the law.

My heart truly breaks for my friend and her son who are trying to keep this daughter/sister safe and find a way to help her understand the need to reach out for treatment that has proven effective in the past or to convince the mental health system that she needs very intensive services. Until then, all I can do is be a friend, a sounding board, offer some advice on how to approach the mental health system that no longer seems to believe in long-term hospitalizations or intensive assisted outpatient services and who are not legally obliged to require someone to stay in treatment unless they are a "clear and present danger to themselves or others."

My friend's daughter's situation one more reason why I advocate for changes to our Mental Health Procedures Act in Pennsylvania through the proposed assisted outpatient treatment law, SB 226. Although the majority of people with a mental illness can and do reach out for treatment, this small minority of people with a severe mental illness and lack of insight need a compassionate law that will help them and require intensive mental health services of those whose jobs it is provide treatment.

With the support of other advocates, including this mother, we will hopefully see a better mental health system in place.

The trouble with our mental health system

I just posted a comment on the blog site, The Trouble with Spikol, regarding an article, Leave Britney Alone, that she had posted on February 19th and which I had also referenced on my post of February 13th, Understanding Mental Illness.

My comment to her post:

I've been on the phone this morning with a friend whose daughter was incarcerated for attempting to rob a drug store and who, after spending over a month in jail, was just cleared last week of the charges because they realized that she did so while she was not receiving treatment for her mental illness. Her mother had paid $440 to get her out of jail just barely a month ago, (jails and prisons are now the places where many people with a severe mental illness end up instead of psychiatric hospitals). After bringing her daughter home, she wandered off, listening to the voices in her head that told her to leave, and was found walking in Philadelphia with no shoes on her feet on a very cold, rainy day in January by a good Samaritan who took her took a hospital. Her daughter was given treatment through a 303 involuntary commitment which should have been for 20 days but lasted for 2 weeks.

Back home since this past Monday, she still leaves her home and walks away (she does not drive) at all times of the day and night. Her mom, brother, and neighbors try to take turns watching her, trying to keep her safe on these cold, wintry snowy days. In the past few months, she has been found wandering and has slept in parks and was once found in the parking lot of the Philadelphia Zoo, having taken an overdose of over-the-counter drugs (they did hospitalize her then because she was a "clear and present danger" as required by our current law).

But the voices continue to tell her to leave, and this morning she wandered off again. Her mom called 911. The police picked her up and the mom told him that her daughter was still technically on a commitment order to be in treatment (which should have been the 20 days commitment in a hospital). But, she was released early and, in case you're not aware, that commitment order means nothing in this state once you're released. In theory it should, but it doesn't.

So, this mom and son of this very ill woman who desperately needs treatment just took her to an emergency room to see if they would involuntarily commit her this daughter/sister again, because they are concerned for her health and safety and for want could happen the next time she wanders off without medications or an understanding of the need to seek shelter on a freezing day or night. The mom just called me to say that the crisis center would not admit her because she doesn't qualify under our state’s "clear and present danger" criteria requirement.

So, for anyone who believes that someone with a severe mental illness who lacks the insight to remain in treatment and who constantly put themselves in precarious situations, who does something while not thinking clearly and ends up in jail, who is found unconscious in a parking lot or walking around the city without shoes on a cold, wintry day, please explain to me why you wouldn't want to help someone so vulnerable and ensure that she receives shelter and treatment in a hospital.

No, this woman does not want to be in a hospital, she says that she needs to listen to the voices in her head (these are audio hallucinations that are a part of the psychotic symptoms of some severe mental illnesses). But as a caring, humane society, shouldn't we be helping her in a time of need when she doesn't know better and is making decisions that put her very life in jeopardy? Someone, please explain why withholding treatment is the right thing to do.

Yes, our current laws say that is the right thing to do, do you?

What does it take

It is hard to understand just what it will take before states with too stringent criteria treatment laws, that require an imminent or clear and present danger before treatment is provided, will come to understand the need for timely treatment for individuals with severe mental illnesses who lack the insight to seek and remain in treatment. What happened at Virgina Tech should have opened the eyes of legislators to the need for an effective assisted outpatient treatment (AOT) law, but they failed to act on a proposed bill that could have put an effective law in place.

In an editorial in the Washington Post, After Virginia Tech, the author expressed regret that they didn't really address what needed to be changed, "Other states have adopted more flexible standards under which people can be detained who are likely to become dangerous if not treated, or whose condition is rapidly deteriorating, or who are incapable of making rational decisions about their treatment. The effect of those reforms is to provide treatment to people before they are in extreme crisis -- in other words, before it may be too late."

Virginia's proposed SB 177, as well as Pennsylvania's proposed SB 226, would require the type of supportive services that would help someone avoid extreme crisis and which also helps to reduce hospitalizations, homelessness, and incarcerations.

I look forward to the day when legislators in every state understand the need for sensible, timely AOT laws

Understanding mental illness

Sometimes you read or hear a story about someone who really understands the struggles that individuals with a mental illness and their families encounter and it touches your heart in such a way that it brings tears to your eyes.

The reporter who wrote the article in the Los Angeles Times, Leave Britney alone, had that effect on me this morning.

I also have a family member who was diagnosed with schizo-affective disorder and she is the reason that I advocate for changes to our treatment laws. Witnessing someone you love go through the deterioration caused by untreated mental illness when they lack the insight to receive treatment, while waiting for them to reach a level of dangerousness required by law, is one of the most heartbreaking experiences that you can imagine.

I was recently contacted by CNN asking what it was like to have to seek involuntary commitment orders for my daughter. They then asked if my daughter would appear on TV for an interview, talking about her experiences dealing with her illness. At first she was willing, thankfully she now has the insight to remain in treatment, but after we talked it over, we declined. A big part of the reason was that I didn't want her to appear on their news show because I didn't want her to become a part of the circus that the media has made out of Britney Spears experience.

Although I think that station would have handled the topic of mental illness with dignity, I don't know what other media sources might have picked up on it and I certainly wouldn't want the person who I admire and respect for her courage in dealing with her illness to be exposed to any humilation as some media sources have done to that entertainer and her family. My sympathy goes to all of them.

Mental illness is a biological disease that should be treated and discussed with the utmost respect and compassion for those whose lives are affected by it. The timely treatment that assisted outpatient treatment laws provide should be given to all of those who lack the insight to seek their own treatment.

Involuntary commitment - helpful in times of crisis

Treatment for mental illness sometimes does require an involuntary commitment when someone lacks the insight to seek treatment on their own which can then lead to times of crisis. As posted in an article on Pantagraph.com, "In Illinois, a new law taking effect this summer could make it easier for people to obtain mental health treatment before they reach such a crisis level."

In Pennsylvania, Senate Bill 226 could help to prevent crisis situations from occurring at all, since it is an assisted outpatient treatment (AOT) law, modeled after Kendra's Law, that has proven results that show a reduction in hospitalizations, homelessness and incarcerations.

Timely, compassionate treatment can make the difference between someone suffering needlessly and finding themselves in dangerous situations that could have been avoided and receiving treatment that allows them to return to their usual routines.

How unkind and unfair it is to withhold the treatments that work - as a caring society, we should do better than that.

Virginia reviews involuntary commitment standard

Virginia's House of Delegates subcommittee has begun their review of the standard used for involuntary commitments for individuals with a mental illness who do not voluntarily seek treatment. VA's commitment law currently requires an imminent danger to self or others and the proposed legislation, House Bill 559, would change that to ‘There is a substantial likelihood that, as a result of that mental illness, a person will, in the near future, cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting or threatening such harm, or any other relevant information,’”

Just as in Pennsylvania, where our clear and present danger criteria and inability to include a history of prior hospitalizations when determining the need for treatment, Virginia's overly strict criteria often stands in the way of timely treatment that can help prevent the type of dangerous situations that both of our states' laws now require before someone is provided treatment.

In an article from Virginia's The Daily Progress, Mental health bill vetted by panel: Proposal would ease involuntary commitment standard, by Bob Gibson, January 12, 2008, Alex R. Gulotta, executive director of the Charlottesville-based Legal Aid Justice Center, stated “If we had the time and money, we would create more services at the front end” and prevent people from getting worse and needing involuntary commitments."

Providing more services alone does not identify what is at the core of the problem for those with a severe mental illness and a lack of insight (a.k.a. anosognosia) to seek treatment. If someone does not realize that they need support because they are experiencing the symptoms of a mental illness that could be helped with treatment, they will not ask for treatment, either before they are "getting worse" or when they are in dire need of immediate help, whether or not services are available.

In my own situation and from the many families I have spoken with, services were available for their family member: club houses, day programs, group therapy during hospitalizations and mental health professionals were also available: psychiatrists, therapists, and case managers. The only thing missing was a law that would require the person in need of help for the symptoms of their illness to accept the prescribed treatment from the mental health professionals who had evaluated their needs for medication, therapy, and services.

Laws such as PA's proposed Senate Bill 226 are court-ordered assisted outpatient treatment (AOT) laws that provide the services and treatments that an individual with a severe mental illness may need for an initial period of just 6 months, followed by a review and, if required, an additional year. The law would also require the designated provider to be responsible for providing the support and follow-up of services the individual may need. This type of timely, consistent support has been proven to be effective, as the outcomes from NY's Kendra's Law show so clearly.

Hopefully, over time, the results of effective AOT laws will lead other states around the country to use that model so that individuals with a severe mental illness and lack of insight to seek support on their own will have the benefit of timely, compassionate treatment.

AOT - a compassionate outreach

I am advocating for changes to our treatment laws in Pennsylvania for those with a severe mental illness and lack of insight into the need to seek or remain in treatment. Although many advocate for changes to treatment laws due to violent incidents that can occur with untreated mental illness and those stories are the ones that we most often see in the media, that is not what brought me to advocate for changes in my state.

My main concern for my daughter when she stopped taking the medications that helped keep the voices under control was that when she wandered off at the suggestion of those voices, she would put herself in too dangerous a situation, and would be victimized. A friend of mine whose daughter wandered off when not taking medications ended up in jail, with a charge of robbery, because she tried to get money from a drug store, even though she had a bank account that she could have accessed. She wasn't thinking clearly and she shouldn't be incarcerated now in order to finally receive the treatment she needed but lacked the insight to request.

Vermont is another state looking into changes for their treatment laws. An article in the Times Argus, "Involuntary medication acts to divide" simplifies the delay of taking medications by stating that people would be eligible for voluntary commitments simply because they don't "comply with a doctor's treatment plan within a week."

Assisted outpatient treatment (AOT) laws such as Kendra's Law in New York, (which is also the law that PA's proposed SB 226 is modeled after) have much more stringent criteria before someone would be required to remain in treatment, including a history of hospitalizations or incarcerations.

AOT laws are compassionate outreach programs designed to help someone regain the ability to take control of their own treatments. Without timely intervention, then the chances of homelessness, incarcerations, victiminizations, and yes, sometimes violence are increased significantly.

Preventive, timely treatment for those with mental illness and lack of insight is just common sense and shouldn't be a divisive issue.