Illusions, delusions and possible solutions

On March 29, the Joint Committee on Judiciary held a hearing on raised bill, SB 452, which is now dead. Unfortunately, the committee was largely presented with a highly distorted and misinformed picture of Connecticut’s existing civil commitment law and what the bill would have done. The discussion centered on patient rights and the ineffectiveness of “forced medication;” it ignored many of the realities of untreated mental illness and the need for such laws.

Among the critical information largely absent from the discussion:

Every state in the country has some form of court-ordered treatment laws, sometimes called mandated treatment or involuntary treatment. Connecticut is no exception.

Every state in the country allows for individuals who are a danger to themselves or others (defined differently in virtually every state) to be held against their will, in a hospital setting. Connecticut is no exception.

Every state has laws for guardianship provisions or conservatorship provisions (often used for elderly individuals suffering from diseases like Alzheimer’s). Connecticut is no exception.

Every state has laws, procedures or regulations to medicate a person overcome by severe mental illness in a hospital setting when certain standards are met (“forced medication”). Connecticut is no exception.

Where Connecticut deviates from the majority of the country is in its absence of an option for court-ordered community treatment (assisted outpatient treatment, or involuntary outpatient commitment) as a less restrictive alternative to hospitalization or jail. Connecticut is one of only six states without an option for court-ordered community treatment.

SB 452 would not have changed this.

The reason assisted treatment laws are necessary is because a small, but significant, number of individuals with severe mental illness are so ill that they are unable to seek mental health treatment voluntarily.

This lack of capacity to understand they are sick – a neurological syndrome called anosognosia – is believed to be the single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications (or seek treatment). The condition is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar disorder.

In their well-intentioned efforts to advocate for the larger population affected by mental health problems who are capable of seeing medical care voluntarily, many mental health advocates discount or ignore those who are so ill they can only choose treatment after they have received involuntary treatment to stabilize them. This is the population that ends up trapped in the revolving door of criminal justice, homelessness and emergency rooms.

The next time that Connecticut has the opportunity to make improvements to its civil commitment law, a better strategy for addressing the issue of untreated mental illness would be to provide an option of assisted outpatient treatment to those patients too ill to seek treatment voluntarily.

Assisted outpatient treatment laws typically utilize a court order to provide for a comprehensive treatment and services plan, which may include medication and, when implemented, require the individual patient to follow his or her treatment plan. These laws do not typically authorize the actual administration of medication. Rather, the purpose of the court order is to help individuals (often with a history of non-compliance) to comply with treatment and to ensure more oversight from community mental health agencies in order to prevent costly and more intrusive consequences such as arrest, incarceration, hospitalization.

Results from multiple studies demonstrate that when implemented, assisted outpatient treatment laws work at reducing rates and incidents of hospitalization, arrests, emergency room visits, victimization, and violence. For example, one study of results under New York’s law found that:

  • 77 percent fewer experienced hospitalizations compared to before participation.
  • 74 percent fewer experienced homelessness compared to before participation.
  • 83 percent fewer experienced arrests compared to before participation.
  • 88 percent fewer experienced incarceration compared to before participation.

Assisted outpatient treatment is a bridge to the “recovery” that advocates speak so passionately about. By providing structured, early intervention outside of psychiatric hospitals, these laws encourage patients to be engaged in their own recovery through active participation in their treatment plans.

The overwhelming majority of individuals testifying on March 29 focused on their perceived negative consequences of “involuntary outpatient commitment” and equated outpatient commitment to forcible medication (e.g., physically forcing an individual to take medication). Both perceptions are without basis – the first disproven by a large body of independent research and the second because it is without factual accuracy.

A more constructive use of such advocacy energies would be to focus on ways to help this neglected population while making the most effective and efficient use of scarce resources.

 

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