Position on Outpatient Commitment of the New York Association of Psychiatric Rehabilitation Services (NYAPRS)

Replacing Outpatient Commitment Initiatives With Strategies That Work To Engage People In Need

Background

Outpatient commitment is a legal strategy that utilizes court orders and other means to force individuals with psychiatric disabilities to participate in mandatory treatment, merely because someone else has made a judgement that they would benefit from psychiatric treatment. An individual can be forced into treatment despite the fact that no crime has been committed and notwithstanding that he/she does not meet the requirements for inpatient commitment (i.e., that the person is a clear and present danger to self and/or others).

Recently, a number of legislative proposals elaborating on and expanding the scope of the Bellevue Hospital Involuntary Outpatient Commitment pilot program have been developed largely as a reaction to a small number of tragedies involving several people who have a psychiatric disability. First out, was a proposal by Attorney General Eliot Spitzer that has met with broad criticism from mental health consumers, providers, legal rights groups and a number of family-based organizations as well. Last week, Assemblywoman Elizabeth Connelly released a bill (A.5721) aimed at institutionalizing the Bellevue model across the state. The New York City Department of Mental Health has indicated it will soon propose to expand the Bellevue model across all five boroughs. And Senate Mental Health Committee Chairman Thomas W. Libous has been developing a fourth proposal that is said to focus more on the targeting of additional coordination of services for groups in need.

NYAPRS has taken a very strong position against the introduction of court-ordered forced service interventions and instead has advocated for state and local mental health service systems to assume their own proper responsibility for providing adequate and appropriate services, especially to those who have been deemed "hard to serve" in the current environment.

Discussion

Under the Spitzer bill, almost anyone—a roommate, family member, significant other, provider—can initiate the process of involuntary outpatient commitment. Once initiated, the individual is forced to cooperate with the process. If committed to outpatient treatment, the individual must either participate in forced treatment, including forced medicating, or face inpatient commitment. In addition, any provider included in the outpatient commitment plan is court-ordered to monitor and report any suspicious behavior—in essence destroying the trust that is the basis of any therapeutic relationship, and transforming providers into "mental health sheriffs."

We have urged legislators, policy-makers and the public alike to reject such dreadful "knee-jerk" political reactions to the horrific death of Kendra Webdale, and a handful of similar tragedies over the past 18 to 24 months. These incidents do not indicate that individuals diagnosed with mental illnesses are threats to society. Rather, they represent isolated incidents of violence committed by individuals with psychiatric disabilities. These events should not be used to abrogate the civil and constitutional rights of a segment of our citizenry.

America is a country built on the rights and freedoms of all of its citizens. In the United States, these rights may not be trampled upon lightly. This nation is built on the principles of freedom of choice, and liberty in the pursuit of happiness. We must consider carefully any effort that modifies or destroys such personal rights. Before we adopt such a drastic measure as involuntary outpatient commitment, let us take these facts into consideration.

1. People diagnosed with mental illnesses can and do recover, especially when provided access to recovery-oriented services founded upon rehabilitation and self-help.
2. A growing array of community-based rehabilitation and peer-operated services have proved to be very effective in helping individuals with psychiatric disabilities to manage these disabilities and engage in productive, independent lives. This is true even for the so-called "hard-to-serve."
3. People diagnosed with mental illnesses, as a class, are no more violent than the general society. A recent study by the MacArthur Foundation the Violence Risk Assessment Study found that, "There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse significantly raised the rate of violence in both..." (Archives of General Psychiatry, 1998; 55:393-401)
4. Individuals with psychiatric disabilities frequently decline psychiatric treatment for good and rational reasons historically that treatment has been abusive and dehumanizing; and many of the typical anti-psychotic drugs have painful and debilitating side effects. Recent items in the Hartford Courant, the New York Post and the Boston Globe regarding dangerous practices such as the overuse of seclusion and restraint as well as risky drug testing without proper consent amplify this point.
5. Forcing someone into treatment does not make for good treatment. Force destroys the trust relationship necessary for effective treatment. Force may get the person into the treatment environment, but it does not guarantee that the person will benefit from treatment in fact, it may enhance resistence to treatment.
6. Involuntary outpatient commitment is a form of preventive detention that results in significant violations of the individual's civil and constitutional rights. There are adequate mechanisms and protocols in place to safeguard both the individual and society if the individual becomes dangerous. We must not implement unnecessary strategies that impede individual freedoms, especially those that will not achieve the intended outcomes. Imagine what other civil rights might be threatened in the future if we are not successful in the battle against involuntary outpatient commitment.
7. Involuntary outpatient commitment has NOT been demonstrated to have a positive impact upon peoples' mental health. What makes a difference is the scope, flexibility, responsiveness and coordination of community based psychiatric treatment and rehabilitation services. This was the key finding of the Bellevue Involuntary Outpatient Commitment Pilot Study conducted by Policy Research Associates. (Executive Summary, Bellevue Involuntary Outpatient Commitment Pilot Research)
8. Involuntary outpatient commitment is a very costly effort to the individual, to the mental health system, to the criminal justice system, and to society that holds no promise of the avoidance of violence in our society, nor of recovery for the individual. It diverts badly needed funding away from effective community-based mental health services, especially those founded upon the recovery vision.

When all is said and done, we know what works and what doesn't work. Force doesn't work. Force is violence that encourages helplessness, kills self-esteem and chases away hope for recovery. Force, in one fashion or another, has been the hallmark of traditional mental health services since their beginnings. Force doesn't lead to healing...to recovery...or even to well- being. Force is based on fear which is based on stigma false ideas of what mental illness is and who becomes psychiatrically disabled.

Recommendations

Recovery-oriented services work—services that respond to the individual; services that focus on rehabilitation and that offer rich options to the individual; services that are preventive and well coordinated; in short, services that preserve the dignity of the person. True concern for the individual works. Early intervention works. Effective discharge planning works. Rehabilitation works. Self-help works. Choice works.

It is well-past time to kill the discrimination and shame of mental illness. It is well-past time to celebrate the many contributions and achievements of those among us who struggle with psychiatric disabilities. It is well-past time to champion services and approaches that work, and to reject efforts to debilitate and impede our sisters and brothers in their quest for recovery.

Involuntary outpatient commitment is a poor substitute for good services that are well coordinated, flexible, accessible and responsive to the needs of individuals with psychiatric disabilities. Programs that work well are based on choice, not force. Force leads to resistence, and the threat of forced treatment leads to the avoidance of services altogether.

The primary barrier to community-based mental health care has always been adequate funding of these services. And that is where the effort to respond should be invested. Rather that involuntary detention which has not been shown to be effective, invest in services that are well coordinated, flexible and responsive to individuals—services that have been shown to work effectively. Use what is out there to offer the hope of recovery while offering rehabilitation- oriented treatment, support and assistance needed and wanted by the individual. Offer an adequate range of service options which people want and identify as responsive to their needs and that promote wellness, healing, independence and personal responsibility.

Involuntary outpatient commitment is a strategy that seeks to substitute faulty experimentation for the provision of an appropriate system of mental health care. The NYAPRS Board and organization strongly reject the policies of letting involuntary outpatient commitment impose force and steal personal civil rights as a substitute for adequate, well-coordinated, flexible, responsive and accessible community-based services.

NYAPRS President Jack Guastaferro
February 1999
Buffalo, New York

We refer the reader to the following sources:

The June 1997 Mental Health publication by the Western Interstate Commission for Higher Education of Dr. Courtenay Harding's landmark 25-year study (no longer online) demonstrating that even the most "severely and persistently mentally ill" individuals could attain a full recovery if offered an approach that fostered "self-sufficiency, rehabilitation, and community integration" as opposed to "maintenance, stabilization with medications, and entitlements" as the only goals. Nonetheless, as Dr. Harding declares, "I would propose that most community mental health centers have become just as sturdy institutions as the old state hospitals were. The CMHCs in the U.S. have chosen the medication management and entitlement model of care because 'that's what the Fed's pay for.' Stabilization and maintenance are the goals. Such strategies promote and extend chronicity."

A mental health system that predominantly numbs its clients by relying excessively on high dosages of medicine, abysmally low expectations and little room for hope and smoke-filled treatment centers with all too few opportunities to play a meaningful or productive role is a system that frequently drives people either down...or in the serious instances under discussion here, drives them away.

Dr. Anthony Lehman of the Center for Mental Health Services Research at the University of Maryland School of Medicine and principal investigator of the National Institute of Mental Health's Patient Outcomes Research Team (PORT) study found that fewer than half of patients under treatment for schizophrenia were receiving appropriate treatment. "Medication alone is not enough," stated Dr. Lehman. "..The most effective approach integrates (medicines) with psychosocial (rehabilitative) treatments."

In most parts of the country even today, people with psychiatric disabilities are receiving inadequate, incomplete or uninformed care. Hence, people falling through the cracks of local systems are a tragically common occurrence.

"Restraint and Seclusion Practices in New York State Psychiatric Facilities, and Voices from the Frontline: Patients' Perspectives of Restraint and Seclusion Use" September 1994 Findings from the NYS Commission on the Quality of Care for the Disabled:

1. "The use of restraint and seclusion in state psychiatric centers has almost doubled over the past decade (1984-1993) and has been associated with over 100 patients deaths over that period. At the same time, the Commission found wide variations in the frequency with which these interventions were used by psychiatric facilities in New York State."
2. "62 percent of respondents who had been restrained or secluded reported unnecessary force, psychological abuse, ridicule or threats by staff. 29 percent alleged they were physically abused, with 26 percent reporting injuries, and 10 percent reported they were sexually abused; 47 percent of respondents said staff placed them in restraint or seclusion without first trying to calm them down or resolve their problem."
3. "Almost three quarters asserted they had not been dangerous to themselves or others when they were restrained or secluded, that staff merely thought them "upset" or their behavior inappropriate. Others alleged restraint and seclusion were used as punishments for not taking medication or obeying staff "

Given the pattern of abuse many individuals reported only a few years ago while receiving care in the state's hospital system, it should come as no wonder that many individuals are very reticent if not resistant to receiving care from that system. All too often such resistance is dismissed as a symptom of an irrational thought disorder that can be best addressed by the often forcible administration of psychiatric medications.

More recent accounts of abuses within mental health services that all too often discourage or drive away people in need:

Boston Globe series showing widespread patient abuses due to risky non-consensual psychiatric drug testing.

A Hartford Courant series (no longer online) on the numbers of residents of psychiatric facilities who either died or were seriously injured by seclusion and restraint procedures (leading to the recent JCAHO discussions on reform).

City Limits expose revealing continued deplorable conditions in today's NYC psychiatric hospitals.

1. Forced Service Interventions Don't Work!
   The research study of the Bellevue Hospital Involuntary Outpatient Commitment Pilot Program found that coordinated, compassionate community mental health care helps engage "hard to serve" groups, not forced treatment interventions.
   
2. Forced Service Interventions Actually Drive People Further Away.
   A California Department of Mental Health survey showing that 55% of former patients reported an avoidance of traditional mental health services because of their experiences of being involuntarily committed (Campbell and Schraiber).
   
3. Forced Service Interventions Damage the Therapeutic Relationship, Turning Professionals into Police
   
4. Forced Service Interventions Are Costly, Diverting Precious Resources From Services That Work.
   
5. Forced Service Interventions are Discriminatory, If Not Unlawful.
   The (Spitzer) bill threatens the liberty of all persons who have been psychiatrically hospitalized within thirty-six months, regardless of whether the hospitalization was for dangerousness, regardless of whether the hospitalization was voluntary or involuntary, and regardless of whether the hospitalization was caused by refusal of treatment. Thus the bill will create a strong disincentive to seeking psychiatric hospitalization.
   
   The bill disregards completely the constitutionally protected liberty interest of all persons in controlling their medical care. In sum, the outpatient committed person loses all voice in what medication he takes, and can be summarily forced to take whatever medication the outpatient psychiatrist orders, without an opportunity to be heard by the court or even to be heard by the outpatient psychiatrist. The bill creates a psychiatric dictatorship which violates due process under the New York and United States Constitutions (Cliff Zucker, Executive Director, Disability Advocates, Inc. Albany, NY).
   
6. Public Calls for Forced Service Interventions are Frequently Based on Inaccurate Public Stigma
   Despite sensationalized views of people with psychiatric disabilities as typically dangerous, research shows that not only are they no more dangerous than the general public, per the MacArthur Study on Violence and Mental Illness, such individuals are more often than not the victims of violence from a recent Duke University study as reported by the ABC website.