Connecticut recently received an “F” grade in a national report for being one of three states that doesn’t allow the courts to order people with mental illnesses to comply with outpatient treatment.
But Miriam Delphin-Rittmon, commissioner of the Connecticut Department of Mental Health and Addiction Services, and other key mental health care advocates wouldn’t have it any other way.
“I find it difficult to believe that a system that has as robust mental health services as Connecticut would earn an ‘F’ because the system values engagement rather than forcing someone into treatment,” Delphin-Rittmon said.
She added that historically the state has not been in support of outpatient commitment, also known as assisted outpatient treatment (AOT).
Forty-seven states have laws that allow outpatient commitment, according to the national Treatment Advocacy Center (TAC), a nonprofit that supports and advocates for the practice. All states have had involuntary inpatient laws for decades.
Connecticut, along with nine other states, received an F from TAC in a recent report. The report graded each state on its involuntary commitment laws by analyzing its emergency psychiatric evaluation process, and its inpatient and outpatient laws.
Twenty-two states scored at or above a B minus. If a state doesn’t have an outpatient commitment law — as Connecticut, Maryland and Massachusetts do not — it fails.
The first outpatient commitment laws were passed in the 1980s. Since then, the practice has been heavily debated, generating strong reactions from both supporters and opponents. Many researchers have released studies over the last three decades that examine the efficacy and success of the practice.
The American Psychiatric Association’s Board of Trustees took a position on outpatient commitment in 2015.
The association’s position says “if systematically implemented and resourced, (outpatient commitment) can be a useful tool to promote recovery through a program of intensive outpatient services designed to improve treatment adherence, reduce relapse and re-hospitalization, and decrease the likelihood of dangerous behavior or severe deterioration among a sub-population of patients with severe mental illness.”
But in Connecticut, state officials have rejected this position, arguing instead that outpatient commitment will alienate people from the professionals and services that could help them, and that there are other ways — voluntary ways — to treat those who are severely mentally ill.
“We all know for many people choice, or being stripped of certain choices, is connected to trauma within their own lives,” said Delphin-Rittmon. “We don’t want to perpetuate that in the treatment system.”
Supporters of the practice, however, say it only applies to a small subset of people with very severe mental illnesses who are unable or unwilling to participate in prescribed treatment. Consequently, their conditions deteriorate, which can result in repeated involuntary hospitalizations, homelessness and involvement with the criminal justice system.
In some states, a judge can order outpatient commitment for someone who is already involuntarily hospitalized, allowing them to leave the hospital. In other states, and the model that TAC supports, outpatient treatment can be court-ordered before someone meets the criteria for inpatient commitment.
TAC Executive Director John Snook said that in these cases, someone — usually a doctor or a family member — files a petition with the civil court for an outpatient commitment hearing. After that, a psychiatrist has to provide the results of a recent examination or conduct an exam of the person.
A judge then determines if the petition and examinations support a hearing. If the judge decides they do, the person is notified and a hearing is held, unless the person waives his or her right for a hearing and agrees to the conditions of the outpatient commitment order.
While there’s historically been little appetite in Connecticut for outpatient commitment, the concept did publicly surface after the Sandy Hook shootings.
Dr. Harold (Hank) Schwartz, psychiatrist in chief emeritus at the Institute of Living, an outpatient and inpatient psychiatric facility in Hartford, has supported outpatient commitment for years in Connecticut. Schwartz said during a recent interview that he understands the concerns about the practice and that research on the outcomes of outpatient commitment varies greatly in its conclusions.
“The devil is very much in the details of of any law passed,” Schwartz said. “I don’t think that should stop us from focusing on the safety and the wellbeing of the most disabled of the mentally ill.”
Schwartz, who is also a psychiatry professor at the UConn School of Medicine, said outpatient commitment would benefit a very small, but very sick group of people.
“There’s a subset of patients who, no matter what degree of access to services may be available, simply do not believe they are ill and (believe they) do not need treatment,” he said. “That is the subset of patients who become the revolving door patients.”
CT focuses on voluntary treatment, instead
Delphin-Rittmon pointed out that Connecticut does have inpatient commitment laws. These laws include allowing hospitals to hold an individual for 72 hours if he or she is a threat to his or herself or others, and to medicate if necessary. Individuals can also be civilly committed for inpatient treatment for psychiatric disability through the Probate Courts.
The state scored a 41 out of 50 for its inpatient commitment laws in the TAC report.
Delphin-Rittmon said that instead of embracing outpatient commitment, the state has developed a myriad of team-centered programs that work to provide treatment to people with severe and persistent mental illnesses, without a judge’s order.
According to DMHAS, there are ten ACT, or Assertive Community Treatment, teams working throughout the state to provide outreach, treatment, family education, peer support, and health and vocational services. ACT is an evidence-based practice and the teams include therapists, prescribers, employment specialists and peer specialists. The peer specialists are individuals also with mental illnesses.
These services are intensive and often support individuals who have been discharged from an inpatient setting or have not succeeded at a lower level of care. The goal is to divert individuals from inpatient and emergency services by providing intensive, community-based services, according to DMHAS.
In the state’s fiscal year 2018, ACT teams helped 751 residents throughout the state.
DMHAS also has 15 mobile crisis teams that respond when someone is having a behavioral health crisis. The teams connect with individuals by phone or in-person, often going to the person. In 2018, the teams responded to more than 8,000 calls, serving nearly 6,000 people.
Crisis intervention teams, which include state workers, also work with law enforcement. When responding to a call from someone having a mental health emergency, the teams will work with police in an effort de-escalate and diffuse the situation, and to divert the person from jail into treatment.
TAC’s take
Snook agreed that Connecticut’s mental health system does provide many services, especially for those involved with the criminal justice system.
“The one giant chasm is when it comes to providing outpatient commitment, providing people care in a situation where they’re too sick to understand that they need treatment on their own, but they aren’t yet dangerous or won’t ever be violent in the manner that the current commitment standard requires.” Snook said.
“The folks who are in that window – in need of care but not well enough to participate voluntarily – experience negative outcomes associated with a lack of treatment. Symptoms get worse and they are at increased risk of homelessness, victimization, arrest, loss of employment, disconnections with family, etc,” he said. “This is a proven tool in the toolbox, which Connecticut doesn’t want to use and the reason given isn’t one based on science.”
But Kate Mattias, executive director of the Connecticut chapter of the National Alliance on Mental Illness (NAMI), doesn’t see outpatient commitment as the “panacea” that many people do.
“I see it as diverting time, attention and potential resources,” Mattias said. “You can mandate services, but if the services aren’t there, they’re not going to get the services they need.
“We really strongly believe that there are so many steps and so much that needs to be filled in the state mental health system before one can even have a conversation around AOT,” she said.
She also said she sympathized with family members who have loved ones with severe mental illnesses.
“I certainly understand,” she said. “My husband had a serious mental illness. Sometimes the illness will make family members feel absolutely helpless. I understand that.”
“What I also understand is that it is happening to an individual who is an autonomous individual, who maybe not in that moment can make the best decisions for themselves. But there are things you can do that would allow family members under those circumstances to understand what that individual wants.”
Mattias said this can include completing an advance directive, like people do for end-of-life care. This legal document can describe treatment preferences and name someone to make treatment decisions, should the person with a mental health condition be unable to make or communicate decisions.
But while NAMI-CT opposes outpatient commitment, its parent organization, NAMI national, supports it.
“We view it as a last resort and a mechanism appropriate for a relatively small number of people,” said Ron Honberg, senior policy advisor at NAMI.
“Certainly, voluntary treatment is always our preference. But some folks are very difficult to engage, even when services are available to them,” he said. “The severity of their symptoms may prevent them from recognizing that they are ill or from agreeing to services no matter what you do.”
He also said that the voluntary system of treatment isn’t always effective and that outpatient commitment is often misunderstood.
“It conjures visions of people being forcibly injected with medications by police, which is not the case,” he said.
When done correctly, outpatient commitment can include peer and family supports, employment services, shared decision making, and other services designed to help people recover, he said.
“If you have a system that’s only voluntary, you run the risk of leaving those individuals who are most ill behind and shifting the burden to the criminal justice system.”
But he said, since outpatient commitment is a state issue, “We typically defer to priorities set by our state organizations and try to provide assistance whenever feasible. We also understand that NAMI Connecticut works with a large coalition of organizations in setting priorities and adopting positions on specific issues.”
Jeffrey Swanson, professor in psychiatry and behavioral sciences at Duke University, has researched outpatient commitment for more than 30 years with his colleague, Dr. Marvin Swartz.
Swanson said sufficient evidence exists to justify wider implementation of outpatient commitment, based on his years of research and his reviews of literature about the practice.
“There are states where there are outpatient commitment laws on the books and they’re not using it at all,” he said.
But Swanson stressed that outpatient commitment “has to target the right people at the right time.”
“It has to be this group of people who can benefit from it and who would not participate in treatment voluntarily” he said. “You don’t want to apply it over broadly. Most people with mental illness want to get treatment and recover on their own terms.”