Protection & Advocacy Systems News
http://www.protectionandadvocacy.com/PANewsWin99.htm
Involuntary Outpatient Commitment:
If It Isn't Voluntary....
Maybe It Isn't Treatment
by Elaine Sutton Mbionwu
Director of Management Services
Imagine that you are sitting home watching television with your family. You hear a
knock at your door and think it is odd that someone is knocking this late at night.
You answer the door and it's a police officer coming to take you to a psychiatric
hospital. You have not hurt anyone. Your family is safe and happy. The only "crime"
you committed was that you did not want to continue to live with the side effects of
Lithium and you chose to stop taking the drug prescribed for your bi-polar disorder.
Does this sound incredulous? Hardly. Situations like this are happening nationwide and
they are happening every day. Not only that, these numbers will continue to rise as
states increase efforts to force people with mental illness to be committed to
institutions against their will and/or force them to adhere to a prescribed treatment
plan.
Several high-profile media cases about crimes committed by people with mental illness
are feeding into a stereotype that they are dangerous to the community. Actually,
according to a recent study, the prevalence of violence among people discharged from a
psychiatric hospital who do not have symptoms of substance abuse is about the same as
the prevalence of violence among other people living in their communities who do not
have symptoms of substance abuse.(1)
People with mental illness who live in the community are capable of making informed
treatment decisions. In 1998, officials at Bellevue, a psychiatric hospital in New
York, traced people with mental illness who were being released into the community
after being at the institution. (2) There were two groups in this study: one group
consisted of people who were given a court order to receive a specific treatment plan
in their community, called outpatient commitment. If this treatment plan was not
followed, the police could enforce that person to adhere to the plan. The other group
did not have a court order and could choose their own treatment. The study found that,
"there is no indication that, overall, the court order for outpatient commitment
produces better outcomes for clients in the community than enhanced services alone."
Despite this research, more than 35 states currently have laws which permit the
government to order individuals with mental illness to comply with forced psychiatric
treatment while residing in the community. These court orders are known as
"Involuntary Outpatient Commitment" (IOC).
Involuntary Outpatient Commitment: Prescription or Persecution
IOC can provide either general guidelines for treatment regimens and conditions, or
place the individual in the care of a specific individual or facility that assumes
responsibility for a treatment plan. IOC can be enforced in three different ways and
they are: conditional release from inpatient hospitalization; commitment to an
outpatient program as a less restrictive setting for a person who meets inpatient
commitment criteria; and commitment to outpatient treatment based on less stringent
criteria than are required for inpatient commitment, sometimes called preventive
commitment.
The fear of forced treatment causes people with mental illness not to seek treatment
voluntarily. Forced treatment could include being involuntarily committed to a
psychiatric hospital; being required to take medications even though they may cause
side effects; or becoming subjected to electric shock treatment without proper consent.
A handful of high-profile cases has led to public support of IOC. This support has
resulted in IOC legislation becoming the quick-fix solution for making individuals
with mental illness submit to a psychiatric treatment regimen against their will in
order to put at ease the fears and anxiety of the "what if" and "this would not have
happened" conventions.
The Problems with Involuntary Outpatient Commitment
Singles out a class of individuals and mandates submission to forced psychiatric.
Forced treatment based upon mental diagnosis infringes upon the individual's civil
liberties.
Expansion of involuntary commitment laws to cover outpatient commitment is a direct
attack on and leads to the imposition of forced treatment on individuals who do not
present a danger to themselves or others.
Outpatient commitment interferes with a person's right to choice. People recover when
they have choice among alternative treatments and services, when they are empowered to
make their own decisions and take responsibility for their lives, and when they are
offered hope.
The ability for individuals with mental illness to exercise their right to refuse
treatment is non-existent in the confines of Involuntary Outpatient Commitment.
P&As: Advocacy Against IOC
Michigan - In 1995, the Michigan legislature was in the process of amending the Mental
Health Code. As was true in most states at that time, mental health providers in
Michigan imposed treatment plans on consumers that identified medications, therapies,
means of a control, etc. that the provider had available, whether or not the consumer
wanted the services. Non-compliant consumers were generally subjected to the Michigan
Forum of Out-Patient Commitment, alternative treatment orders, and could be whisked
back to hospital if they failed to conform to the terms of the treatment plan
developed by their provider.
Michigan Protection and Advocacy Services (MPAS) was successful in convincing the
Michigan Legislature to include a requirement for a "person centered" planning
process. Basically, this process requires that the treatment plan be developed in
partnership with the consumer, at a time and place convenient to the consumer and with
persons present of the consumer's choosing.
In 1997, MPAS began advocacy efforts to secure a grievance and appeal process for
consumers. These advocacy efforts were successful and the Michigan Department of
Community Health implemented effective October 1, 1998, a consumer grievance and
appeal process.
MPAS is continuing its strategy of focusing on expanding consumer choice and control.
MPAS is the lead advocacy agency developing a mental health advance directive statute.
A key component of MPAS'sadvocacy strategy includes consumer involvement in the
development of the mental health advance directive to make sure that the statute meets
their needs and is consumer friendly.
New York - On March 3, 1999, State Attorney General Eliot Spitzer proposed legislation
authorizing people with mental illness who stop taking their medications to be taken
to court by people concerned about their condition. New York's Commission on Quality
of Care for the Mentally Disabled (New York P&A) advocated for the right of
individuals with mental illness by testifying at legislative hearings, conducting
public forums, and educating the public about the truth concerning individuals with
mental illness and their propensity for violence. On November 1, 1999, New York's IOC
law was enacted and the New York P&A is keeping a close watch on cases resulting from
the enactment of this law.
Nevada - In response to its state's move to enact IOC laws, the Nevada Disability
Advocacy and Law Center (NV P&A) compiled an extensive "critical study" report
outlining the negative impact IOC laws will have on the individual with mental
illness. (3)
In the Critical Study, the Nevada P&A raised several key issues to consider when
looking at the enactment of IOC laws. These issues include: substantive due process,
right to refuse treatment; presumption of competence to make treatment decisions;
availability of treatment; and the right to treatment. The issues of availability of
treatment and the right to treatment should be reviewed carefully because the lack
thereof can mean an extended stay in psychiatric facilities even though they may not
meet civil commitment criteria until such services are made available.
Alternatives to Forced Treatment
Offer an adequate variety of dignified and humane treatment choices: services, which
people want, services that meet their needs, and services that keep the dignity of
individual persons.
Provide sufficient funding with access to services.
Provide adequate crisis prevention and crisis management services, including peer-run
programs for hospital diversion and respite, peer-operated drop-in centers.
For the homeless community, provide safe, decent, and affordable housing options along
with access to an array of services designed to fit individual needs.
Assist people in preparing and filing advance directives to take effect in the event
of a crisis.
Patient Protections
Court ordered treatment, of course, presupposes that the required treatment is, in
fact, available. But, what happens in the event that such mandated services are not
available? Does not the status of outpatient commitment create a corresponding right
to receive adequate treatment?
At the least two states with outpatient commitment statutes, Georgia and North
Carolina, guarantee the right to treatment. Abuses occur, however, when the services
mandated by the court are not available. Under the Georgia statute, if services are
unavailable, an individual is held in an institution pending a hearing even though
such person does not meet the criteria for civil commitment.
The North Carolina statute, by contrast, forbids forcible detainment while a person
awaits the availability of court mandated services and places the burden upon the
examining psychiatrist or psychologist to identify the proposed treating center and to
ensure that an appointment is made for the client at such treating center. (4)
Unfortunately, the provisions of the North Carolina statute are often ignored, and
instead, most persons on preventive commitments are hospitalized prior to their
hearings. (5)
Resources need to be invested to create a full continuum of community based
non-coercive treatment services that will keep people from falling through the cracks.
This includes voluntary community hospital inpatient services, day treatment,
intensive case management including assertive outreach, medication management,
outpatient therapies, rehabilitative services, vocational and housing support, and
other necessary supportive services. All of these services need to be available in all
communities. The inadequate patchwork of services that currently exists in most
communities is a symptom of how seriously mentally ill people are neglected and is a
bigger problem than can be solved by IOC.
The bottom-line is that there is no quick or easy fix to our country's longstanding
neglect of people with serious mental illness. Only the long unfinished business of
committing adequate political will and resources to create comprehensive non-coercive
systems of care will solve the problem.
Peoplehood does not exist in varying degrees. Therefore, the rights of
decision-making, autonomy, and human dignity must be respected and regarded as sacred
at all times and void of society's definition of who is afforded personhood.
Involuntary Outpatient Commitment - Did You Know?
Outpatient commitment is a mechanism whereby a person can be forced to take a course
of treatment as an outpatient with the threat of inpatient commitment if he/she does
not comply.
Outpatient commitment is not effective. The recently-released results of a three-year
pilot study of outpatient commitment at Bellevue Hospital show no difference in
outcomes between a group of people who were subjected to outpatient commitment and a
control group who received voluntary services.
Research indicates that in a given year, about five million American adults experience
severe mental illness such as schizophrenia, bipolar disorder, or major depression.
In that same year, an estimated 60% receive outpatient mental healthcare, either
through the specialty mental health sector or the general medical system. About 17%
receive inpatient care.
Put another way, of those adults with severe mental illness, nearly half receive no
community mental health services of any kind. Of those that do receive care, many
receive services that are inadequate or inappropriate.
While popular belief has it that individuals with mental illnesses are more likely to
be violent than the general population, hard research does not support this view.
In a recent MacArthur Foundation study assessing the "violence risk" posed by persons
with mental illnesses compared to others, researchers gathered data on the behavior of
adults who had been discharged from psychiatric hospitals. They found that the
prevalence of violence among people who had been discharged from a hospital and who
did not have systems of substance abuse was about the same as the prevalence of
violence among other people living in their communities who did not have symptoms of
substance abuse.
Currently, all states have some form of civil commitment procedure, which provides for
a person to be hospitalized against his/her will at the determination of a civil
magistrate after a hearing if the person is judged to be an immanent danger to himself
and/or others. Some states add a third criterion of being unable to substantially care
for oneself in basic skills (feeding oneself, dressing, etc.).
Coercion is bad for people's mental health. Research shows that people subjected to
forced treatment are at increased risk for drug dependence, disabling side effects of
medication, and suicide. It can result in damage to self-esteem and motivation for
recovery and the re-triggering of problems associated with past violence and abuse.
Involuntary Outpatient Commitment Links
http://www.madnation.org/news/IOC/
http://www.MindFreedom.org/
http://www.modmh.state.mo.us/cps/civil/cd_outpatient.htm
http://www.cqc.state.ny.us/invtreat.htm
http://www.legislature.state.al.us/CodeofAlabama/1975/22-52-10.3.html
http://www.peer-resource.org/announcement.html
http://aesir.damerica.net/~mhcc/
http://www.bazelon.org/welcome.html
http://pages.whowhere.com/community/camhpra2/LPSinfo.html
http://www.expatient.org/themacarthurcoercion.htm
http://www.tim1.demon.co.uk/News/mental.html
http://www.psych.org/pnews/98-09-04/opd.html
These links are provided as a public service only. NAPAS does not review the material
on these sites on a regular basis, and does not verify any of the information they
contain. Nor do we mean anything by the omission of a site. If we have overlooked an
important site, please let us know so our list can be as complete as possible.
1. 0The MacArthur Risk Assessment Study, Executive Study, September 1999.
2. 0Final Report, Research Study of the New York City Involuntary Outpatient
Commitment Pilot Program, submitted by Policy Research Associates, Inc. Delmar, New
York. December 4, 1998.
3. 0Why Involuntary Outpatient Commitment Won't Work for Nevada: A Critical Study
4. 0N.C. Gen. Stat. Sec. 122C-263(d)(1985)
5. 0Stefan at 297, ftnt. 23, citing Hiday and Scheid-Cpook, "The North Carolina
Experience in OutpatientCommitment: A Critical Appraisal," presented to the
International Congress of Law and Psychiatry, (June 1986), p. 7. [Attachment 6].
*** NOTICE: In accordance with Title 17 U.S.C. Section 107, this material is
distributed without profit to those who have expressed a prior interest in receiving
the included information for research and educational purposes. Feel free to
distribute widely but PLEASE acknowledge the source. ***
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