Monday, March 28, 2005
TAC Newsletter 3/25/05
ENEWS - TREATMENT ADVOCACY CENTER
TREATMENT ADVOCACY CENTER
Visit our web site www.psychlaws.org
March 25, 2005
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1. MANDATORY MEDICATION LAW IS NEEDED - CAPITAL WEEKLY, March 25, 2005
2. KENDRA'S LAW A GOOD TOOL TO PROTECT SOCIETY - TROY RECORD, March 11, 2005
3. PRESS RELEASE FROM NEW YORK GOVERNOR GEORGE E. PATAKI, March 7, 2005
4. RESOLUTION OF MAINE CHIEFS OF POLICE ASSOCIATION, March 15, 2005
5. THE CURSE OF A BIPOLAR DISORDER: ECSTACY & DESPAIR - DECATUR DAILY, March 13, 2005
6. SUICIDE IS AN IMPORTANT ISSUE - SUMMIT DAILY NEWS, March 15, 2005
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CAPITAL WEEKLY (Augusta, ME), March 25, 2005
[Editor's Note: Maine Senator John Nutting's proposal to bring assisted outpatient treatment to his state was fortified this week by the strong and lengthy editorial endorsement below from Augusta's Capital Weekly. It is hard for Maine advocates to look for more than their capital city's paper branding their measure "bold, incisive - and sensitive." Our only addition to this editorial would be to highlight that Senator Nutting's primary goal with this bill is to address improve the condition of those that it is used to help.]
MANDATORY MEDICATION LAW IS NEEDED
Editorial
Sen. John Nutting of Leeds has introduced a bill that deserves the backing of the Legislature and the people of Maine.
His bill is bold, incisive - and sensitive - for it pits the rights of the mentally ill against the safety of family members, co-workers, and community members who live within range of the severely mentally ill with violent tendencies.
Nutting's proposal would allow the courts to force a small segment of the mentally ill to take their medications or face going back to the hospital, where the drugs would be automatically administered.
Maine is one of only eight states that does not have a mandatory medication law for persons with mental illness who also have a history of violence or self-destruction when they go off medication.
Nutting's bill addresses a very small slice of the mentally ill population in Maine, somewhere between 50 and 100 people, who repeatedly go off medications, then spiral downward until they wind up in the hospital. This happens over and over and over again, according to testimony from doctors and other caregivers who showed up for the public hearing on LD 151 a few weeks ago.
Right now the bill has been turned over to an impartial 15-member committee of legislators, family members, doctors and others who will study the language and make sure the proposed legislation allows for full due process.
The bill is expected to go back to the Health and Human Services Committee by May 1.
Nutting's bill is not aimed at highly functional people who take antidepressants, for example, and decide to go off them. They do not pose a threat to public safety or to other people.
But there is a segment of the mentally ill population that has a history of violence when not on medication, a history of going off medication, and for whom it has been shown that irrational or dangerous behavior disappears when the person is put back on drugs.
Under Nutting's bill, a person in that category could be forced under court order to stay on medication for six months and remain in close touch with a psychiatrist. If the person still refused to take the necessary drugs, he or she could be taken back to the hospital.
Due process would be assured during the court proceeding by having an attorney or an advocate present for the mentally ill person. And a judge might very well rule that the mentally ill person can remain off drugs if carefully monitored.
The need for Nutting's bill is obvious. Homeless shelters are repositories for the mentally ill, some of whom are dangerous, especially when drinking or on drugs. Horrific crimes have been committed in Maine by severely mentally ill people who were off medications and hallucinating. Mentally ill people are arrested every day for petty and serious crimes, arrests that could be avoided if a medication regime were adhered to.
In New York state, when a mandatory medication law was passed, violent crimes committed by the mentally ill went way down, arrests of the mentally ill went down, and 91 percent of those who were not taking medication began taking it just because that law was on the books.
The law in New York, by the way, is called Kendra's Law and is named for a young woman who was pushed in front of a subway car by a mentally ill man who was off his medications and hearing voices.
The question of patients' rights comes up at a time like this, as well it should. Advocates for the mentally ill say that patients, no matter how sick, have a right to go without medication. We disagree with that argument. A person's right extends only as far as the safety of another person. When a mentally ill person with a history of violence goes off medication, that becomes a societal issue, not a personal choice.
Advocates for the mentally ill do make some good points. They note that transportation to medical appointments is a problem because most severely mentally ill people don't have cars. There's also the problem of finding a psychiatrist who will spend more than 15 minutes with a patient and monitor that patient closely.
And it's true that community services are not what they should be. In our rush to empty out mental hospitals in the 1970s and beyond, we simply could not keep pace with community needs for the mentally ill. The result for some has been a revolving door of hospitalizations, release into a stressful world, and readmittance to the hospital.
If we had mandatory medication laws for the most dangerous segment of the mentally ill population, millions of dollars could be freed up from hospital care and transferred to community services.
Maine was once a leader in mental health care, with one of the first mental hospitals in the country. But over the years our system became frayed around the edges and gradually broke down, for lack of money and lack of will.
And somewhere along the way, the rights of patients became more important than the rights and safety of society, to the point that the patients and their advocates are calling the shots.
This has to end. And Nutting's bill would help do that.
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TROY RECORD (NY), March 11, 2005
[Editor's Note: The legislation that created Kendra's Law expires on June 30. The effort to remove this expiration date on New York's assisted outpatient treatment program and to make the law permanent has already picked up some supporting editorials, including this one.]
KENDRA'S LAW A GOOD TOOL TO PROTECT SOCIETY
Editorial
Kendra's Law is a controversial mandate in New York state that offers outpatient services to the mentally ill, a good thing, but which also allows court-ordered treatment, which is where the controversy comes in.
Advocates for the mentally ill like much of the law but object strenuously to the provisions that allow families or caseworkers to petition the courts to have people potentially harmful to themselves or others ordered into a rehabilitation facility.
The law is temporary, due to expire June 30 after a five-year trial as to the law's effectiveness.
Supporters of the law are eager to see it made permanent, while many advocates are looking for major overhauls that would include striking any language that allows forcible treatment.
We believe the state Office of Mental Health is correct in praising the program and urging that it enter the permanent-law roster. The success rate in the treatment of 6,600 people over these past five years speaks for itself.
Not that we think advocates are totally out of line when they say the law may speak for itself, but who speaks for the mentally ill who are mandatorily detained against their wills.
In our opinion, the unvarnished truth is that some mentally ill people do not know what is good for them. More important, we believe the courts should have a say in what is good for society as a whole.
The American Civil Liberties Union has chimed in, raising issues of constitutionality in that people can be held for up to 72 hours without a hearing while being evaluated by health professionals.
But the courts have sided with the state.
We argue that the 72-hour limit is what makes even the odious practice of court-ordered treatment acceptable, if not completely palatable. It is not as if a person can be arbitrarily detained for an indefinite period of time.
The law is named after Kendra Webdale, a Fredonia native who was killed when pushed in front of a subway train by a sometimes-violent diagnosed psychotic who refused to take his prescribed medicine.
Caseworkers and family are the people who can most closely monitor a known psychotic and detect when a person is in danger of going over the edge. Who better to seek aid for the person in mental turmoil?
Personal rights are precious and should not be violated heedlessly, but there are times when the public good must be served, and we believe this is one of those times and that the Legislature should leave Kendra's Law on the books and intact
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PRESS RELEASE FROM NEW YORK GOVERNOR GEORGE E. PATAKI, March 7, 2005
[Editor's Note: Who better to assess the performance of a program than the people running it? Since Kendra's Law took effect on Nov. 8, 1999, the management of Kendra's Law has been the responsibility of New York Governor George E. Pataki and his administration. The Governor's opinion of assisted outpatient treatment? - He wishes to make the program permanent.]
GOVERNOR GEORGE E. PATAKI
OFFICE OF THE GOVERNOR
STATE OF NEW YORK
FOR IMMEDIATE RELEASE:
March 7, 2005
GOVERNOR INTRODUCES BILL TO MAKE KENDRA'S LAW PERMANENT
Report Documents the Success of Individuals Receiving Assisted Outpatient Treatment
Governor George E. Pataki today introduced legislation to make New York's Assisted Outpatient Treatment (AOT) law permanent. The measure, known as Kendra's Law, was first enacted in 1999 and is currently scheduled to sunset on June 30, 2005. It is named in memory of Kendra Webdale, who tragically died after being pushed in front of a subway train by a man with a history of mental illness and hospitalizations. Since being enacted Kendra's Law has successfully provided specialized services to more than 6,600 New Yorkers with mental illness.
"For the past five years, Kendra's Law has provided New Yorkers with mental illness access to the treatment they need in an effective manner that ensures their safety, as well as that of the public," Governor Pataki said.
"The vast majority of these individuals are already leading productive and fulfilling lives in their communities, but the results are clear -- Kendra's Law works. That's why I am proposing that this extremely successful program be made permanent."
Kendra's Law established a process for identifying individuals with mental illness who, in view of their treatment history and circumstances, are likely to have difficulty living safely in the community without supervision.
A five-year evaluation of the program was released last week by the Office of Mental Health (OMH) and has shown the program to be a resounding success. The use of mental health services by the population now being served by AOT has gone up by 89 percent over what was utilized prior to the implementation of the program.
Patricia Webdale, Kendra's mother, said, "The Assisted Outpatient Treatment program is having positive results, and I would like to commend OMH for a job well done. On a personal note, it brought tears to my eyes to see Kendra's name on the AOT report's cover. When we began this journey five years ago, my husband Ralph and I were hopeful that we could do something that would help just one person. We are very pleased to see that this program has helped so many."
Sharon E. Carpinello, R.N., Ph.D., OMH Commissioner, said, "Thanks to Governor Pataki's leadership, we have seen improved access to mental health services, improved coordination of service planning, enhanced accountability, and improved collaboration between the mental health and court systems. But when summarizing the results of AOT, it is most important to note the positive impact the program is having on the people who have successfully used it. Individuals with mental illness who participate in AOT are able to make and maintain real gains in their recovery -- the data tells us that, and so do the recipients."
Kendra's Law has created a procedure for obtaining court orders for certain individuals to receive outpatient treatment for mental illness. It also ensures that local mental health systems give these individuals priority access to case management and other services necessary to ensure safe and successful community living.
In addition to assisted outpatient treatment, Kendra's Law also addresses the need to ensure that mentally ill people who are moving from hospitals or correctional facilities to the community receive necessary psychiatric medications without interruption. Fully funded in the Governor's Executive Budget, the law's statewide medication grant program enables counties to provide people who are discharged from psychiatric hospitals, state prisons or county jails with psychiatric medication they may need while they are applying for Medicaid.
In addition, the law clarifies and authorizes the sharing of necessary clinical information of patients with mental illness between psychiatric hospitals as well as between psychiatric hospitals and general hospital emergency rooms. This sharing of information helps to provide clinicians with accurate clinical histories, resulting in better diagnoses and treatment.
The five year report that was recently released reviews the impact and outcomes of various elements of the AOT program from its initial implementation in November 1999 through December 2004. During that time, 10,078 individuals were referred for AOT assessment. Of those, 3,766 individuals received services under an AOT court order, and an additional 2,863 received service enhancements without a court order.
AOT participants show a significantly increased participation in case management, substance abuse, and other treatment services; increased adherence to prescribed medication; improvements in social and family functioning; and improvements in community living. They also demonstrate a reduction of harmful behaviors, including reduced incidence of hospitalization, homelessness, arrest and incarceration.
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Read the full report: http://tacenews.c.topica.com/maadkG3abfsirbfGwZEb/
Read a summary by TAC: http://tacenews.c.topica.com/maadkG3abfsirbfGwZEb/
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RESOLUTION OF MAINE CHIEFS OF POLICE ASSOCIATION, March 15, 2005
[Editor's Note: In the last E-News, we commented that members of law enforcement almost always favor treatment law reform. That is certainly the case in Maine. Last week we shared a resolution supporting the introduction of assisted outpatient treatment from that state's Sheriffs' Association. Below is one from the Maine Chiefs of Police Association that takes that same policy stand.
This resolution is available on our website in its original formatting at:
http://tacenews.c.topica.com/maadkG3abfsisbfGwZEb/ ]
RESOLUTION
MAINE CHIEFS OF POLICE ASSOCIATION
SUPPORTING LEGISLATION CREATING ASSISTED OUTPATIENT TREATMENT FOR PEOPLE WITH SEVERE MENTAL ILLNESSES
WHEREAS, the role of Maine law enforcement officers in responding to serious crises involving people with severe mental illnesses is continually increasing; the safety of law enforcement officers and citizens, particularly those who are mentally ill, is seriously jeopardized; and an inordinate amount of law enforcement resources are being expended for this purpose at a time when we can least afford it; and
WHEREAS, nationally, people with severe mental illnesses are nearly four times more likely to be killed in altercations with police. Too often these altercations arise because a person with a severe mental illness stops taking their medication; and
WHEREAS, law enforcement too often responds to preventable and heart-wrenching tragedies involving people with severe mental illnesses such as an 18-year old man committed suicide after he stopped taking medication for bipolar disorder and a mother with schizophrenia who tried to kill her 11-year old daughter; and
WHEREAS, current law in Maine prevents families, law enforcement officers, and mental health professionals from helping a person who refuses treatment for severe mental illness until the person "poses a likelihood of serious harm", and also limits the remedy that judges have to ordering inpatient hospitalization, unlike other state laws that allow judges to court order outpatient mental health services before a crisis occurs; and
WHEREAS, 42 other states have laws that allow for court-ordered outpatient treatment (also known as "assisted outpatient treatment") for people with severe mental illnesses who refuse treatment, in most cases because the illness prevents them from recognizing that they are ill; and
WHEREAS, empirical evidence from studies and states using assisted outpatient treatment (AOT) shows that AOT is effective in reducing incidents of hospitalization, homelessness, arrests and incarcerations, victimization, and violent episodes among people with severe mental illnesses who otherwise refuse treatment. AOT also increases treatment compliance and promotes long-term voluntary compliance for people with mental illnesses. Among other benefits, these outcomes reduce law enforcement contact with people with severe mental illnesses; and
WHEREAS, it is clear that providing for assisted outpatient treatment could have prevented some of our state's recent tragedies by ensuring early intervention and sustained treatment in the community for people who otherwise are unable or unwilling to access such treatment, particularly medication;
NOW, THEREFORE, BE IT RESOLVED, by the Maine Chiefs of Police Association that we support the passage LD-151, a bill providing for assisted outpatient treatment in Maine; and be it further
RESOLVED, that the incidents and tragedies cited above as well as the many not mentioned herein demonstrate the significant stake that law enforcement has in ensuring the efficacy of state funded mental health services in treating people with severe mental illnesses.
SIGNED: CHIEF JERRY HINTON, President
ATTEST: ROBERT M. SCHWARTZ, Executive Director
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DECATUR DAILY (AL), March 13, 2005
[Editor's Note: We know it happens, we can process the concept of it, but it is almost impossible for someone who has not experienced the inexplicable gloom and rootless but overpowering hopelessness to truly understand how the symptoms of severe mental illnesses can cause people to take their own lives. Eric Fleischauer, the gifted author of this piece, provides insight into this startling phenomena and provides other educating glimpses into what it is like to have bipolar disorder.
Approximately 5,000 people with bipolar illness and schizophrenia commit suicide each year. Details on this monumental tragedy are in our fact sheet at:
www.psychlaws.org/BriefingPapers/BP6.htm ]
THE CURSE OF A BIPOLAR DISORDER: ECSTACY & DESPAIR
By Eric Fleischauer, Daily Staff Writer
Adorned with dim chandeliers and heavy silence, the Huntsville funeral home holding the ashes of Linda Beshears clashed with the view from its foyer.
The clash between inside solemnity and outside commerce echoed the self-destructive impulses within a woman who worked tirelessly for her family, but felt responsible for crimes that she could not have committed.
A Wal-Mart bustled with shoppers as last week's memorial took its course, customers' horns and voices made quiet by thick windowpanes. People yanked at doors and pulled at furniture at the U-Haul shop next door, eager to get from here to there. A steady stream of people trickled into Hollywood Video, emerging in minutes with their $4 escapes in hand.
High Cost Of Escape
For Beshears of Lacey's Spring, the cost of escape - from internal clashes between mania and depression - was high. The coroner labeled her death suicide, but the 120 people at her memorial service knew better.
Beshears died from the disease that plagued her for the last eight years of her life. She died of the internal war called bipolar disorder.
One in 20 suffering from bipolar disorder ultimately kill themselves. One in two try.
Beshears' death tracked the emotional extremes that plagued her. Doused in gasoline, she flamed in heat so extreme it melted the windows of her car.
Then she immersed her burned body in the frigid waters of the Tennessee River in Morgan County.
While Beshears' life was the most recent one snatched by bipolar disorder in this area, it was not the first.
In August, Janet Pearsall Haney, 26, killed herself with carbon monoxide by locking herself in a shed with her running car. In January 2004, 29-year-old Farron Barksdale, saddled by the disorder, shot and killed two police officers.
What Is Bipolar?
Bipolar disorder typically involves alternating cycles of mania and depression that lead to abnormal behavior. The most serious cases are a living hell as patients and families try desperately to find an unclouded reality, an emotional baseline.
People suffering from a manic episode are either euphoric or irritable. Other symptoms of mania, according to Dr. Andree Stoves at The University of Alabama at Birmingham Medical Center, include impulsiveness, decreased need for sleep, hypersexuality and dramatic increases in energy level.
"They feel grandiose," explained Stoves, who is director of psychiatric emergency services and psychiatric consultation services at UAB Medical Center. "They may even think they are having special communications from God. They often feel invincible."
The depressive episodes are just as bad.
"This is not the blues. You can't pull yourself up by the bootstraps," said Larry Cantor, Ph.D., a director at Decatur General Hospital West. "Some don't know how to live. Some feel death is the only answer."
Some with severe bipolar disorder develop a compulsion for self-injury, particularly "cutting." The term means something broader than suicide, but typically involves a laceration to the wrist.
Sometimes the intent is suicide, but at other times it is a means to break the mood cycling. At other times, it is a cry for help as a patient realizes he or she is losing his battle against suicide.
Listing the symptoms of bipolar is easy. Understanding the disorder's toll is not.
"No one understands being bipolar," said a 47-year-old woman suffering from the condition.
Like many of those suffering from the disorder, she will not use her real name due to the stigma associated with the diagnosis. She asked to be called "Rosebud."
"Other bipolars can't understand being me," Rosebud said. "I can't understand being other bipolars."
The cause of bipolar disorder is not well understood. There is a definite genetic component. Most who suffer from the disorder have a relative who also had it, but one identical twin may have bipolar disorder when the other does not.
"Extremely stressful situations can cause symptoms to manifest," according to Stoves. "So can the use of drugs. ... They may not be able to tolerate a stressor like a normal brain would."
From The Inside
The disease is bad enough. It is made worse for patients who experience social condemnation for the diagnosis.
Forty-year-old Randy said, "You can't imagine what it is like with the mental-illness label. It seems that with any other body part, it is socially acceptable for it to go bad, but if it's the brain, then you're a social leper."
Rosebud explains.
"Bipolars have to learn to be actors and actresses. People don't like us if they know what we are. I don't ever tell anyone what I am."
While the extremes of mania can be horrifying - replete with paranoia, irrational guilt and delusions - the less dramatic hypomania is sometimes pleasant.
Rosebud's nearly overwhelming anger at what bipolar disorder has done to her life includes frustration about her manic episodes.
"So I am stuck ... in this hell-hole of depression. I can't even be a decent bipolar," Rosebud said. "I can't go full-manic because of my ministry background. It holds me back from being the bad-girl, hypersexual person."
Forty-year-old "Shout" said the disorder is nerve-wracking even when its symptoms dissipate.
"Bipolar is never knowing who you really are," Shout said. "When you are manic, you are wonderful and when depressed, you are s---. When you're stable, you spend much of your time worrying that it won't last."
Manic Episodes
One person with bipolar said he woke up at 3 a.m. in a manic phase and proceeded to paint his basement in tropical colors. On Sept. 11, 2001, he feared the planes were headed for him, so he hid behind a chair with his "last meal," a bowl of cereal.
Some of those suffering from severe mania have a bond with their co-sufferers. Some can laugh at their antics, but not for long.
One man had a "magic pen" during a manic episode. He talked to it and it talked back as it helped him write a novel.
Another woman recalled pulling her pants down in a crowded restaurant, mooning a table of businessmen. The story triggered amusement from others who share her diagnosis, until she continued. "I want someone to put their arms around me and tell me it will be OK. I'm flying free, but scared."
Before shooting two police officers last year, Barksdale suffered severe paranoia as a result of his bipolar disorder, his lawyer said. Paranoia is sometimes a symptom of mania.
Beshears was apparently delusional, believing that she was responsible for terrorist attacks. She told a rescuer that the only way she could stop the violence she caused was to kill herself.
Treatment Of Bipolar
Stoves said this is an exciting time in the research of treatments for the disorder. She hopes that ongoing genetic research will lead to treatment, and an increasing number of medications are available to ease symptoms.
"Several drugs have gotten FDA approval for the management of manic episodes, and drugs are being found almost daily that modulate symptoms. There is even some research suggesting certain nutritional things, changes in food and diet, can affect the outcome," Stoves said.
Most people with bipolar disorder respond well to mood-stabilizing medication. For some, the problem is making themselves take it.
Cantor said one reason it is difficult to get bipolar patients to take medicine is that it disrupts the pleasure they feel during their hypomanic episodes. Some experience boundless optimism and creativity during these phases.
Their self-impression is not always off. Cantor said many successful businessmen and artists suffer from the disease. During their manic stages they are geniuses, but they come down hard when the depressive episodes hit.
"Some feel able to get a lot done, very confident," Stoves said. "The last thing they want is for someone to rain on their parade."
Getting patients to take medicine during depressive episodes is difficult for other reasons.
"They feel so depressed that they may be too exhausted to physically get up and get their medications," Stoves said. "Sometimes they feel so hopeless that they decide there is no need to take the medicines anyway, that it won't help."
For some patients, the disease becomes a part of their identity.
A bipolar woman reacted with fury to a bad interview question. Once her anger abated, she explained.
"My reaction to you describing my illness as 'hideous' was understandable when you consider how closely some of us identify with our disease. How could I not take your description personally?" she said.
The unwillingness to take medication is fodder for many an academic debate.
"I have always felt strong about civil rights," explained Cantor, "but this is a tough issue."
Alabama has an involuntary commitment law, but some consider it hard to use and sometimes slower than necessary for the protection of the patient or for the protection of others.
Limestone County Probate Court records indicate Barksdale was committed on several occasions. He would stabilize on medications, be released, and then stop taking them.
"What do we do? We know if we could just put them asleep for 72 hours, they would wake up as a different person," Cantor said.
While counseling is an important part in the treatment of those with bipolar disorder, it is not always successful in preventing suicide. Lessons learned between episodes may not stick.
"It's very difficult for people when they are in a given mood state to recall clearly when they didn't feel that way," Stoves said.
"Guilty ruminations," the term doctors use to describe symptoms such as those expressed by Beshears, are often present in severe bipolar disorder. They sincerely believe they are responsible for things over which they have no control.
"For most (bipolar) people who commit suicide," Stoves said, "if you really understand their thought processes, the suicide is a rational thing from their point of view. If I am to blame for all this, they figure, I don't deserve to live."
While the efforts of Stoves, Cantor and others have improved treatment, many remain in the disorder's deadly grasp.
"I rapid cycle, and when I am manic I am filled with rage and often don't remember clearly what I do," said Chilly, a 34-year-old man. "Then the guilt hits."
"Sometimes," he continued, "my mind races so much, the only way to slow it down is by cutting."
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SUMMIT DAILY NEWS (CO), March 15, 2005
[Editor's Note: With an able pen, Bonnie Norling highlights the catastrophic connection between mental illnesses and suicide along with the "choice" her own brother made because her state's treatment laws forbade his getting needed care.]
SUICIDE IS AN IMPORTANT ISSUE
Letter to the Editor
By Bonnie Norling, Silverthorne
Thank you Kimberly Nicoletti, for your informative and sensitive article about mental illness and suicide.
Thank you for bringing it forward even though denial is much more comfortable. After the personal experience of my Schizophrenic brother killing himself 4 years ago, I am painfully aware of the ramifications of these issues.
I listened for years as the "mental health" workers told us their hands were tied, because of current laws, to give him the help he really needed. He was an "adult" and had choices. The mentally ill are victims of their illness.
My brother was unable to make a healthy choice regarding the ramifications of not being on helpful drug therapy or his future well being. The tormenting voices and despair plagued him until he made his final "choice."
President Reagan's shooting, Willie Morrison's murder in Alma, and many suicides that we've experienced here in Summit County are results of mental illness.
The tragedies will continue if we aren't willing to recognize and talk about the need at a personal and community level.
With fearless attention and compassion, I believe there are solutions. So thank you Kim for bringing, once again, an important issue forward for discussion and hopefully thoughtful action.
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Treatment Advocacy Center E-NEWS is a publication of the Treatment Advocacy Center.
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TREATMENT ADVOCACY CENTER
Visit our web site www.psychlaws.org
March 25, 2005
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1. MANDATORY MEDICATION LAW IS NEEDED - CAPITAL WEEKLY, March 25, 2005
2. KENDRA'S LAW A GOOD TOOL TO PROTECT SOCIETY - TROY RECORD, March 11, 2005
3. PRESS RELEASE FROM NEW YORK GOVERNOR GEORGE E. PATAKI, March 7, 2005
4. RESOLUTION OF MAINE CHIEFS OF POLICE ASSOCIATION, March 15, 2005
5. THE CURSE OF A BIPOLAR DISORDER: ECSTACY & DESPAIR - DECATUR DAILY, March 13, 2005
6. SUICIDE IS AN IMPORTANT ISSUE - SUMMIT DAILY NEWS, March 15, 2005
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CAPITAL WEEKLY (Augusta, ME), March 25, 2005
[Editor's Note: Maine Senator John Nutting's proposal to bring assisted outpatient treatment to his state was fortified this week by the strong and lengthy editorial endorsement below from Augusta's Capital Weekly. It is hard for Maine advocates to look for more than their capital city's paper branding their measure "bold, incisive - and sensitive." Our only addition to this editorial would be to highlight that Senator Nutting's primary goal with this bill is to address improve the condition of those that it is used to help.]
MANDATORY MEDICATION LAW IS NEEDED
Editorial
Sen. John Nutting of Leeds has introduced a bill that deserves the backing of the Legislature and the people of Maine.
His bill is bold, incisive - and sensitive - for it pits the rights of the mentally ill against the safety of family members, co-workers, and community members who live within range of the severely mentally ill with violent tendencies.
Nutting's proposal would allow the courts to force a small segment of the mentally ill to take their medications or face going back to the hospital, where the drugs would be automatically administered.
Maine is one of only eight states that does not have a mandatory medication law for persons with mental illness who also have a history of violence or self-destruction when they go off medication.
Nutting's bill addresses a very small slice of the mentally ill population in Maine, somewhere between 50 and 100 people, who repeatedly go off medications, then spiral downward until they wind up in the hospital. This happens over and over and over again, according to testimony from doctors and other caregivers who showed up for the public hearing on LD 151 a few weeks ago.
Right now the bill has been turned over to an impartial 15-member committee of legislators, family members, doctors and others who will study the language and make sure the proposed legislation allows for full due process.
The bill is expected to go back to the Health and Human Services Committee by May 1.
Nutting's bill is not aimed at highly functional people who take antidepressants, for example, and decide to go off them. They do not pose a threat to public safety or to other people.
But there is a segment of the mentally ill population that has a history of violence when not on medication, a history of going off medication, and for whom it has been shown that irrational or dangerous behavior disappears when the person is put back on drugs.
Under Nutting's bill, a person in that category could be forced under court order to stay on medication for six months and remain in close touch with a psychiatrist. If the person still refused to take the necessary drugs, he or she could be taken back to the hospital.
Due process would be assured during the court proceeding by having an attorney or an advocate present for the mentally ill person. And a judge might very well rule that the mentally ill person can remain off drugs if carefully monitored.
The need for Nutting's bill is obvious. Homeless shelters are repositories for the mentally ill, some of whom are dangerous, especially when drinking or on drugs. Horrific crimes have been committed in Maine by severely mentally ill people who were off medications and hallucinating. Mentally ill people are arrested every day for petty and serious crimes, arrests that could be avoided if a medication regime were adhered to.
In New York state, when a mandatory medication law was passed, violent crimes committed by the mentally ill went way down, arrests of the mentally ill went down, and 91 percent of those who were not taking medication began taking it just because that law was on the books.
The law in New York, by the way, is called Kendra's Law and is named for a young woman who was pushed in front of a subway car by a mentally ill man who was off his medications and hearing voices.
The question of patients' rights comes up at a time like this, as well it should. Advocates for the mentally ill say that patients, no matter how sick, have a right to go without medication. We disagree with that argument. A person's right extends only as far as the safety of another person. When a mentally ill person with a history of violence goes off medication, that becomes a societal issue, not a personal choice.
Advocates for the mentally ill do make some good points. They note that transportation to medical appointments is a problem because most severely mentally ill people don't have cars. There's also the problem of finding a psychiatrist who will spend more than 15 minutes with a patient and monitor that patient closely.
And it's true that community services are not what they should be. In our rush to empty out mental hospitals in the 1970s and beyond, we simply could not keep pace with community needs for the mentally ill. The result for some has been a revolving door of hospitalizations, release into a stressful world, and readmittance to the hospital.
If we had mandatory medication laws for the most dangerous segment of the mentally ill population, millions of dollars could be freed up from hospital care and transferred to community services.
Maine was once a leader in mental health care, with one of the first mental hospitals in the country. But over the years our system became frayed around the edges and gradually broke down, for lack of money and lack of will.
And somewhere along the way, the rights of patients became more important than the rights and safety of society, to the point that the patients and their advocates are calling the shots.
This has to end. And Nutting's bill would help do that.
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TROY RECORD (NY), March 11, 2005
[Editor's Note: The legislation that created Kendra's Law expires on June 30. The effort to remove this expiration date on New York's assisted outpatient treatment program and to make the law permanent has already picked up some supporting editorials, including this one.]
KENDRA'S LAW A GOOD TOOL TO PROTECT SOCIETY
Editorial
Kendra's Law is a controversial mandate in New York state that offers outpatient services to the mentally ill, a good thing, but which also allows court-ordered treatment, which is where the controversy comes in.
Advocates for the mentally ill like much of the law but object strenuously to the provisions that allow families or caseworkers to petition the courts to have people potentially harmful to themselves or others ordered into a rehabilitation facility.
The law is temporary, due to expire June 30 after a five-year trial as to the law's effectiveness.
Supporters of the law are eager to see it made permanent, while many advocates are looking for major overhauls that would include striking any language that allows forcible treatment.
We believe the state Office of Mental Health is correct in praising the program and urging that it enter the permanent-law roster. The success rate in the treatment of 6,600 people over these past five years speaks for itself.
Not that we think advocates are totally out of line when they say the law may speak for itself, but who speaks for the mentally ill who are mandatorily detained against their wills.
In our opinion, the unvarnished truth is that some mentally ill people do not know what is good for them. More important, we believe the courts should have a say in what is good for society as a whole.
The American Civil Liberties Union has chimed in, raising issues of constitutionality in that people can be held for up to 72 hours without a hearing while being evaluated by health professionals.
But the courts have sided with the state.
We argue that the 72-hour limit is what makes even the odious practice of court-ordered treatment acceptable, if not completely palatable. It is not as if a person can be arbitrarily detained for an indefinite period of time.
The law is named after Kendra Webdale, a Fredonia native who was killed when pushed in front of a subway train by a sometimes-violent diagnosed psychotic who refused to take his prescribed medicine.
Caseworkers and family are the people who can most closely monitor a known psychotic and detect when a person is in danger of going over the edge. Who better to seek aid for the person in mental turmoil?
Personal rights are precious and should not be violated heedlessly, but there are times when the public good must be served, and we believe this is one of those times and that the Legislature should leave Kendra's Law on the books and intact
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PRESS RELEASE FROM NEW YORK GOVERNOR GEORGE E. PATAKI, March 7, 2005
[Editor's Note: Who better to assess the performance of a program than the people running it? Since Kendra's Law took effect on Nov. 8, 1999, the management of Kendra's Law has been the responsibility of New York Governor George E. Pataki and his administration. The Governor's opinion of assisted outpatient treatment? - He wishes to make the program permanent.]
GOVERNOR GEORGE E. PATAKI
OFFICE OF THE GOVERNOR
STATE OF NEW YORK
FOR IMMEDIATE RELEASE:
March 7, 2005
GOVERNOR INTRODUCES BILL TO MAKE KENDRA'S LAW PERMANENT
Report Documents the Success of Individuals Receiving Assisted Outpatient Treatment
Governor George E. Pataki today introduced legislation to make New York's Assisted Outpatient Treatment (AOT) law permanent. The measure, known as Kendra's Law, was first enacted in 1999 and is currently scheduled to sunset on June 30, 2005. It is named in memory of Kendra Webdale, who tragically died after being pushed in front of a subway train by a man with a history of mental illness and hospitalizations. Since being enacted Kendra's Law has successfully provided specialized services to more than 6,600 New Yorkers with mental illness.
"For the past five years, Kendra's Law has provided New Yorkers with mental illness access to the treatment they need in an effective manner that ensures their safety, as well as that of the public," Governor Pataki said.
"The vast majority of these individuals are already leading productive and fulfilling lives in their communities, but the results are clear -- Kendra's Law works. That's why I am proposing that this extremely successful program be made permanent."
Kendra's Law established a process for identifying individuals with mental illness who, in view of their treatment history and circumstances, are likely to have difficulty living safely in the community without supervision.
A five-year evaluation of the program was released last week by the Office of Mental Health (OMH) and has shown the program to be a resounding success. The use of mental health services by the population now being served by AOT has gone up by 89 percent over what was utilized prior to the implementation of the program.
Patricia Webdale, Kendra's mother, said, "The Assisted Outpatient Treatment program is having positive results, and I would like to commend OMH for a job well done. On a personal note, it brought tears to my eyes to see Kendra's name on the AOT report's cover. When we began this journey five years ago, my husband Ralph and I were hopeful that we could do something that would help just one person. We are very pleased to see that this program has helped so many."
Sharon E. Carpinello, R.N., Ph.D., OMH Commissioner, said, "Thanks to Governor Pataki's leadership, we have seen improved access to mental health services, improved coordination of service planning, enhanced accountability, and improved collaboration between the mental health and court systems. But when summarizing the results of AOT, it is most important to note the positive impact the program is having on the people who have successfully used it. Individuals with mental illness who participate in AOT are able to make and maintain real gains in their recovery -- the data tells us that, and so do the recipients."
Kendra's Law has created a procedure for obtaining court orders for certain individuals to receive outpatient treatment for mental illness. It also ensures that local mental health systems give these individuals priority access to case management and other services necessary to ensure safe and successful community living.
In addition to assisted outpatient treatment, Kendra's Law also addresses the need to ensure that mentally ill people who are moving from hospitals or correctional facilities to the community receive necessary psychiatric medications without interruption. Fully funded in the Governor's Executive Budget, the law's statewide medication grant program enables counties to provide people who are discharged from psychiatric hospitals, state prisons or county jails with psychiatric medication they may need while they are applying for Medicaid.
In addition, the law clarifies and authorizes the sharing of necessary clinical information of patients with mental illness between psychiatric hospitals as well as between psychiatric hospitals and general hospital emergency rooms. This sharing of information helps to provide clinicians with accurate clinical histories, resulting in better diagnoses and treatment.
The five year report that was recently released reviews the impact and outcomes of various elements of the AOT program from its initial implementation in November 1999 through December 2004. During that time, 10,078 individuals were referred for AOT assessment. Of those, 3,766 individuals received services under an AOT court order, and an additional 2,863 received service enhancements without a court order.
AOT participants show a significantly increased participation in case management, substance abuse, and other treatment services; increased adherence to prescribed medication; improvements in social and family functioning; and improvements in community living. They also demonstrate a reduction of harmful behaviors, including reduced incidence of hospitalization, homelessness, arrest and incarceration.
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Read the full report: http://tacenews.c.topica.com/maadkG3abfsirbfGwZEb/
Read a summary by TAC: http://tacenews.c.topica.com/maadkG3abfsirbfGwZEb/
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RESOLUTION OF MAINE CHIEFS OF POLICE ASSOCIATION, March 15, 2005
[Editor's Note: In the last E-News, we commented that members of law enforcement almost always favor treatment law reform. That is certainly the case in Maine. Last week we shared a resolution supporting the introduction of assisted outpatient treatment from that state's Sheriffs' Association. Below is one from the Maine Chiefs of Police Association that takes that same policy stand.
This resolution is available on our website in its original formatting at:
http://tacenews.c.topica.com/maadkG3abfsisbfGwZEb/ ]
RESOLUTION
MAINE CHIEFS OF POLICE ASSOCIATION
SUPPORTING LEGISLATION CREATING ASSISTED OUTPATIENT TREATMENT FOR PEOPLE WITH SEVERE MENTAL ILLNESSES
WHEREAS, the role of Maine law enforcement officers in responding to serious crises involving people with severe mental illnesses is continually increasing; the safety of law enforcement officers and citizens, particularly those who are mentally ill, is seriously jeopardized; and an inordinate amount of law enforcement resources are being expended for this purpose at a time when we can least afford it; and
WHEREAS, nationally, people with severe mental illnesses are nearly four times more likely to be killed in altercations with police. Too often these altercations arise because a person with a severe mental illness stops taking their medication; and
WHEREAS, law enforcement too often responds to preventable and heart-wrenching tragedies involving people with severe mental illnesses such as an 18-year old man committed suicide after he stopped taking medication for bipolar disorder and a mother with schizophrenia who tried to kill her 11-year old daughter; and
WHEREAS, current law in Maine prevents families, law enforcement officers, and mental health professionals from helping a person who refuses treatment for severe mental illness until the person "poses a likelihood of serious harm", and also limits the remedy that judges have to ordering inpatient hospitalization, unlike other state laws that allow judges to court order outpatient mental health services before a crisis occurs; and
WHEREAS, 42 other states have laws that allow for court-ordered outpatient treatment (also known as "assisted outpatient treatment") for people with severe mental illnesses who refuse treatment, in most cases because the illness prevents them from recognizing that they are ill; and
WHEREAS, empirical evidence from studies and states using assisted outpatient treatment (AOT) shows that AOT is effective in reducing incidents of hospitalization, homelessness, arrests and incarcerations, victimization, and violent episodes among people with severe mental illnesses who otherwise refuse treatment. AOT also increases treatment compliance and promotes long-term voluntary compliance for people with mental illnesses. Among other benefits, these outcomes reduce law enforcement contact with people with severe mental illnesses; and
WHEREAS, it is clear that providing for assisted outpatient treatment could have prevented some of our state's recent tragedies by ensuring early intervention and sustained treatment in the community for people who otherwise are unable or unwilling to access such treatment, particularly medication;
NOW, THEREFORE, BE IT RESOLVED, by the Maine Chiefs of Police Association that we support the passage LD-151, a bill providing for assisted outpatient treatment in Maine; and be it further
RESOLVED, that the incidents and tragedies cited above as well as the many not mentioned herein demonstrate the significant stake that law enforcement has in ensuring the efficacy of state funded mental health services in treating people with severe mental illnesses.
SIGNED: CHIEF JERRY HINTON, President
ATTEST: ROBERT M. SCHWARTZ, Executive Director
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DECATUR DAILY (AL), March 13, 2005
[Editor's Note: We know it happens, we can process the concept of it, but it is almost impossible for someone who has not experienced the inexplicable gloom and rootless but overpowering hopelessness to truly understand how the symptoms of severe mental illnesses can cause people to take their own lives. Eric Fleischauer, the gifted author of this piece, provides insight into this startling phenomena and provides other educating glimpses into what it is like to have bipolar disorder.
Approximately 5,000 people with bipolar illness and schizophrenia commit suicide each year. Details on this monumental tragedy are in our fact sheet at:
www.psychlaws.org/BriefingPapers/BP6.htm ]
THE CURSE OF A BIPOLAR DISORDER: ECSTACY & DESPAIR
By Eric Fleischauer, Daily Staff Writer
Adorned with dim chandeliers and heavy silence, the Huntsville funeral home holding the ashes of Linda Beshears clashed with the view from its foyer.
The clash between inside solemnity and outside commerce echoed the self-destructive impulses within a woman who worked tirelessly for her family, but felt responsible for crimes that she could not have committed.
A Wal-Mart bustled with shoppers as last week's memorial took its course, customers' horns and voices made quiet by thick windowpanes. People yanked at doors and pulled at furniture at the U-Haul shop next door, eager to get from here to there. A steady stream of people trickled into Hollywood Video, emerging in minutes with their $4 escapes in hand.
High Cost Of Escape
For Beshears of Lacey's Spring, the cost of escape - from internal clashes between mania and depression - was high. The coroner labeled her death suicide, but the 120 people at her memorial service knew better.
Beshears died from the disease that plagued her for the last eight years of her life. She died of the internal war called bipolar disorder.
One in 20 suffering from bipolar disorder ultimately kill themselves. One in two try.
Beshears' death tracked the emotional extremes that plagued her. Doused in gasoline, she flamed in heat so extreme it melted the windows of her car.
Then she immersed her burned body in the frigid waters of the Tennessee River in Morgan County.
While Beshears' life was the most recent one snatched by bipolar disorder in this area, it was not the first.
In August, Janet Pearsall Haney, 26, killed herself with carbon monoxide by locking herself in a shed with her running car. In January 2004, 29-year-old Farron Barksdale, saddled by the disorder, shot and killed two police officers.
What Is Bipolar?
Bipolar disorder typically involves alternating cycles of mania and depression that lead to abnormal behavior. The most serious cases are a living hell as patients and families try desperately to find an unclouded reality, an emotional baseline.
People suffering from a manic episode are either euphoric or irritable. Other symptoms of mania, according to Dr. Andree Stoves at The University of Alabama at Birmingham Medical Center, include impulsiveness, decreased need for sleep, hypersexuality and dramatic increases in energy level.
"They feel grandiose," explained Stoves, who is director of psychiatric emergency services and psychiatric consultation services at UAB Medical Center. "They may even think they are having special communications from God. They often feel invincible."
The depressive episodes are just as bad.
"This is not the blues. You can't pull yourself up by the bootstraps," said Larry Cantor, Ph.D., a director at Decatur General Hospital West. "Some don't know how to live. Some feel death is the only answer."
Some with severe bipolar disorder develop a compulsion for self-injury, particularly "cutting." The term means something broader than suicide, but typically involves a laceration to the wrist.
Sometimes the intent is suicide, but at other times it is a means to break the mood cycling. At other times, it is a cry for help as a patient realizes he or she is losing his battle against suicide.
Listing the symptoms of bipolar is easy. Understanding the disorder's toll is not.
"No one understands being bipolar," said a 47-year-old woman suffering from the condition.
Like many of those suffering from the disorder, she will not use her real name due to the stigma associated with the diagnosis. She asked to be called "Rosebud."
"Other bipolars can't understand being me," Rosebud said. "I can't understand being other bipolars."
The cause of bipolar disorder is not well understood. There is a definite genetic component. Most who suffer from the disorder have a relative who also had it, but one identical twin may have bipolar disorder when the other does not.
"Extremely stressful situations can cause symptoms to manifest," according to Stoves. "So can the use of drugs. ... They may not be able to tolerate a stressor like a normal brain would."
From The Inside
The disease is bad enough. It is made worse for patients who experience social condemnation for the diagnosis.
Forty-year-old Randy said, "You can't imagine what it is like with the mental-illness label. It seems that with any other body part, it is socially acceptable for it to go bad, but if it's the brain, then you're a social leper."
Rosebud explains.
"Bipolars have to learn to be actors and actresses. People don't like us if they know what we are. I don't ever tell anyone what I am."
While the extremes of mania can be horrifying - replete with paranoia, irrational guilt and delusions - the less dramatic hypomania is sometimes pleasant.
Rosebud's nearly overwhelming anger at what bipolar disorder has done to her life includes frustration about her manic episodes.
"So I am stuck ... in this hell-hole of depression. I can't even be a decent bipolar," Rosebud said. "I can't go full-manic because of my ministry background. It holds me back from being the bad-girl, hypersexual person."
Forty-year-old "Shout" said the disorder is nerve-wracking even when its symptoms dissipate.
"Bipolar is never knowing who you really are," Shout said. "When you are manic, you are wonderful and when depressed, you are s---. When you're stable, you spend much of your time worrying that it won't last."
Manic Episodes
One person with bipolar said he woke up at 3 a.m. in a manic phase and proceeded to paint his basement in tropical colors. On Sept. 11, 2001, he feared the planes were headed for him, so he hid behind a chair with his "last meal," a bowl of cereal.
Some of those suffering from severe mania have a bond with their co-sufferers. Some can laugh at their antics, but not for long.
One man had a "magic pen" during a manic episode. He talked to it and it talked back as it helped him write a novel.
Another woman recalled pulling her pants down in a crowded restaurant, mooning a table of businessmen. The story triggered amusement from others who share her diagnosis, until she continued. "I want someone to put their arms around me and tell me it will be OK. I'm flying free, but scared."
Before shooting two police officers last year, Barksdale suffered severe paranoia as a result of his bipolar disorder, his lawyer said. Paranoia is sometimes a symptom of mania.
Beshears was apparently delusional, believing that she was responsible for terrorist attacks. She told a rescuer that the only way she could stop the violence she caused was to kill herself.
Treatment Of Bipolar
Stoves said this is an exciting time in the research of treatments for the disorder. She hopes that ongoing genetic research will lead to treatment, and an increasing number of medications are available to ease symptoms.
"Several drugs have gotten FDA approval for the management of manic episodes, and drugs are being found almost daily that modulate symptoms. There is even some research suggesting certain nutritional things, changes in food and diet, can affect the outcome," Stoves said.
Most people with bipolar disorder respond well to mood-stabilizing medication. For some, the problem is making themselves take it.
Cantor said one reason it is difficult to get bipolar patients to take medicine is that it disrupts the pleasure they feel during their hypomanic episodes. Some experience boundless optimism and creativity during these phases.
Their self-impression is not always off. Cantor said many successful businessmen and artists suffer from the disease. During their manic stages they are geniuses, but they come down hard when the depressive episodes hit.
"Some feel able to get a lot done, very confident," Stoves said. "The last thing they want is for someone to rain on their parade."
Getting patients to take medicine during depressive episodes is difficult for other reasons.
"They feel so depressed that they may be too exhausted to physically get up and get their medications," Stoves said. "Sometimes they feel so hopeless that they decide there is no need to take the medicines anyway, that it won't help."
For some patients, the disease becomes a part of their identity.
A bipolar woman reacted with fury to a bad interview question. Once her anger abated, she explained.
"My reaction to you describing my illness as 'hideous' was understandable when you consider how closely some of us identify with our disease. How could I not take your description personally?" she said.
The unwillingness to take medication is fodder for many an academic debate.
"I have always felt strong about civil rights," explained Cantor, "but this is a tough issue."
Alabama has an involuntary commitment law, but some consider it hard to use and sometimes slower than necessary for the protection of the patient or for the protection of others.
Limestone County Probate Court records indicate Barksdale was committed on several occasions. He would stabilize on medications, be released, and then stop taking them.
"What do we do? We know if we could just put them asleep for 72 hours, they would wake up as a different person," Cantor said.
While counseling is an important part in the treatment of those with bipolar disorder, it is not always successful in preventing suicide. Lessons learned between episodes may not stick.
"It's very difficult for people when they are in a given mood state to recall clearly when they didn't feel that way," Stoves said.
"Guilty ruminations," the term doctors use to describe symptoms such as those expressed by Beshears, are often present in severe bipolar disorder. They sincerely believe they are responsible for things over which they have no control.
"For most (bipolar) people who commit suicide," Stoves said, "if you really understand their thought processes, the suicide is a rational thing from their point of view. If I am to blame for all this, they figure, I don't deserve to live."
While the efforts of Stoves, Cantor and others have improved treatment, many remain in the disorder's deadly grasp.
"I rapid cycle, and when I am manic I am filled with rage and often don't remember clearly what I do," said Chilly, a 34-year-old man. "Then the guilt hits."
"Sometimes," he continued, "my mind races so much, the only way to slow it down is by cutting."
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SUMMIT DAILY NEWS (CO), March 15, 2005
[Editor's Note: With an able pen, Bonnie Norling highlights the catastrophic connection between mental illnesses and suicide along with the "choice" her own brother made because her state's treatment laws forbade his getting needed care.]
SUICIDE IS AN IMPORTANT ISSUE
Letter to the Editor
By Bonnie Norling, Silverthorne
Thank you Kimberly Nicoletti, for your informative and sensitive article about mental illness and suicide.
Thank you for bringing it forward even though denial is much more comfortable. After the personal experience of my Schizophrenic brother killing himself 4 years ago, I am painfully aware of the ramifications of these issues.
I listened for years as the "mental health" workers told us their hands were tied, because of current laws, to give him the help he really needed. He was an "adult" and had choices. The mentally ill are victims of their illness.
My brother was unable to make a healthy choice regarding the ramifications of not being on helpful drug therapy or his future well being. The tormenting voices and despair plagued him until he made his final "choice."
President Reagan's shooting, Willie Morrison's murder in Alma, and many suicides that we've experienced here in Summit County are results of mental illness.
The tragedies will continue if we aren't willing to recognize and talk about the need at a personal and community level.
With fearless attention and compassion, I believe there are solutions. So thank you Kim for bringing, once again, an important issue forward for discussion and hopefully thoughtful action.
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Treatment Advocacy Center E-NEWS is a publication of the Treatment Advocacy Center.
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