THE CONFLICT: OUTPATIENT CARE(7/2002)
Should the state force persons with a mental illness to undergo involuntary outpatient treatment if their relatives or roommates believe that these persons are potential threats to themselves or others?
Prior to the 20th century, medical care for the mentally ill was limited mainly to incarceration. By the 1950s, advances in both the scientific understanding of mental health and pharmacological treatments for the symptoms of mental disorders mental health providers and the state to reject hospitalization and endorse, in its place, a variety of outpatient and/or community-based programs.
As the number of mentally ill persons in state-run hospitals plummeted throughout the 1960s, however, so did the funding for the voluntary outpatient treatment programs that were to follow.
This decrease in funding and public awareness meant that the very communities that were supposed to absorb persons with mental illness were ill prepared to do so, from both a financial and cultural standpoint. The dearth of treatment services for persons experiencing the early onset of a mental illness and scant public education devoted to mental health means that few of those who suffer from such illnesses and/or their families or friends understand the causes or symptoms of these disorders, let alone the full range of available treatments. (DOC)
A lack of detection, early treatment, education and other preventative strategies has pushed hundreds of thousands of mentally ill persons into the criminal justice system as their conditions deteriorate from a personal or familial problem to a public safety concern.
The result is a constellation of laws, funding schemes, treatment programs, and social attitudes that may gloss over voluntary and casual mental health care (PDF) while concentrating public attention on involuntary legal and medical interventions in the final stages of an untreated mental illness.
Such is the context for Assemblymember Helen Thomson’s AB 1421, which seeks to facilitate involuntary outpatient treatment in order to increase the number of persons receiving such care.
Amended on several occasions over the course of the last year, AB 1421 allows a person’s medical history and prognosticated future to be used as evidence in determining sufficient cause for involuntary commission to treatment. Such information was to have broadened the 1967 criteria which requires that a person be unable to care for herself or present a threat to her or another’s welfare in order to qualify for involuntary treatment.
AB 1421 also attempts to expand the set of persons who could initiate such an intervention by proposing that a family member or even a house mate of a person suspected of suffering from a mental illness could petition for her initial detention and examination based on the criteria described above.
These changes to existing law have been praised, on the one hand, as advances in public safety and criticized, on the other, for threatening the success of existing and proven voluntary treatment programs.
Regardless of the outcome of AB 1421, the heated debate surrounding its legal ramification lights the path to a broader discussion: is public safety policy the best means for addressing the current mental health malaise? Is involuntary treatment more effective than voluntary treatment? (PDF)
By targeting mental illness in its final stages, public safety discussions may inadvertently further an association between illness and criminal activity and, more sensationally, between mental illness and violent crime. This symbolic link could reinforce negative stereotypes of mental illness, contributing to social and political attitudes that preclude preventative care.
Assemblymember Helen Thomson, (D) of Davis, has introduced a spate of mental health related legislation as her final term nears completion. A former psychiatric nurse, Thomson’s AB 1421 has resonated with widespread frustration over a chronic lack of mental health care services. By emphasizing the possible public safety benefits of involuntary treatment, the bill has become popular with the media and law enforcement officials.
The National Alliance for the Mentally Ill is one of the largest and most influential mental health advocacy groups in the United States. Representing the families of persons with mental illness as well as consumers of mental health services, NAMI has fought for increased access to treatment, promoted public awareness of mental heath, and campaigned against the stigma of mental illness. They have also championed AB 1421. NAMI’s critics charge that its endorsements of drug treatment programs are tainted by the fact that the organization receives most of its funding from pharmaceutical companies. They are joined in support of this bill by the California Psychiatric Association.
The California Network of Mental health Clients is one of several consumer/survivor organizations opposed to AB 1421. Representing persons who are under treatment or have recovered from a mental illness, groups like the CNMHC are highly critical of laws that alter the criteria for committing persons to involuntary treatment. The CNMHC points to increased voluntary programs as a better solution. They are joined on this issue by the California Mental Health Directors Association and the Judicial Council of California. The former worries that involuntary treatment may create antagonism between patient and practitioner while the latter is concerned that litigation resulting from AB 1421 would create unnecessary costs.
Assemblymember Darrell Steinberg, (D) of Sacramento, has authored two bills, AB 34 and AB 334, that expand voluntary treatment for the mentally ill and conduct studies to verify the efficacy of these outpatient programs. Unlike AB 1421, Steinberg’s bills have provided funding in the form of grants to the participating counties. According to the California Department of Mental Health, AB 34 has been very successful at preventing relapses and criminal activity among persons suffering from mental illness. (PDF)
A report by the Rand Corporation has been used by both opponents and proponents of AB 1421. However, the following quote from the California Senate Health and Human Services Committee Analysis indicates that Rand suggests only a qualified endorsement: “the author of the Senate-commissioned RAND study… recommended the Legislature, before revising the law statewide, establish a demonstration program, testing the effectiveness of a voluntary outpatient program with intensive, comprehensive services against the effectiveness of an involuntary outpatient program with the same intensive, comprehensive services. The RAND study author noted that…court ordered treatment may benefit one sub-group of persons with mental illness: those with psychotic disorders who are also at the highest risk of poor outcome. (However, AB 1421 would allow persons to be ordered into outpatient treatment who have never had a psychotic disorder).”
Those in favor might say:
The decision to invite mandatory medical assistance when a person suffering from mental illness is no longer capable of caring for themselves cannot be left exclusively to psychologists and/or psychiatrists, nor to the person suffering from a mental disorder. The families, partners and housemates of an afflicted person must be empowered to intervene for the benefit of that person’s welfare. If a person suffering from mental illness has previously been provided with treatment and refused it, this behavior may be proof that this person is unable to decide for herself on a course of action that will preserve her welfare and/or the wellbeing of their family and community relationships.
Those against might say:
Existing law already provides the state with the authority to compel a person to submit to treatment if she is unable to care for herself or presents threat to herself and/or others. Allowing family members and/or housemates to initiate a legal and medical proceeding where the self-determination and self-awareness of a person is scrutinized may invite abuse in cases of domestic violence or when a mentally ill person is being exploited for fiduciary gain by a caregiver. Voluntary treatment programs may be as effective as involuntary programs and they create a healthy relationship between the patient, family and friends, and the therapeutic care providers.
Excerpts from An act to add and repeal Article 9 (commencing with Section 5345) of Chapter 2 of Part 1 of Division 5 of the Welfare and Institutions Code, relating to mental health.: This bill, until January 1, 2008, would enact the Assisted Outpatient Treatment Demonstration Project Act of 2002, which would create an assisted outpatient treatment program for any person who is suffering from a mental disorder and meets certain criteria. The program would operate in counties that choose to provide the services.