Reform in Idaho Makes State’s Commitment Law Among the Nation’s Best

After sweeping through the legislature without the trace of a single nay vote, S.B. 1426 was signed into law by Governor Otter on April 1! The bill improves Idaho’s commitment process and standard and addresses some of the deficiencies in the current law.

S.B. 1426 provides assisted outpatient treatment as an option at all commitment hearings in the state. Assisted outpatient treatment is a less restrictive, less expensive treatment alternative for people who need intervention but do not require inpatient hospitalization.

The new law substantially broadens the definitions of “likely to injure himself or others,” and “gravely disabled,” which are now the eligibility criteria for court-ordered placement in both inpatient and outpatient treatment. The reform also allows courts the option of ordering individuals in crisis to receive outpatient treatment rather than releasing those in need of treatment into the community to await another crisis.
S.B. 1426 takes effect on July 1, 2008.

Sadly, Just Another Monday

Mount Holly, New Jersey – April 23, 2008

A Superior Court judge ruled yesterday that a man accused of smothering his mother to death in 2004 is not competent to stand trial because of his mental illness.

Two psychiatrists testified that Wiley M. Smith does not want to use an insanity defense because he would rather go to jail than stay in the psychiatric hospital. He also denies that he is mentally ill, the doctors said.

Both doctors, however, said Smith suffers from severe and persistent mental illness, specifically paranoid schizophrenia. However, with medication and other treatment he has made marked improvement during his time at the hospital, they said.

Seattle, Washington – April 23, 2008

A second man was arrested in the beating death of Noel Richard Lopez at a downtown construction site.

According to court filings, Lopez annoyed the arrested man's friends, so he and another man took Lopez to the construction site to "handle this problem and straighten him out." Investigators wrote that the pair knocked Lopez unconscious in a beating that lasted for hours.

Friends reported that Lopez was bipolar and was turned away when they sought help for him at two local hospitals.

Escondido, California – April 23, 2008

The North County Times reported that a mentally ill man who screamed "God bless America" and dived off a top bunk in a Vista jail cell has filed a $15 million lawsuit. The fall broke Henry Kodimer’s neck, leaving him quadriplegic. Kodimer’s attorney contends that various governmental authorities should have steered his client toward treatment, not jail.

Kodimer has suffered from paranoid schizophrenia for most of his life.

Déjà Vu All Over Again

In 1848 Dorothea Dix helped to usher in an important era of mental health reform all across America. Witnessing the inherent cruelty of warehousing people with severe mental illnesses in prisons and jails, Dix observed:

“Humanity requires that every insane person should receive the care appropriate to his condition…. Hardly second to this consideration is the civil and social obligation to consult and secure the public welfare: first in affording protection against the frequently manifested dangerous propensities of the insane; and second, by assuring seasonable and skillful remedial care, procuring their restoration to usefulness as citizens of the republic, and as members of the communities.”

Today, nearly one hundred and sixty years later, 2,000,000 Americans remain untreated for severe mental illness. With the mass deinstitutionalization of public hospitals, our streets and jails have become de facto asylums. A recent report by the Treatment Advocacy Center confirms that there is a shortage of at least 100,000 public psychiatric beds across our nation. In the meantime, over 10% of our prison population consists of people with severe mental illness, and nearly 300,000 people with severe mental illness live among the homeless.

How Painful Tragedy Can Result In More Treatment And Less Stigma

Not-for-profit organizations play a vital role in the policy process through research, advocacy, and political activities. However, the impetus for change is many times based on factors outside of advocates’ control.

Unfortunately, the impetus for change in mental health laws tends to occur in the wake of terrible tragedies. Such tragedies occur each day, many times because severe psychiatric disorders are left untreated.

The Treatment Advocacy Center educates legislators, members of the media, and the general public that the failure to treat individuals Incapacitated by severe mental illnesses is a major reason so many of them end up being victimized, homeless, and in jails. The media tends to seize upon extreme examples, which often leads to misconceptions and stereotypes. But, we continue to strive to point out that these headline-grabbing incidents are but extreme manifestations of a far broader and profound societal crisis and to hopefully create opportunities for positive changes in the policy, legislative and social arenas.

Not only can these changes provide treatment to those most in need of care before they become dangerous, but they can also simultaneously help to dispel the stigmas surrounding individuals with severe psychiatric disorders generally periodically created by those most at risk and in need or care.

Common Sense 101

On April 16, 2007, thirty-two people were killed at Virginia Tech by Seung-Hui Cho, a student whose mental illness and dangerous actions were known to university officials.

In the wake of this tragedy, the Department of Education has proposed new regulations to clarify when an educational institution may lawfully disclose a student’s medical information to parents or others. The new regulation reads in pertinent part:

An educational agency or institution may disclose personally identifiable information from an education record to appropriate parties including parents of an eligible student, in connection with an emergency if knowledge of the information is necessary to protect the health and safety of the student or other individuals. Family Education Rights and Privacy, 73 Fed. Reg. 57 (March. 24, 2008) p. 15601.

The new regulation does not change the conditions under which personal information may be disclosed. Rather, it merely aims to remove confusion about those conditions. Most notably, it seeks to help prevent tragedies such as occurred exactly a year ago at Virginia Tech.

In response to the Virginia Tech tragedy, the Secretary of Education investigated and found that many educators across the United States did not have a proper understanding of existing federal disclosure requirements. These educators generally believed that the existing disclosure restrictions imposed significantly greater limitations than they really did.

Besides clarifying the specific circumstance under which a disclosure to parents or others is lawfully permitted, the new regulation also provides safeguards for students to ensure that these disclosures are not made inappropriately. If a complaint is made about the particular circumstances surrounding the disclosure of a student’s personal information, the Department of Education is authorized to review these circumstances to verify that there was a rational basis for the institution’s action.

Some organizations have already expressed opposition to this proposed regulation. At least one organization has characterized this new regulation as heralding in a new hands-off approach that places at risk the confidentiality of student’s mental health information.

For some, it seems that the need to protect personal privacy always trumps the need to protect people from hurting themselves or others. However, it is high time that we apply common sense in balancing public safety and privacy concerns. The Department of Education should be commended for clarifying that medical information can be properly released in emergency situations in which a student with a mental illness is threatening harm to himself or others.

Severe Mental Illness, Homelessness & Choice (or lack thereof)

The San Bernardino Sun offers a poignant profile of and commentary on a homeless encampment in Ontario, California.

One of the commentators is Manuel Aybar, identified as a mental health consultant and a person who has seemingly been involved in projects to aid the homeless population in San Bernardino. "Mental illness is not synonymous with homelessness," Aybar asserts …. "most people who are homeless choose to have that lifestyle."

That is undoubtedly the case for some. But for approximately one-third of the chronic homeless, the condition is far less a choice of lifestyle and far more a symptom of illness. The reporter found convincing evidence of that in her visit to the tent city.

One woman sat hunched over, yelling and swearing into a cell phone. "I'm wondering how lazy you are." "Stop dragging on all day!"

The phone wasn’t working.

Two yards away, a 36-year-old man exclaimed, "You go to the one-hour photo. You go look at the clothes. ... You go to the motel because once you stay at the motel your lens is gonna change."

His response when asked if he had any mental health issues: "Someone is gonna take your blood and drink it. My cholesterol was going up. Now I want to get a place to stay and sleep for a while, but every time I go anywhere the Mexicans follow me.”

He eventually added that he’d been diagnosed with “schizophrenic manic-depressive. ... But I take care of my pops. ..."

Consultant Aybar was reluctant to link mental illness to homelessness; he stressed that “the choice to be homeless is not necessarily a sign of mental illness.” True – not necessarily, but that only highlights the need to help those who have no choice or even the ability to choose.

Character Flaw?!

Character is a combination of both virtues and flaws that make up an individual’s moral fiber. Everyone has some sort of character flaw. Whether it is arrogance, stubbornness, selfishness… no character is without defect. The idea that an individual is suffering from a severe mental illness because of a “character flaw” is absurd and simply untrue.

As Marya Hornbacher states in a recent interview with the Washington Post, one of the biggest misconceptions about people with a mental illness is, “[t]he idea that [mental illness] is about character, that it's not really an illness and it's a character flaw. I'd invite all those people who believe that to an anatomy-of-the-brain class, and they can learn that it is a brain disease! It's not about being a bad person or committing sin.”

In fact, schizophrenia and bipolar disorder are neurobiological brain disorders that affect over 4 million individuals in the United States alone.

Unfortunately, many state laws do not reflect the current scientific understanding surrounding mental illnesses. The standards in many state statutes do not seek to prevent the deterioration of a severe mental illness. Instead, those laws make families and treatment providers wait for moments of extreme crisis to occur before authorizing the use of involuntary treatment, by which time it may be too late to help the individual. From both a commonsense and medical perspective, these statutes discriminate against those individuals with a severe mental illness whose symptoms are discernible in less violent ways.

Treatment Law Reform’s Scope In Proper Perspective

As vital is the need for rational treatment laws, it might be surprising that we at the Treatment Advocacy Center often think their significance unduly exaggerated by others in the mental health field.

Progressive treatment laws can be critical in bringing care and stability for those most in crisis, but efforts for them are most emphatically not aimed at whole-scale revision of mental health systems generally. Assisted treatment mechanisms are, by design, targeted at only a small sliver of all those with psychiatric disorders – the sickest of the sick.

According to one opponent, “almost anyone who ever had a psychiatric diagnosis and disagreed with their psychiatrist’s treatment plan could be forced to take drugs in their own home” under a 2007 proposal for assisted outpatient treatment in Virginia.

It is easy to establish that people would not have been physically forced to take medication in their own homes pursuant to that measure (there was no provision for that), but it is much harder to determine how many people with a psychiatric diagnosis would have been affected. That Virginia bill never became law.

We can, however, make a very close comparison. The bill in Virginia was a version of Kendra’s Law, and New York makes available a regularly-updated wealth of data on that program.

Those decrying the 1999 legislation that created Kendra’s Law loudly labeled it a “dragnet,” estimating that 10,000 New Yorkers would be forced into treatment each year. Over nine years later, we are still waiting for that 10,000th person. At the current usage rate, he or she won’t be placed in assisted outpatient treatment until 2013.

About 770 initial outpatient treatment orders are issued each year in New York. That is about one out of every 25,000 of the state’s citizens. Annually, the law is used to help only one out of every 400 people with schizophrenia or bipolar disorder.

And that is about the right amount.

Hollywood and Stigma

Hollywood loves to make movies with crazed killers, suspenseful moments, and plenty of gore. This weekend, the remake of “Prom Night” will be released featuring a knife wielding psychopath who slices and dices his way through a group of screaming teens.

How do we best fight this stigma?

For some, the answer is simply to deny that people with severe mental illnesses, as a group, are any more dangerous than the rest of society. The good news is that such an assertion is fully sustainable for those people with severe mental illnesses who receive effective treatment.

However, for the more than 2,000,000 Americans overcome with a severe mental illness who remain untreated, no such assertion can be made. The plain truth is that people with untreated severe mental illnesses are statistically more dangerous than people without severe mental illness. Does this mean that all people with untreated severe mental illnesses are more violent? Absolutely not, but there is a heightened propensity to harm others (and themselves) that can sometimes lead to headlines and movie scripts.

Therefore, in the long run, the best way to fight the stigma of severe mental illness is to treat it.

Assisted Outpatient Treatment: Using What is Already In Place

Various forms of assisted outpatient treatment laws exist in 42 states. When used effectively, assisted outpatient treatment substantially improves the lives of those suffering from severe mental illnesses.

Numerous scientific studies have proven that assisted outpatient treatment is effective in ensuring treatment compliance. However, many states still fail to employ what is at their disposal. Instead, readmissions, homelessness, and incarceration often triumph over the development of protocol. Although states often blame the lack of resources for the problem, restrictive commitment standards based on dangerousness alone are often the reason for not using existing assisted outpatient treatment laws. Other times, it is the simple lack of bureaucratic gumption. We should be seeking changes in both the laws and the processes (or lack of) to ensure that people in need of treatment receive it.

SOMETIMES NEEDED: A PATH TO THE RECOVERY PATH

A growing focus in the mental health field is the recovery model, which centers on allowing people with severe mental illnesses control over their own treatment. The theory is that being able to direct their own care both allows patients to choose what is best suited to them and empowers them to further capabilities of independence.
It is a good approach. The affects of a severe mental illness can strip away one’s self-appreciation, and the best cure for that is successfully regaining a capable autonomy. Recovery-based treatment models are well-matched to this task, with a goal of instilling the message that “hope and restoration of a meaningful life are possible, despite serious mental illness.”

Yet while the Treatment Advocacy Center encourages recovery-based efforts, some proponents of it view our efforts to promote rational treatment laws as anathema to the care model. We see them as complimentary. Any treatment model – whether medical, intervention, recovery or other – cannot be the one best suited to each and every person with all the varieties of mental illnesses, the varying degrees of them, and the particular manifestation in each individual. Indeed, we support the use of recovery-focused approaches in the vast majority of cases – but there are instances in which the direction of care cannot be left to a person rendered incapable of directing it.

As pointed out by Treatment Advocacy Board Member Fred Frese:

[M]any individuals are so disabled with mental illness that they do not have the capacity to understand that they are ill. Giving such individuals the right to make decisions about their treatment is tantamount to abandonment. …[I]t is inconsistent with the recovery paradigm to allow incapacitated individuals to remain victims of their serious mental illness. For these persons, measures must be taken so that they become well enough to be able to benefit from the recovery model.

We urge you to read the rest of this excellent commentary of Dr. Frese and his fellow authors on “Integrating Evidence-Based Practices and the Recovery Model.”

Public Versus Private Beds

Some officials defend the emptying of public psychiatric hospitals by pointing to the increase of psychiatric beds in general hospitals. However, as pointed out by the Treatment Advocacy Center’s recent study The Shortage of Public Hospital Bed for Mentally Ill Persons, eighty one percent (81%) of the psychiatric beds in general hospitals are in private versus public hospitals.

According to KRIS TV of Corpus Christi, Texas, the night before Khandi Busby recently threw her two sons off a bridge and jumped herself, relatives sought treatment for her at a local psychiatric hospital. Busby suffered from bipolar disorder, had stopped taking her medications, and was engaging in odd behavior. However, the hospital refused to admit her because she did not have proper insurance coverage.

This is one more reason why states like Texas must take steps to address their severe shortage of public psychiatric hospital beds.