After Newtown: A rethinking of Connecticut law on outpatient commitment

The first time Jeanne Maillet's family called the police on her mentally ill relative, they thought he would finally get to a doctor, get treatment and get better.

"We were so naïve," she said.

Instead, it was only one step in what Maillet calls five years of hell, trying to get him help in Connecticut's mental health system. When he's not taking his medication, he hears voices and believes he's being followed. At one point, he slept with a hammer under his bed and a machete in his car. He's had psychotic episodes and been hospitalized nine times in five years. He spent eight months in jail after starting a fire in his apartment.

He doesn't think he's ill. And Maillet wishes there was a way to require he get treatment -- something she thinks would be possible in nearly every other state.

Forty-four states have laws that allow court-ordered treatment, under certain circumstances, for people with mental illness who are not hospitalized -- a concept known as outpatient commitment, or assisted outpatient treatment.

Connecticut is one of six states without such a law, and at least until recently, there was little appetite for creating one. Advocates for people with mental illness say Connecticut's system is at the leading edge of a model that takes the opposite approach, with a focus on having people with mental illness make choices about their treatment, the same way a cancer patient would.

But the concept is almost certain to come up in a new context this year as lawmakers take a closer look at mental health policies after the shooting at Newtown's Sandy Hook Elementary School.

Senate Majority Leader Martin M. Looney, D-New Haven, said outpatient commitment, while controversial in the past, "bears looking at again" in the legislative session that begins next week.

"I think in the wake of what happened in Newtown, obviously there's going to be a new framework for many of these debates," he said. "Much of the country has already embraced this."

But advocates for people with mental illness say mandating treatment will backfire, alienating people from the services and professionals that could help them, and would drain resources from community programs that could stop a person from reaching a crisis point.

They point out that most people with mental illnesses are not violent, and say it would be a mistake to embrace outpatient commitment because of the Newtown shooting.

"We're all a little emotionally raw as a result of what's happened in Newtown, but it might just be a knee-jerk reaction that is unfounded," said Christine Limone, political advocacy director for the National Association of Social Workers' Connecticut chapter. "It concerns me to have policy being developed in an emotional, knee-jerk fashion."

A pendulum swing

Like a pendulum, the way laws treat people with mental illness has swung back and forth over the past two centuries, from laws that made it easy to hospitalize someone involuntarily to those that made it possible in only limited circumstances.

"We have swung all the way from that very, very liberal interpretation of how people can be committed to very, very restrictive interpretations requiring very imminent sense of harm to self or others and even then allowing only very, very short hospitalizations," said Harold "Hank" Schwartz, psychiatrist-in-chief at the Institute of Living in Hartford.

In much of the country, the pendulum has swung back somewhat in the past 15 years, Schwartz said, as states have embraced outpatient commitment laws meant to address a small subset of people with mental illness who are "revolving door" patients. They typically don't believe they have an illness and don't take medication or get treatment when they're not hospitalized.

Outpatient commitment laws allow judges to require a person to get treatment while outside the hospital or face sanctions, although even supporters say such laws are not always used effectively.

That pendulum swing hasn't happened here.

"In a state like Connecticut, we've been essentially left with no way to control anybody in any way, shape or form once they leave the hospital," Schwartz said.

A legislative proposal that would have changed that died in committee last year after generating a strong backlash. It would have allowed courts to order medication for people if remaining unmedicated would have left them or others at risk of harm. But even the measure's main proponent, Hartford Probate Judge Robert K. Killian Jr., who proposed it after growing frustrated at seeing severely mentally ill people cycle through his court to be committed to hospitals and losing their stability in the community, acknowledged that it was "a reach by Connecticut standards."

What makes Connecticut different?

Some people cite the state's well-developed advocacy community. It coalesced in the late 1990s as the state hospitals closed and public officials talked of creating a world-class community-based mental health system -- but never funded it, said Kate Mattias, executive director of the National Alliance of Mental Illness Connecticut.

Along with that has been an "individual civil rights movement" of people with mental illness demanding input in their treatment and that the state be responsive to their needs, Mattias said.

Schwartz said that's influenced the state's resistance to considering outpatient commitment.

"There's a kind of cultural attitude about the rights of the mentally ill in Connecticut which make it almost verboten to raise the subject," he said.

Double standard or reasonable distinction?

Will the Sandy Hook shooting change things?

"I would be really shocked if the tone didn't change," said Kristina Ragosta, legislative and policy counsel for the Treatment Advocacy Center in Virginia.

In many states, outpatient commitment laws were inspired by crimes committed by people with mental illness and bear the names of victims. New York's Kendra's Law was named for Kendra Webdale, who died in 1999 after a mean with untreated mental illness pushed her in front of a subway train.

Those laws aren't a way to permanently commit a person, but a tool for getting him or her able to be independent, Ragosta said.

"They're meant to get people well and to find treatment that works for them so they can be on that quote unquote road to recovery," she said.

Critics of outpatient commitment say there's a double standard, that no one would consider a law that forces diabetics to take their insulin, even if remaining untreated would land them in the emergency room with a medical crisis.

"I think that's an example of the discrimination that goes on for individuals that have mental illness," said Patricia Rehmer, Connecticut's commissioner of mental health and addiction services.

Ragosta says it's not an accurate parallel because there are people whose mental illness itself prevents them from recognizing that they're ill. For the small group of people who would be affected by outpatient commitment, she believes Connecticut's model of giving people choices about their treatment doesn't make sense.

"The population we're talking about, that has a potential for danger, has a history of violence, history of noncompliance, I think to say that we need to leave all these decisions up to them on treatment seems pretty ignorant to me," she said. "You're ignoring the reality of the disease and not only doing harm to that individual but to their families and the public."

Rehmer counters that there are ways to get people who don't think they're ill to get treatment, often through the urging of someone they have a strong relationship with. Requiring treatment would undermine those relationships and turn people away from the system, she said.

It's ethically questionable to commit someone to treatment against their will unless they had the ability to choose and access every level of care, the commissioner said.

And Rehmer noted that other states that have had mass shootings, including Virginia, Colorado and Arizona, have outpatient commitment laws. The man who killed eight people and himself at the Hartford Distributors warehouse in Manchester in 2010 did not have prolonged mental illness, while the man who killed four people and himself at the state lottery headquarters in 1995 was under the active care of a psychiatrist and taking medication voluntarily, Rehmer said. It's not yet known whether Adam Lanza, the Newtown gunman, had a diagnosed psychiatric illness, although Rehmer said he "wasn't known to us."

"We don't know whether outpatient commitment would have in fact stopped any of this behavior," she said.

Watching a slow deterioration

The first time her relative entered a psych unit, Maillet worried how he'd ever get a job after that. She used to spend her drives to him in tears.

Now she has different expectations.

"You kind of mourn that person," she said. She wishes he could get a volunteer job a couple of hours a week.

For now, he moves from crisis to crisis. And crisis means he'll be hospitalized for 10 days.

She and her sister got him disability and an apartment. They make sure his cellphone bill is taken care of and get calls from him when he loses his keys.

"We're the ones who have his whole life taped together," she said.

She's frustrated by what she considers a lack of responsiveness from the state's mental health system, and the inability to do anything about his circumstances. She's complained that he lives in squalor, and been told that it's his choice.

Most recently, she learned that he's once again off his medication.

Rehmer said she speaks frequently with parents who are frustrated with their inability to do something to help their child, who is often in their twenties or thirties and has deteriorated slowly.

"What I often say to people is that recovery is a process," she said. "Even if somebody goes into the hospital, it's not unusual for somebody to go into the hospital and start taking medication and actually recompensate pretty well, and then end up going to probate court, and the judge isn't able to commit them because they look so different on medications. But then they stop taking the medications when they leave."

"And I think it's our job, again, to work to engage them and get them involved in their treatment and try and work with them where they're at," she said.

She acknowledged that that doesn't necessarily address family members' frustrations.

"It's an awful thing to have to watch as a parent and as a family member," Rehmer said. "But again, these are adults and we have to also work to protect people's civil rights."

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