Requiring Treatment for the Mentally ill (State laws)

[welsummerchicks]

I guess we've all heard and read many news reports about tragic events involving a mentally ill person who harms self or others. There have been so many reports like this in the news of late. The trouble is that many people who become very sick, don't realize they are ill. Fully 50% of severely mentally ill may not be able to understand they are sick. They then won't seek out or accept help. So they just get sicker and sicker. Some of these people will be violent.

Most states already have a so-called 'hospital law'. This is a law that says, basically if a mentally ill person is a danger to himself or others, he can be confined in a hospital. The state laws have slight differences in wording, but all are similar.

Some states now also have a 'Kendra's Law', a law that sets up a process for requiring outpatient treatment. Our state is looking at adopting a sort of 'Kendra's Law' as well. The 'Kendra's Laws' are named for a woman whose tragic end involved a mentally ill person. Some states have named their law after a person in their own state who lost their life, but all the Kendra-like laws have a lot in common. The idea is that the person stays in the community - going to a mental health service or doctor, instead of a hospital.

There are many difficulties at all levels with both laws.

The central difficulty is the severity of the illness and how deeply it affects thinking. Most people assume that the person just couldn't get affordable help. But the problem actually runs much deeper. People with severe illness often refuse any and all help.

The basic problem is that the law in America is set up with a fundamental right to refuse medical help, and that includes mental health help. That's a basic right. But in the case of the violent mentally ill, that right crashes into the rights of the people of the community as a whole.

With the hospital laws, we have clearly seen a great many people 'fall through the cracks' and tragedies occur with regularity.

But the new 'Kendra's Laws' are getting criticized too, on many fronts. Some say the new laws need to be more like the old laws. Others say they need to be LESS like the old laws! Some say the new laws set the bar too low for who should be in the program; others say the bar is too high. Others say that they'll cost too much to carry out.

I have studied some existing Assisted Outpatient Treatment programs. I was very, very surprised to see so many requirements to qualify. These clearly weren't covering a lot of people. I saw numbers like 700 people over a period of eight years! In fact, for the people most in need of the program, the requirements seemed to be virtually impossible to meet. The person had to have a solid history of following treatment! If they had that history, they wouldn't be pointed at Assisted Outpatient Treatment in the first place! It was almost like saying, 'To get into this program for ex-Felons, you need to have never been in jail'. It really seemed THAT DUMB!

I find myself weighing a lot of tough questions. There will be meetings to discuss these laws, I hope to attend.

 

[thaiturkey]

It's a complex issue and one often in the public eye in the UK too. Take the law to one extreme and opponents of an authoritarian regime can be called insane and locked up. Go to the other extreme and those who are allowed to refuse treatment may kill someone. Furthermore, administration of any programme is put into the hands of low level government employees who seem often to miss someone who should not be walking the streets until it is too late. Also in the UK, violent mentally ill people have been released from their special prisons on the recommendation of a psychiatrist and then have killed within days.

Individuals should, by and large, be free to take or refuse medical treatment as they wish if they are of sound mind. Try to define that in an objective and universally applicable way! Those incapable of making their own decision may be taken to hospital, in the UK, for treatment. Mentally ill people in the UK who may be a danger to themselves or others may be 'sectioned' by a qualified doctor under the Mental Health Act. That means that the are held securely in a psychiatric ward in a hospital for examination and observation until a full diagnosis can be made and a decision made regarding their treatment and possible release into the community. Unless a crime has been committed, the decisions are made by psychiatrists with patient welfare and individual and public safety being the main deciding factors. If a patient is held under the Act, he or she can appeal to the Courts. If a crime has been committed it's a Court matter and the Courts take into account what happened and psychiatrists reports and opinions.

As has been discussed elsewhere on BYC, treatment in the UK is not paid for by the patient so this probably makes decision easier than would be the case in some other countries.

 

[redhen]

The mental health laws today are a joke.
There are more TRULY mentally ill people in JAIL then in the hospitals getting help.
Our country also just turns them out on the streets to fend for themselves... many are homeless. Its shame..

 

[debilorrah]

You people do realize that these poor folks are out on the streets because of legislation right?

 

[welsummerchicks]

I don't think the mentally ill homeless issue is as simple as just 'legislation'. I don't care for the overly familiar speech that starts, 'Wellllll....forty years ago, we closed all our state hospitals....and...that's why we have a problem today...'.

I think that 'cause of our problems today' is - complete and total baloney. Irrelevant. I don't think 'locking people up' is the answer. I think treating the illness correctly FROM THE START is the answer. The old state hospital system was no better a solution than what we have today. It was corrupt, the care people got was at a very poor standard, and the poor were out on the street after a month rather than a week - big deal. Same lousy results ultimately.

I also don't think that mentally ill offenders are invariably homeless. Quite the contrary. The problem of mental illness and violence is much broader than that.

Our legal system has always relied on the 'danger to the community' principle to deal with mental illness. THat's always been part of the problem. Because the mentally ill person is 'noticed' only AFTER and IF he commits a violent act. That's the single worst flaw in our system. That's too late.

We LET people deteriorate. THEN they become violent. Many severely ill people aren't diagnosed for ten or even fifteen years AFTER their illness starts. By then, the illness has become much more severe.

We basically stand by doing nothing and let people get really, really sick, then throw up our hands and shout, 'Well! Will you look at that awful thing that happened! What a shock!'

I think treating the illness appropriately from the start is the answer. I think that is where we START TO FAIL.

I also believe mentally ill homeless are generally and majorly, homeless because of their disease rather than any other cause.

I also believe there is not one single official, judge or doctor, who actually WANTS mentally ill people in jail. That they are, is due to a complex legal and financial web, that includes 'for profit' hospitals, emergency shelters, and most of all, federal principles that hamstring state commitment laws.

But the state commitment laws are just - gutless wonders. The person who wrote the wording used in state laws, was basically ONE MAN - and he stated, clearly and emphatically, the state laws were worded as they are for one purpose and one purpose alone - NOT to protect the community OR the mentally ill person - but to reduce the state's costs. That's it. Reduce the state's costs. Basically, they're written to be vague enough that just about anyone can justify not putting out the bucks for treatment of a sick person. No matter HOW MUCH risk they are to the community or themselves.

To be clear, most mentally ill people are far more at risk themselves, than they are a risk to the community. They are more likely to be robbed than to rob, and more likely to BE assaulted than to assault. But the only real point where the law 'cares' is if someone harms another person. The law doesn't 'care' if a person deteriorates so badly they become dependent on full care...it SHOULD 'care', but it does not. Legal intervention for the mentally ill has always legally rested on the principle of harm, but not on PREVENTING harm but REACTING TO IT AFTER IT HAS OCCURED.

The law IGNORES the burden the deteriorated person puts on the community when he never actually harms someone else but the burden is huge, financially, culturally. The law does not address his eventual burden to the community as a deteriorated dependent that now requires full nursing home care and 24 hour supervision. It also ignores the fact that after years of NO treatment, medical treatment applied so late in the game, will not be guaranteed to maintain or improve independence.

Under the law, persons are guaranteed some level of self determination and autonomy. By allowing the severely sick person to deteriorate without treatment, we actually remove any hope of their long term self determination and autonomy. They become a burden to the community and live a less independent life because they have deteriorated. We are actually violating the basic civil rights of the severely ill person.

I also believe that many emergency shelters are 'part of the problem' and have poor recognition of severe symptoms, and a poor response to them. I've seen severely ill untreated people live in shelters for over a decade...this is not the mission statement of the shelter, but they wind up being a place where people avoid treatment. Their mission and purpose is to provide TEMPORARY EMERGENCY SHELTER, and direct people toward solutions and change.

I've also seen one of these 'end all homelessness! get everyone a home!' agencies get an apartment for a severely ill person, who then spent the first 48 hrs screaming in terror in his 'not homeless any more, so the problem is solved' apartment. The complaint got rolling and he was in that apartment about forty NINE hours! What exactly is the point of that? It only makes the person feel more hopeless and less likely to get any help.

 

[I have WHAT in my yard?]

This is an issue near and dear to my heart.

I ran a non-profit program for many years that provided a wide array of services to mentally ill homeless people. The endless struggle was always with a one size fits all attitude. A person crippled by profound chronic depression does not require the same treatment or case management as a person suffering from schizophrenia. For one brief period in time we reached a wonderful state.

We had in place, out-patient substance abuse programs for homeless people - we were told it would never work - it worked wonderfully because all of the city's shelters could send their clients to this one program. AND patients who had left the shelter system could still attend.

We had a case management team that provided real world day to day services for those who were chronically mentally ill. This was able to include daily medication delivery for those who needed close monitoring all the way to well being checks on those who could not or would not go into any housing at all. We were able to monitor them and place them if they became dangerous to themselves or others.

We bought a small apartment complex for our most intractable long term patients so we controlled all aspects of their housing while giving them their own space and freedom and privacy.

We helped over 800 patients a year, cut inpatient hospital stays by one third and became the go to agency for the police whenever they were faced with a public issue by a mentally ill person. They would decide just how dangerous they were and call us in to help end the issue.

While this sounds like a huge undertaking it really was not. We had fewer than forty staff at any given time. A small office with meeting rooms, a couple of cars a receptionist that was a work release patient......

It worked. So the state cut its funding in half.
We reorganized to meet federal criteria but it never worked quite the same again. It no longer exists.

Those writing these laws usually focus on one sensational case and write a law designed to prevent that. There are hundreds of mental illnesses and many reasons why one person ends up homeless when another does not. You and I do not wear the same size clothing? Why should all mentally ill people be shoved into the same size treatment approach?

 

[welsummerchicks]

It's only because of people like you that there are any such solutions in place. Extraordinary people who go above and beyond to think of practical solutions.

Did I mention your efforts were extraordinary?

I hope that you got a lot of personal satisfaction from your efforts.

The laws, and the conflicts between the state and federal laws, the lack of funding, the backwards agendas of people often attracted to these agencies...'organizational territoriality' (no, We DON'T want you to come up with a better solution, we want to perpetuate our organization, and that's ALL we want to do...')...the illnesses themselves which make people resist help...all huge hurdles to fight.

I do see what you mean about passing more laws to appear to respond to an extraordinary case without really putting a sensible whole system in place. Do you feel the Kendra Laws and Assisted Outpatient Treatment fall under that category of 'more laws that do less'?

 

[PineappleMama]

This sort of reminds me of probation/parole... you know the person is a threat to others, yet there's no room to keep them so you let them out in a supervised way... require set visits, etc.

And how many times have we heard about people on probation/parole not showing up to their appointments, committing another act, etc? Tons. These are the ones that are fully functioning, know what they're doing... can't imagine putting the same kind of rules on someone who is NOT all there and expecting it to work any better.

But putting any kind of tracking device on them is 1-very expensive and 2-gets everyone up in arms about their rights to privacy ect. So what can you do? Can't keep them all (prisoners or all folks who need hospitalization)... so you have to winnow and keep the worst ones and just hope for the best with the rest.

Keep in mind too that most often it takes two, if not three, full weeks of scheduled doses for a medication to get stabilized in your system... and that's assuming that the first med they try works... that they don't have to start over because there's a less than stellar reaction to it... minimum two weeks. But how long are hospitals required to keep a person in, no insurance/court order or not etc, before the Admin requires them to move them out because there's a backed up line? So you send out folks you KNOW are NOT stable on new meds and just hope that they keep taking them... I've seen this SO many times... in the hospital YES you can force someone to take meds, but once they leave it's on them. If they don't want to take them... if they forget to take them... if they lose them... if they don't even remember where they are... well they're just going to end up doing something bad to themselves or others and wind up right back in there for another week or two stint... then back out... and so on.

Unless a boatload of money falls out of the sky to build a boatload of new buildings, hire a boatload of new staff, pay for meds, pay for tracking for released folks... well... this cycle is never going to end. Not that that ramble is in the least helpful, I have no clue how to fix this problem... other than perhaps further funding for human brain studies... maybe if the problem can fully be explained then we can begin to really fix it... but other than that? *shrug*

 

[Yay Chicks!]

I worked for a number of years in community mental health. So many heart breaking stories. So many desperate families. So many times that I would send a person to the hospital because they were threatening suicide with intent and plan and when the arrived at the hospital they would tell the doctor that they were not suicidal and be released. Or they would be in a paranoid psychotic state, threatening to hurt others, but at the hospital they would pull it together enough to say that they were not a danger to themselves or others. And so the doctor, who has known the patient for 5 minutes, determines they are fine and sets them loose. The mental health wards in hospitals are always full and they work to discharge as quickly as possible. The make an outpatient appointment for the patient who, of course, then does not show up for the appointment. The system is a mess. Underfunded, those that want to help are worked to the point of exhaustion and paid so little that many, with expensive masters degrees, are barely making it. And the ill person just gets caught in a loop, hospitalization (or arrest), release, sent to outpatient, doesn't show up and round and round we go. I don't know what the answer is. But I do know that the 'fee for service' system does not work. That the levels of paperwork required to get funding to help these people leaves the workers using 70% of their time doing paperwork and 30% of their time trying to help a huge caseload. These are among the most vulnerable of our society. Most of them are not violent, but that is what you see in the news and so it creates an 'us against them' atmosphere.
This is too close to my heart and I am not being particularly articulate. I left community mental health because I got burnt out and discouraged. There is a huge turnover in these agencies which leads to a lack of any consistency for those being treated.
That's all I can say right now. Not much help from me, but I appreciate the forum to discuss this.

 

[MandyH]

And what about the middle class americans that are going broke trying to afford the meds needed to keep them stable?