One of Hartford Probate Judge Robert K. Killian Jr.'s frequent "customers" is an elderly woman whose mental illness gives her delusions that there are dangerous people living in her cellar. When she's not taking her medication, she calls police, who come and reassure her. Every few times, they take her to be examined, and she ends up getting committed to a hospital.
Killian worries she'll end up losing her home.
It's a cycle that the judge says he sees too often: people with severe mental illnesses not taking their medications when they're at home, leading to behavior that lands them in the hospital involuntarily, or in jail. While there, they don't receive disability benefits and fall behind on their rent, eventually getting evicted and becoming homeless, losing one of the keys to stability in the community.
"I'm seeing some of these people three or four times a year for commitments," Killian said. "We spend an awful lot of time trying to find housing for discharged patients from mental hospitals ... And I hate a system that forces them to lose it."
Killian wants Connecticut to follow the lead of the majority of other states by allowing for people with psychiatric disabilities to be medicated, even if they object, while they're in the community, if remaining unmedicated would leave them or others at risk of harm. He believes the proposal, which would allow for up to 120 days of forcible medication, would offer a chance for people to become stabilized and potentially choose to take the medications, making them more likely to avoid the cycle that brings them back to the hospital.
The concept, part of a bill pending before the legislature's Judiciary Committee, is vehemently opposed by advocates for people with mental illness, who say it could undermine efforts to engage people in treatment and would go against the state's efforts over the past decade to create a behavioral health system that emphasizes clients' choices and participation in their own treatment.
Even Killian acknowledged that it's "a reach by Connecticut standards."
"Would you do that with somebody who refused to take their diabetes or their heart medication?" asked Daniela Giordano, public policy director for the National Alliance on Mental Illness, Connecticut. "Are you going to mandate that? No, you wouldn't. There would be a huge civil liberties outcry."
"If this went through, I think this would be a significant step backward for the state," said Patricia Rehmer, the state's commissioner of mental health and addiction services.
Rehmer said she understands Killian's perspective. It might seem that if the people he sees repeatedly could be medicated, they would stay out of the hospital. But she worries that would backfire, breaking down the opportunity for a respectful relationship and leading to more difficulty engaging them.
A better way, Rehmer said, is through supportive housing, making sure people have a stable place to live, then trying to engage them in services and trying to get them to comply with treatment. Gov. Dannel P. Malloy's administration has supported the concept, but there's still a need for more, Rehmer said.
On that need, and the ultimate goals, Killian and the critics of his idea are in agreement.
"I think one thing we all agreed on was the fact that probably one of the most fundamental things we could do to promote the recovery and stability of folks is housing," said Jan VanTassel, executive director of the Connecticut Legal Rights Project, and part of a group of advocates who met with Killian last week. "The outcomes are just tremendous. The problem is we don't have enough rental assistance certificates."
But Killian believes something more needs to be done in the meantime.
"I truly believe that there are lots of alternatives that can also cut down recidivism amongst these patients, but we're not there yet," he said.
Of the advocates, he added, "I would ask them when they really think we're going to be in a position to quadruple the amount of available housing we have for these people. I don't see it in the short-term or mid-term cards. I hope it's there in the long-term ones."
A voice of experience
Critics of the proposal call the concept "outpatient commitment," a term Killian disputes. A public hearing on the bill drew a crowd of opponents to the state Capitol complex Thursday.
Pamela Spiro Wagner of Wethersfield told lawmakers that involuntary treatment is "the worst possible thing you can do to a person with a chronic psychiatric condition," making that person even more likely to stop taking the medications later on, particularly if they bring problematic side-effects.
She spoke from experience. Spiro Wagner, who has schizophrenia, described being hospitalized and taken off her regular medications three years ago. A hospital psychiatrist wanted her to take a different medication, but she refused because she knew it would make her miserable. Ultimately, she said, the hospital's security staff subdued her, stripped off her clothes, restrained her and injected her with another drug.
Allowing people to be medicated against their will in the community won't work, she said.
"In my opinion it is just coercion and cruelty masquerading as treatment, but it won't help anyone," she said. "It will only drive the would-be consumer as far away from so-called 'treatment' as they can get."
Other critics of the proposal said allowing people to be forcibly medicated could undermine their relationship with those providing treatment, which could hurt their chances of recovery.
"Every use of outpatient commitment discredits treatment among a naturally suspicious group of people whose encounters with the courts and treaters have not been positive," Robert E. Davidson, executive director of the Eastern Regional Mental Health Board, said in testimony. "People refuse meds for good reasons. We can counter those reasons, but only by convincing them that things have changed. If this proposal passes, that task becomes impossible."
In the past decade, the state has moved toward a "recovery-oriented" model for behavioral health. Rehmer described it as focused on working with people seeking or receiving treatment, and giving them choices and options for their treatment.
"What we've seen is that we've learned a great deal from individuals who have utilized the system or who are in recovery by talking with them about what works and what doesn't work," she said. "While medication seems like a primary treatment issue and it is for some people, we also know that really what helps people get into recovery and stabilize in recovery is housing, jobs and some sort of sense of involvement in their community and purpose in life."
"Those are almost as equally, if not equally, important as the clinical treatment that people engage in," she added.
VanTassel described the change in the mental health system as moving from one in which people are told what they have to do to one in which people are asked what they can do with their lives, and how the system can help them get there.
If a person says he wants to be an astronaut, she said, you could dismiss it. Or you could engage him by suggesting he look into what would be required and come back and discuss it with you. Odds are he would find the requirements aren't for him. But he'd have reached that conclusion himself.
Shorter hospital stays
When Killian became a probate judge 29 years ago, hospital stays could be measured in months. Now they typically last five to seven days, with the majority of psychiatric work handled on an outpatient basis -- a change he applauds. But the shorter inpatient periods mean less time to adjust medications, potentially ending with patients discharged before they take full effect.
Both Rehmer and Killian believe the population that could potentially be subject to the outpatient medication provision, if adopted, would represent a very small percentage of the people who receive services through the Department of Mental Health and Addiction Services; Killian estimated it at half of 1 percent. The bill would apply only to those leaving psychiatric facilities, and would allow the head of the facility to ask the probate court to appoint a conservator to authorize giving the person medication. There would have to be no less intrusive beneficial treatment, and, without medication, the person's psychiatric disabilities would have to put the person or others at risk of harm.
Killian said the proposal is aimed at people for whom voluntary supports have not succeeded, leading to involuntary hospitalization.
"I'm not talking about somebody who has a depression," he said. "I'm talking about people who are profoundly mentally ill, most of whom are hearing voices, voices that tell them to do things, many of which are antisocial things, and part of the problem is our inability to properly treat this segment of the mentally ill."
But Rehmer said there's a slippery slope; the intentions behind a law, or the limitations it was created with, don't always guide the way it's used years after passage.
The bill also contains three other pieces that Killian called modest tweaks, but which advocates oppose. They would:
• Reduce from two to one the number of independent psychiatrists who must examine a person and submit reports in commitment hearings.
• Allow patients in nursing homes who refuse psychiatric medications to be medicated under the authority of a conservator in the facilities. Currently, they must be moved to a hospital, which Killian said can be traumatic.
• Allow people developing treatment or discharge plans for patients in psychiatric facilities to communicate with and get medical records from health care providers who previously treated the patient, and to communicate with the patient's family and anyone the patient lived with in the past year to better understand the patient's medical needs. Killian said this could provide insights into the person, including medications that have been problematic. Advocates say it would violate clients' privacy and could be especially problematic if family members are part of the reason the patient was in crisis. Instead, they say, clients are urged to create advance directives that spell out who can share information and what medications do or don't work for them.
Killian said he hopes those three parts of the bill pass. He's not holding his breath for the outpatient medication piece, at least this year.
"I think it's important that people start talking about it," he said.