February 1st, 2012

Involuntary outpatient treatment bill on legislative docket

PHOTO BY Tom Croke
Judicial commitment to outpatient treatment would be beneficial if backed by enhanced funding and services, says Donald Davidoff, Ph.D., assistant professor at Harvard Medical School and chief of McLean Hospital’s department of neurology.

Fourteen years ago, Rep. Kay Khan (D-Newton) filed a bill (H.1419) intended to prevent tragedies because of medication non-compliance and inadequate treatment for mental health issues. In light of mental health-related tragedies in Danvers and Weymouth this past fall, the bill is garnering renewed attention.

According to Khan, who is a psychiatric nurse and clinical specialist and serves as house chair of the Joint Committee on Children, Families and Persons with Disabilities, in 1998, NAMI (the National Alliance of Mental Illness) of Massachusetts approached her with a request to file this bill. In the ensuing years, she has continued to lobby for its passage.

“A lot of research has been done and I’ve been working with the UMass Medical Center,” says Khan. “The concept of involuntary commitment for someone who’s a danger to themselves and others is well established.”

Massachusetts currently does not have a law that would enforce commitment without the individual’s consent. “Now if a patient is dangerous by reason of mental illness, a judge can commit the person to the hospital,” says Khan. Under what is known as Section 12 commitments, a psychologist, psychiatrist or psychiatric nurse can sign commitment papers, she explains, adding that police can also commit an individual for a three-day evaluation. “If the person is still thought to be a danger, a hearing is held,” says Khan. “A judge can commit the person for more than six months. When a person is committed and uses anti-psychotic medications, he or she improves, but after two weeks can be discharged to outpatient. Some who don’t follow up or take their medications relapse and the process gets repeated.”

Rather than enforce inpatient care, Khan is seeking therapy within the less restrictive setting of community. “Under my bill, a judge could commit a person to receive care on an outpatient basis. If there is deterioration, one could go back to the hospital or jail if a crime is involved,” she says. She cites the bill as a preventative measure to keep individuals with mental illness close to home and emotionally stable. “This type of legislation is being used in many other states. It may not solve all the problems, but it keeps the person within our own community,” Khan says.

Opponents to the bill argue that imposing treatment, even though on an outpatient basis, would violate an individual’s civil liberties. Khan refutes this reasoning. “A person is less likely to lose civil liberties if they are getting treatment in the community. It’s better to be in the community with supervision,” she says. “This bill gives us another option and opportunity to give it a try. If someone has to be compliant [with medications] and is being followed by a mental health professional, it’s more likely he would comply. Folks who are non-compliant end up homeless.”

Khan emphasizes that this bill is intended for the small group of individuals with serious mental illness who need treatment, but cannot make decisions for themselves and don’t see the need for help.

Admittedly, some public education would need to take place before the bill would be implemented, should it pass. “Families should understand and be more vigilant about warning signs,” Khan says. “This is an opportunity to raise consciousness about mental health.”

Not all consumers agree in principle with the bill. “I respect their way of looking at peer support instead, which does good solid work. But this is above and beyond what [peers] can do. It applies to anyone who might lose any perspective on their mental health level. One has to step in in certain cases,” Khan says. Although similar bills have failed to always work as they should, statistics indicate a reduction in the number of possible tragedies, she adds.

The Department of Mental Health (DMH) has never supported the bill, according to Khan. Several attempts to reach DMH for comment were unsuccessful.

Cheryl Grau, LICSW, clinical services executive at Arbour-HRI Hospital in Brookline, oversees all clinical programs, including four partial programs and says the issue is “complicated.” She admits that Khan’s proposal would “in some ways be a benefit.” However, for those who suffer with psychosis, the problem is cyclical. “When these folks go on and off medication, they never reach a higher functioning baseline. They are always a step below,” she says. “Psychotic patients are vulnerable in the community.”

Donald Davidoff, Ph.D., assistant professor of psychology at Harvard Medical School and chief of the department of neurology at McLean Hospital, points out that judicial order may not be as important as the intensity and availability of services along with a commitment from the community to provide those services. But he adds that monetary issues sometimes present a stumbling block. “Mental health services have not been robustly funded in the last few years. If legislation around judicial commitment to outpatient treatment would enhance funding, it would indeed decrease the incidence of re-hospitalization,” he says. “Back in the 60s with deinstitutionalization, the great dream was that with medication and community mental health centers, individuals could be adequately maintained outside constrictive institutions. If this legislation creates a mental health court, if you will, and, in turn, links to increased services, it might be a really good thing and might actually fulfill the dream of deinstitutionalization. Without enhancing services, you are not doing anything but adding another bureaucratic logjam.”

For those who cite the loss of civil rights, Davidoff emphasizes the importance of having a psychiatric advance directive (PAD), which invites patients to take an active role in their care. “There are better outcomes when an individual feels they participate in decision-making,” he says. “Having a PAD is a way of dealing with the abrogation of an individual’s rights.”

Davidoff says, “Like everything else today, this speaks to a societal problem. There is a lack of acknowledgement of mental illness being a true illness, something treatable and manageable.”

According to Khan, hundreds of people have called her in support of the bill. “It’s about protecting people including the individual who is severely mentally ill, the family and the public,” she says. “I’m doing this to be helpful, not hurtful.”

By Phyllis Hanlon

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