Saturday, August 27, 2005




Visit our web site
August 26, 2005


1. THE POWER TO TREAT - Star-Ledger, August 15, 2005


3. N. M. CAN'T FORCE DRUGS - The Albuquerque Tribune, August 24, 2005


5. LAW ENFORCEMENT CAN HELP MENTALLY ILL & THEIR FAMILIES - Columbian Daily Herald, August 10, 2005


STAR-LEDGER (Newark, NJ), August 15, 2005

[Editor's Note: Mark Twain once apologized that he "didn't have time to write a short letter, so [he] wrote a long one instead." The editors of the Newark Star-Ledger apparently had a lot of time to put into this editorial urging New Jersey to adopt assisted outpatient treatment. They persuasively and artfully put forth most of the arguments used in a typical editorial endorsement of the treatment mechanism in a fraction of the usual length, and they are even able to proffer some effective new ones.

New Jersey is one of the eight remaining states still without the option for assisted outpatient treatment.]



It's good that legislation that would let judges force mentally ill people into outpatient treatment stirred passionate debate during a state Senate hearing Thursday.

Good because such a bill deserves very careful consideration so it can be crafted to protect the rights of the mentally ill while increasing the chances that seriously ill people will get the treatment they need to control their symptoms. In most cases, that treatment is medication, which could mean taking it in front of someone at a clinic.

New Jersey needs such a law. Forty-two other states have similar legislation for addressing the small minority (perhaps 400 of the 400,000 mentally ill people in New Jersey) who could be a danger to themselves or others if they do not get treatment to control their symptoms. Given sufficient evidence, a judge could order treatment and commit a person to a hospital for refusing to comply.

The arguments against the legislation, that people have a right to refuse treatment and that forcing them to submit stigmatizes mentally ill people, are not persuasive.

The legal system recognizes that people can be too mentally impaired to make decisions for themselves and permits involuntary inpatient commitments when warranted.

The tragic stories of the few mentally ill people who commit violent acts that might have been prevented are what fan the prejudice against all of the mentally ill. Getting people treatment may help cool that prejudice.

Providing accessible, affordable services is the first and most important requirement for improving the odds that people who need care will get it. The involuntary outpatient commitment law is a necessary last resort.


PSYCHIATRIC NEWS (Vol. 40 No. 16), August 19, 2005

[Editor's Note: We shared with you a number of mainstream press items on the renewal of Kendra's Law, which was signed by New York George Governor Pataki on June 30. Below is a piece on this victory for New York advocates from Psychiatric News, an official publication of the American Psychiatric Society. It gives many details about the law itself and how it functions.]


By Eve Bender

Improved outcomes for people who have serious mental illness and a history of treatment noncompliance lead to a five-year extension of New York's Kendra's Law.

A law mandating outpatient psychiatric treatment for people with serious mental illness in New York has been renewed with the hope that it will continue to reduce hospitalizations, arrests, and homelessness.

On June 30, the date that the five-year-old Kendra's Law was set to expire, New York Gov. George Pataki (R) signed legislation to extend the program for another five years.

The law is named for Kendra Webdale, a 32-year-old woman who in January 1999 was pushed into the path of an oncoming subway train by a man with untreated schizophrenia.

Seven months after her death, Pataki signed Kendra's Law. As of March, there were 3,908 people who had received court-ordered outpatient treatment, or assisted outpatient treatment (AOT), under Kendra's Law.

The legislation is meant to benefit seriously mentally ill people who, due to a history of noncompliance with treatment, cycle in and out of hospitals, jails, prisons, and homeless shelters.

To be eligible for AOT, the person's noncompliance must have resulted in either two psychiatric hospitalizations or treatment in a correctional facility in the prior three years or at least one threat or act of violence toward self or others in the prior four years.

The new law expands the list of those who can petition the courts to ask that a person be evaluated for AOT eligibility to include psychologists and social workers. The initial list included psychiatrists, parents, spouses, adult siblings, adult roommates, directors of hospitals in which the individuals are hospitalized, the mental health director or social services official for the county where the person lives, and parole or probation officers.

After the petition has been filed, a county-designated physician conducts a clinical assessment of the person to determine whether it is appropriate to pursue a court order for AOT.

Those who are deemed eligible for services under Kendra's Law are court-ordered to receive AOT in the community for up to six months. The treatment is usually coordinated through an AOT intensive case manager and, in some cases, an assertive community treatment team.

County mental health directors operate, direct, and supervise AOT programs. In New York City, the Department of Health and Mental Hygiene oversees implementation of AOT, which is administered by teams of employees of the New York City Health and Hospitals Corporation.

The New York State Office of Mental Health (OMH) is responsible for statewide implementation and monitoring of the AOT program.

The updated legislation includes a number of changes designed to improve the coordination and delivery of assisted outpatient treatment (AOT) for eligible recipients.

For instance, to facilitate AOT in rural areas with few psychiatrists, the law authorizes OMH "to make available to counties with a population of less than 75,000 a physician employed by OMH for the purpose of making the affirmation or affidavit required when filing petitions."

The updated legislation also expands eligibility criteria somewhat by excluding the time a person spends in a psychiatric hospital or correctional facility from the period prior to the petition process.

OMH has been evaluating outcomes for those in AOT from the start of the program to March, and the data were released in a report that OMH issued that same month.

The majority of the 2,745 recipients for whom data were available remained in treatment longer than the initial six-month court-ordered period. The average length of time in AOT was 16 months, according to the report.

When OMH researchers analyzed outcomes for recipients who completed AOT, they found that 23 percent had been incarcerated at least once in the three years before receiving AOT, while just 3 percent were incarcerated during their court-ordered treatment.

When researchers looked at the same three-year period preceding AOT treatment, they found that the vast majority (97 percent) had been hospitalized at least once, while just 22 percent were hospitalized while receiving AOT.

In addition, 19 percent of AOT recipients had been homeless before receiving AOT, while 5 percent were homeless during their treatment.

According to Mary Zdanowicz, J.D., director of the Arlington, Va.-based Treatment Advocacy Center, Kendra's law has "greatly improved quality of life" for its recipients in addition to reducing arrests and hospitalizations of seriously mentally ill people in New York.

She also credited AOT with improving New York's mental health system by ensuring that those who are eligible for treatment under Kendra's Law, a population she called "too often ignored and often underserved," have a safety net.

Barry Perlman, M.D., president of the New York State Psychiatric Association (NYSPA) and director of psychiatry at St. Joseph's Medical Center in Yonkers, said that the OMH data indicate that Kendra's Law is promising. While NYSPA supports a time-limited continuation of the law, he said, "we think additional research on services and financing is warranted" before a permanent renewal is legislated.

He noted that early OMH data suggested that most of the referrals to AOT from hospitals were coming from those operated under the auspices of local governments, such as municipal or county hospitals, rather than from the inpatient units of general, not-for-profit voluntary hospitals.

"This may be due to the expenses related to sending a staff psychiatrist to evaluate patients and attend court hearings to obtain AOT for patients," which detracts from hospital revenue, he noted.

"NYSPA approved the change in the law that provided assistance in counties with 75,000 or less," he said. "We hope that in the future the funding will be extended to all counties in the state regardless of population size."

He said that such funding would provide strong encouragement for greater use of AOT by the staff of inpatient units of general hospitals.



[Editors Note: The debate in New Mexico over whether or not to adopt assisted outpatient treatment has been recently fueled by a connected string of tragedies in Albuquerque. Shocking human losses have renewed the call to remove the state from the list of eight without a law permitting the treatment mechanism.]


State Among Few Without Involuntary Treatment For Mentally Ill

By Maggie Shepard, Tribune Reporter

In April, John Hyde's mother told police she was concerned her mentally ill son wasn't taking his medicine.

That might have been enough to start Hyde down the road to an involuntary treatment program - if the state had one.

New Mexico is one of eight states that have no avenue for authorities to force seriously mentally ill patients to take their medicine or face hospitalization.

Mental health advocates promote such laws, often referred to as Assisted Outpatient Treatment. Civil rights advocates, meanwhile, aren't so comfortable with the idea of forced treatment.

Civil rights watchdogs "are opposed for very good reasons," said Jane Lancaster, president of the Albuquerque chapter of the National Alliance for the Mentally Ill. "As a principle, anyone should have the right to refuse medical treatment, but there is a gray area, and we have to deal with that."

That gray area regards people who are so mentally ill they don't know whether to take their medicine when they should, Lancaster said.

"They become a danger to themselves and a danger to others," she said.

Hyde, 48, was found to have schizophrenia and bipolar disorder in 1990, he told a public police oversight meeting in July.

In his 15-year struggle with sanity, Hyde had few run-ins with the law. A speeding ticket and the April incident with his mother were about it, until last week.

Hyde was arrested early Friday. He is charged with killing five people, including two Albuquerque police officers who were trying to take him to Presbyterian Kaseman Hospital for a mental health evaluation.

Benny Lopez, 54, a state Department of Transportation, was found shot dead in his truck at Central Avenue and Unser Boulevard N.W. early Thursday.

Later that day, David Fisher, 17, and Garrett Iversen, 22, were shot dead at Rider Valley Motorcycles on East Central Avenue.

Albuquerque police Officers Michael King, 50, and Richard Smith, 46, were shot around 10 p.m. after they arrived at Hyde's apartment at 1521 Gold Ave. S.E.

The city is about four months into a pilot mental health intervention program called ACT, which stands for Aggressive Community Treatment.

The 10 team members coordinate medicine schedules, housing and other resources for about 30 consistently incompetent people known to the city's criminal justice system, said Barri Roberts, executive director of the Metropolitan Criminal Justice Coordinating Council. The council is a think tank of local high-level criminal justice leaders that recommends policy.

Roberts describes "consistently incompetent" people as those who have come through the criminal justice system repeatedly, more than three times in two years, and each time are declared mentally unfit for trial.

Barry Bitzer, Mayor Martin Chavez's policy adviser, said Hyde probably would not have been a serious enough case for the city's voluntary program but might have been a candidate for mandated supervision.

Hyde spoke of his mental illness after the April incident with his mother, complaining that police unfairly focused on his illness when they responded to his mother's home, where he'd been living. He moved out shortly afterward.

"(In April), this gentleman could have been taken in to allow him to be kept for a certain period and scrutinized," said Sherry Pabich, board member and legislative advocate for the city chapter of the National Alliance for the Mentally Ill.

"We're not about coercion. We're just trying to get people stable enough that they can make rational decisions," Pabich said.

Last year, the city considered supporting the state as it pursued an Assisted Outpatient Treatment law. A bill calling for such a law was never introduced, she said.

Civil rights watchdogs were apprehensive about enacting such a law without first trying voluntary programs such as ACT teams, Bitzer said.

Under Assisted Outpatient Treatment, a court can require a person to comply with treatment, such as taking medicine, as a condition for not being hospitalized, according to the National Treatment Advocacy Center. Patients who refuse treatment can be hospitalized until they're stable.

Both voluntary and involuntary programs are resource-intensive. The city's voluntary system costs about $14,000 a year per participant, Bitzer said.

"It may not ever be cheaper, but it is a much better use of the resources," said Roberts, with the criminal justice collaborative.

Lancaster, with the alliance for the mentally ill, said any effort to compel patients to take their medicine is worth it - as Hyde's case illustrates.

"It's inappropriate to say John Hyde is a monster. He is a human being with a very severe mental illness that led him to do monstrous things," she said. "That doesn't make him a monster, because on medication, he may not have done them."



[Editor's Note: This question and answer centering on Alabama's commitment laws gives a good insight into what the parents face and what it might take in that state for someone to be placed in needed treatment. However, unless you are from Alabama, do not take the advice and information as also necessarily true for the assisted treatment laws in your state. As commitment laws are established by each state legislature, they are also different in each state. For instance, an attorney quoted below puts forth that "coming off medication and returning to full psychotic symptoms may" be, by itself, sufficient to justify placement in treatment. In most states, it would not.]

Psychology Columnists: Dr. Margaret Bibb & Dr. Patrick Quirk


Q. My husband and I are in our mid-60s and have two grown children. Our daughter is happily married with children of her own, but our 26-year-old son is paranoid schizophrenic and has lived with us since he became schizophrenic in his freshman year of college. His struggles have been the most tragic thing I have ever experienced.

We have had him in treatment and when he's on medication he is rational and we all have some quality of life. He stayed on his medicine when he was first out of the hospital, but now he says he doesn't like how it makes him feel and he will just stop taking it without telling us. Then, we notice that he begins to have trouble with sleep, gets more withdrawn, and has more paranoid thoughts. We begin to see strange behavior and sometimes hallucinations. When we get him back on his medication, he insists on monitoring it himself and the cycle begins again. His doctor and the hospital have explained to him that he needs to stay on his medicine, but even when he is rational, he doesn't seem to fully accept that he has an illness. Recently, his behavior is even more disturbing. He has taken my car keys out of my purse and stolen the car several times, and has stayed gone for a few hours or as much as a day.

My daughter tells me that we should commit him, but I've heard that he has to be declared a danger to himself or others. He has not done anything truly dangerous. Besides, as soon as he gets out of the hospital he will come off his medicine again. What can we do?

A. Author's note: The answer to this question is quite complex and we have therefore communicated directly with our questioner and provided a complete answer. Because of the complexity of this issue, we have divided our comments between this week and next, as there are likely a number of readers who could benefit from understanding this information. MB and PQ

Paranoid schizophrenia is a very difficult disease. As with many mental or physical diseases, acceptance of the illness and need for treatment is a significant part of successful treatment. The situation described here, with a schizophrenic who still has some denial about the disorder itself, is not unusual.

Ideally, voluntary treatment is preferable. However, when that option cannot be achieved there are alternatives available. In the case of a person who has committed a criminal act, there is an available Mental Health Court that is a diversion program to get mentally ill people out of the criminal system and into monitored treatment. We will examine that program in detail next week.

In the case of a person who is mentally ill and not involved in the criminal court system, there is a civil commitment procedure. We asked two local professionals with special expertise in this area for their comments.

Coleman Burton, the most common plaintiff's attorney in commitment procedures, works closely with Probate Judge Tommy Ragland. He shared with us that the three primary criteria for commitment are: 1. The individual has a diagnosed mental illness; 2. The individual demonstrates that he or she is a danger to self or others, either by an overt act or indirect behaviors such as severe neglect; and 3. Treatment is provided in the least restrictive environment available.

The issue of an overt act indicating danger to self or others is often the one debated in court. Regarding the current situation in question, Burton did offer evidence that if the son's driving is dangerous, this might meet criteria. Also, in some cases, coming off medication and returning to full psychotic symptoms may be considered sufficient.

Dr. Randy Burleson, clinical psychologist, shared with us about a program supported by state statute that allows a police officer or county sheriff to be called to your home to make a preliminary assessment of whether an individual has a mental illness issue.

If the officer suspects that a mental illness is present, the mental health center can send a Community Mental Health Officer out to make an evaluation. This person can make arrangements for the individual to be taken to Huntsville Hospital for further evaluation, and can facilitate a commitment procedure if appropriate.

Burleson further explained it is not uncommon for young individuals to be in denial of their mental illness, even when they are on medication and clear of most of their symptoms. This is one of the reasons why it is helpful to have ongoing contact with a mental health professional who can help the individual to accept their disorder and more comfortably comply with treatment.

If you have questions regarding treatment issues for schizophrenia, we recommend you contact the mental health center or look in the Mental Health Association's listing for a provider who indicates expertise in that area.

Next week we will take a look at the mental health court program for those mentally ill individuals who have become involved in the criminal system.



[Editor's Note: As with the last piece, this one is about the requirements of commitment laws, in this case Tennessee's. Thus, we do not offer it with an eye to the applicability of its specifics in other states. Rather, what is most generally useful is its advisement for caregivers to know their state's law and be ready to present the circumstances of a crisis so as to best conform them to the criteria for treatment interventions of their state's law.]


By Cheryl Cooper

The National Institute of Mental Health dubbed the decade between 1990 and 2000 the "Decade of the Brain."

During this decade, there were many advances in the treatment of persons with serious and persistent mental illness. Those advances led to an overhaul of the mental health system and subsequent deinstitutionalization of thousands of people previously considered too dangerous to live in the community at large.
Since that time, studies have shown that their families have reported that between 11-27 percent of them have committed at least one violent act within four months of discharge from the hospital. One study showed that those with serious mental illnesses who were not taking their medication committed twice as many violent acts immediately prior to hospitalization as they did immediately following their discharge -- a period of time which would have found them all compliant with their medications.

While deinstitutionalization offers hope and freedom to those with serious and persistent mental illness, the families of the ones who are not always compliant with medications often find themselves with a patient who is lapsing back into a psychotic state. During this period of time, the patient in the psychotic state usually becomes dangerous but may not yet have perpetrated a violent act. It is during this phase of the illness that the caregiver sees the mental health and the law enforcement systems as having failed or abandoned them.

A caregiver who sees the patient becoming dangerously psychotic again may seek the help of the medical provider only to be told that no help is forthcoming. The mental health laws require that the medical provider actually see the patient in person and swear an affidavit to that effect before the patient can be legally committed to a psychiatric facility for evaluation and treatment. Unfortunately, in the psychotic state, the patient generally refuses to see the treating professional. Therefore, the medical provider is unable to commit the patient to a treatment facility.
Finding the medical system to be ineffective, the caregiver then contacts law enforcement with concerns that the patient is sick again. This is usually an emotional time and an emotional call. The caller often is distraught and may not understand that the response of law enforcement must be based upon statues rather than upon the emotional state and dire predictions of the caller. Therefore, the family member is often told "I'm very sorry, there is nothing we can do until the patient has actually done something."

Law enforcement is a valuable resource for families who struggle with a mentally ill family member. The local police are trained in dealing with the mentally ill and have years of experience helping caregivers get their loved ones to an appropriate treatment facility. Unfortunately, many caregivers do not know the laws which empower the police to assist them.

Therefore, while the call to police may be entirely appropriate and predictions of imminent harm to self or others by the patient may be accurate, words spoken to the police often lack the vital information that will allow the police to act within the bounds of the committal statutes. There are words which flow from the statutes themselves which, when combined with information about the current condition and behaviors of the patient, will bring results.

The correct words -- words which will bring a timely and effective response from law enforcement -- are found within the committal statute itself. That particular statute is: T.C.A. 33-6-403: Emergency admission to treatment resource, if and only if

(1) a person has a mental illness or serious emotional disturbance.

The caregiver should convey to law enforcement that the patient's condition is serious. For example: "John has been a schizophrenic since he was 15." Or "Julie is mentally ill and has been treated for bipolar disorder and suicidal depression on several occasions."

(2) the person poses an immediate substantial likelihood of serious harm, ... because of the mental illness or serious emotional disturbance.

Under this section, the caregiver must convey to law enforcement that the patient is in a dangerous mental state and is likely to harm self or others. Behaviors and words of the patient best explain the risk of harm to self or others. For example: "John has been brandishing weapons." Or, "Julie is threatening to kill herself, and she has a stash of lethal medicines hidden in her room." Or even, "John is stalking the young girl next door neighbor and says he is fantasizing about raping her."

(3) the person needs care, training, or treatment because of the mental illness or serious emotional disturbance.

Here, the caregiver must show that the patient needs medical attention because of the mental illness. Words which would convey the need for treatment would be something like this: "John is off his medicine and he becomes violent without them." Symptoms of the mental illness are powerful indicators that the patient needs medical treatment. "Julie is hallucinating. She is responding to voices in her head. The voices are telling her to kill her brother." Or, "John is delusional. He believes there is a computer chip implanted in his brain controlling him that was placed there by Satan. He believes his father is Satan and must kill his father before his father kills him."

(4) all available, less-drastic alternatives to placement in a hospital or treatment resource are unsuitable to meet the needs of the person.

This part of the statute usually determines what steps the medical provider may take in assuring the patients safety. However, the caregiver may certainly relay to law enforcement that home care is no longer an option. Words that would convey this might be something like, "John is out of control. We cannot get him to eat, bathe or take care of himself. In order to keep him alive and from hurting himself or someone else, he needs more care than we can give him in the home at this time."

Unfortunately, many caregivers see the laws that protect the rights of the patient as being laws that restrict their ability to obtain appropriate effective help for their mentally ill loved one. This, however, is not the case. The caregiver should carefully consider the history, symptoms, and dangerous behaviors of the patient and, as calmly as possible, describe all those things to their local police. The laws that protect the rights of the mentally ill are the very laws, which empower the caregiver to get treatment for the patient when he or she begins to lapse back into a dangerous phase of the illness.


Cheryl Cooper is a graduate of Murray State University and Vanderbilt University and is a student at the Nashville School of Law. She is an advanced practice registered nurse who has used the methods described in this article for many years to help caregivers obtain timely and effective help for their loved ones. She currently teaches nursing at Columbia State Community College.


Treatment Advocacy Center E-NEWS is a publication of the Treatment Advocacy Center.

This E-NEWS is provided as a public service by the Treatment Advocacy Center. There is no fee. If you would also like to receive a free subscription to the Catalyst, our bimonthly hardcopy newsletter, please forward your mailing address to

The Center does not accept donations from pharmaceutical companies. Support from individuals who share our mission, however, is essential to our ability to effectively help our most vulnerable citizens. The Treatment Advocacy Center is a 501(c)(3) not-for-profit organization. All contributions are tax-deductible to the extent allowed by law. Donations to the Treatment Advocacy Center should be sent to:

Treatment Advocacy Center
200 North Glebe Road, Suite 730
Arlington, VA 22203
703-294-6001 (main no.)
703-294-6010 (fax)

This page is powered by Blogger. Isn't yours?