Monday, March 13, 2006
ENEWS - TREATMENT ADVOCACY CENTER
TREATMENT ADVOCACY CENTER
Visit our web site www.psychlaws.org
March 10, 2006
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1. OUTPATIENT COMMITMENT OVERVIEW - Harvard Mental Health Letter, March 2006
2. STATE PSYCHIATRIC HOSPITALS DWINDLE - South Bend Tribune, February 20, 2006
3. PROGRAM TEACHES OFFICERS THE SKILLS TO DEAL WITH MENTALLY ILL - Milwaukee
Journal Sentinel, January 17, 2006
4. INVOLUNTARY COMMITMENTS STRAIN POLICE MANPOWER - Asheboro Courier Tribune,
January 9, 2006
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1. HARVARD MENTAL HEALTH LETTER, March 2006
[Editor’s Note: This month’s Harvard Mental Health Letter offers an overview of
assisted outpatient treatment. It is a balanced and, given its length,
insightful summary of the treatment mechanism.
In noting that it “included only a small number of patients, none of whom were
violent, and there was no effective enforcement mechanism,” the newsletter
accurately describes some of the limitations of the Bellevue Study – one of the
very few (of many) examinations to find no statistically significant beneficial
effect of AOT. It does not mention, however, that members of the control group
were hospitalized for a median 101 days in 11 months while the median person
under an AOT order experienced only 43 days of hospitalization. Because of the
small size of the study, this seemingly dramatic result did not reach the level
of statistical significance; as it stands, it was certainly significant for the
participants.]
Outpatient Commitment.
The emptying of mental hospitals began a half-century ago with the hope that
effective treatment would be available on the outside, and patients would be
willing to accept it. But for many neither of those conditions has been met.
Many thousands of so-called revolving-door patients consume a disproportionate
share of the resources of the health care and criminal justice systems as they
move between jails, prisons, emergency rooms, psychiatric hospitals, rented
rooms, group homes, and the street.
At any given time, a third to half of people with schizophrenia or bipolar
disorder are not receiving treatment, and a third of the homeless are mentally
ill. Many are too discouraged or disorganized to take any initiative. Some will
not agree to treatment because they are isolated and withdrawn, or paranoid and
suspicious. Others refuse help because they wrongly believe they are doing well
enough without it. Court-ordered treatment -- known as outpatient commitment,
mandatory outpatient treatment, or assisted outpatient treatment -- has been
proposed as a partial solution to this problem.
What Are The Standards?
The laws of more than 40 states permit outpatient commitment, mainly for
patients who are actually or potentially dangerous to themselves or others. The
best-known state law is Kendra’s Law, passed in New York in 1999 after a woman
was pushed under a subway train by a man with schizophrenia. Under the New York
law, which is fairly typical, assisted outpatient treatment is authorized for
people who, because of failure to comply with treatment, have been in a mental
hospital, prison, or jail within the last three years or have committed an act
of violence in the last four years. To be committed, they have to be in danger
of relapse or deterioration that would result in physical harm to themselves or
others.
Many mental health professionals believe the standards should be less strict,
with a focus on deterioration alone. A study group appointed by the American
Psychiatric Association issued a report in 1999 recommending outpatient
commitment to prevent relapse or severe deterioration that would make patients
either dangerous or unable to care for themselves.
It’s much simpler to require mandatory treatment for the mentally ill if they
use illicit drugs or (less often) commit other minor crimes. No formal judgments
about dangerousness or deterioration are necessary. Addicts can be sentenced to
drug treatment in lieu of or in addition to imprisonment. In some places, courts
arrange to provide treatment for mentally ill lawbreakers. In mental health
courts, defendants who plead guilty are assigned to outpatient treatment instead
of prison.
The Debate
Critics say that outpatient commitment is an attack on privacy, autonomy, and
the right to travel. They also say that it undermines the therapeutic
relationship, reduces the long-term potential for independent living, drives
patients away from seeking treatment, and diverts resources from voluntary
patients. They insist that the dragnet of outpatient commitment will entrap
people who don’t need it.
Defenders of mandatory outpatient treatment say that it promotes compliance,
especially regular use of medications; mobilizes support services; lowers the
risk of homelessness, psychiatric hospitalization, and substance abuse; and
makes it less likely that patients will be victims or perpetrators of violence.
They say there is no evidence that people are prevented from seeking treatment
and point out that patients and their families rarely raise objections. They say
outpatient commitment will not divert resources as long as extra funding is
supplied. It will not be authorized for people who don’t need it if they have
legal representation, regularly scheduled reviews, and the right to appeal
decisions. In response to the argument that outpatient commitment infringes on
civil liberties, its defenders argue that people are not free when their minds
are in thrall to illness.
Apart from these issues, enforcement is a problem. In some states, patients who
do not comply can be brought to a clinic by police. Some think this should be
allowed when it is authorized by a judge based on evidence presented by a
clinician; others think there should be a formal hearing. Involuntary
hospitalization is a solution only for patients who present an imminent danger.
Telling them that they will be hospitalized unless they take their medications
may sometimes be impractical because resources are limited.
What The Studies Show
The New York State Office of Mental Health issued a report on Kendra’s Law in
2005 and pronounced it a success. From 1999 to 2004, nearly 4,000 court orders
were issued, usually for six months, and in two-thirds of cases the orders were
renewed. About 70% of the patients committed under the statute had schizophrenia
and 13% had bipolar disorder. The report found that after commitment these
patients were more likely to take their medications and less likely to be
homeless, arrested, or hospitalized. In interviews, nearly two-thirds of the
patients said they thought that the court order had been good for them.
There are other favorable reports about outpatient commitment but only two
controlled studies. In a trial conducted at Duke University, patients discharged
from a psychiatric hospital were assigned at random to community treatment alone
or to outpatient commitment with community treatment. The researchers found that
after a year, patients assigned to outpatient commitment had a better quality of
life because they were more likely to comply with treatment and less likely to
be victims of violence. The rate of psychiatric hospitalization was the same in
both groups under the original three-month commitment order. Most of the
advantage for outpatient commitment arose after that three-month period, when
the study was no longer controlled.
The second controlled study, a three-year pilot project at Bellevue Hospital in
New York City, found that outpatient commitment made no difference in the
effectiveness of intensive community treatment. The study included only a small
number of patients, none of whom were violent, and there was no effective
enforcement mechanism.
In an independent analysis for the Cochrane Collaboration, reviewers in 2005
concluded that the only strong evidence for the value of outpatient commitment
came from the findings of the Duke study on the risk of criminal victimization.
Willingness to accept treatment is only one side of the problem that has led to
calls for outpatient commitment; the availability of treatment is the other
side. Everyone agrees that mandatory outpatient treatment requires a plan that
includes intensive services. But often those services are not available because
the public mental health system is poorly organized and underfunded. Mandatory
treatment laws, taken seriously, could be an incentive to provide the needed
organization and funding. But it’s also possible that if better services were
available, outpatient commitment would become a less important issue.
References
American Psychiatric Association Council on Psychiatry and Law. Mandatory
Outpatient Treatment Resource Document. American Psychiatric Association,
December 1999.
Cornwell JK, et al. "Exposing the Myths Surrounding Preventive Outpatient
Commitment for Individuals with Chronic Mental Illness," Psychology, Public
Policy, and Law (March-June 2003): Vol. 9, No. 1-2, pp. 209-32.
Hiday VA. "Outpatient Commitment: The State of Empirical Research on Its
Outcomes," Psychology, Public Policy, and Law (March-June 2003): Vol. 9, No.
1-2, pp. 8-32.
New York State Office of Mental Health. Kendra’s Law: Final Report on the Status
of Assisted Outpatient Treatment, March 2005.
Torrey EF, et al. "Outpatient Commitment: What, Why, and for Whom," Psychiatric
Services (March 2001): Vol. 52, No. 3, pp. 337-41
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2. SOUTH BEND TRIBUNE (IN), February 20, 2006
[Editor’s Note: Whether for long-term care or a shorter period after an acute
episode, people overcome by severe mental illnesses can need placement in a
secure setting – for their own welfare and, at times, for that of those around
them. While improvements in outpatient care can mitigate that need, modalities
for secure inpatient care remain essential and will be long into the foreseeable
future.
Currently, there are two types of inpatient facilities available for people with
serious psychiatric disorders – psychiatric and correctional. Psychiatric care
should be supervised by mental health professionals rather than correctional
ones, whether this goal is fostered through rational commitment standards that
permit treatment interventions before the symptoms of an untreated illness lead
to a criminal act or by programs like mental health courts that offer diversion
once the person has entered the criminal system.
Yet, before a person in crisis because of a mental illness can receive care in a
hospital bed rather than a jail cell, there must be a hospital bed available.]
STATE PSYCHIATRIC HOSPITALS DWINDLE
Fewer Options Left For Housing The Mentally Ill.
By Alicia Gallegos
It's 10 p.m. on a Tuesday night.
Someone is standing in the middle of a busy road, careening in and out of
traffic, mumbling incoherently.
A "10-96" goes over the radio, police code for a "mental subject." Officers
arrive and usher the person away from the street.
Police then have three choices, according to a 2000 report from the National
Institute of Justice journal: arrest the person, take him or her to a mental
hospital, or resolve the matter informally.
But officers know that in reality, their alternatives are even more limited,
says Maj. Sam Cochran with the Memphis Police Department. Officers can wait
hours trying to have a person admitted to an area mental health facility, he
explains, only to find the subject doesn't meet commitment standards or must
voluntarily enter the facility.
Throw in unruly, violent behavior, and their options dwindle further.
"Arrest often was the only step available to the officer in situations where
individuals were not sufficiently disturbed to be accepted by the hospital but
were too public in their deviance to be ignored," professor Linda A. Teplin
writes in the NJI article.
For the many untreated mentally ill, the criminal justice system now becomes the
entry point into the mental health system.
"We don't want to put people in jail," says Elkhart County Sheriff Michael
Books. "(But) we have a responsibility to deal with those folks, (especially) if
we have a violent person." The majority of mentally ill offenders are in jail or
on probation for a property or public-order offense, according to a recent study
by the Bureau of Justice Statistics.
The study also found a high rate of homelessness for mentally ill inmates, along
with unemployment, alcohol and drug use and physical and sexual abuse before
their incarcerations.
A lack of state psychiatric hospital beds contributes to the problem, experts
say.
From 1972 to 1990, available beds decreased by more than 70 percent because of
hospital closures, according to the National Association of State Mental Health
Program Directors Research Institute.
In the 1990s, 44 hospitals closed nationwide. From 2000 to 2003, two state
hospitals closed, and a report cited five states that planned to close hospitals
in 2004 and 2005. In Indiana, the last state hospital to close was Central
Indianapolis Hospital 11 years ago, according to Indiana Family and Social
Services Administration.
Indiana was actually the only state listed that planned to increase the size of
one of its hospitals when the closure report came out in 2004.
A new unit was created at Logansport State Hospital this past summer,
specifically designed for patients involved in the criminal justice system, said
Dennis Rosebrough, FSSA communications director. The hospital also has a new
wing in the works that will open even more beds.
Nationwide, general hospital specialty unit psychiatric beds also have
decreased, according to the report. From 1998 to 2003, 23 of 38 states have
experienced declines in their specialty beds.
The reason for the shortages is multifaceted, says Mary Zdanowicz, executive
director of the Treatment Advocacy Center, a national nonprofit agency dedicated
to helping Americans with severe mental illness. Of course, one major reason is
money, she says.
The Institutions with Mental Disease exclusion was implemented in 1965 by
Congress and prevents state psychiatric hospitals from receiving federal
Medicaid funding.
Without that money, many hospitals have closed.
Although the push of mental health care into more community-based solutions is
well-meaning, she says, it doesn't work for everyone.
Some people with mental illness need long-term, structured care. Others have a
harder time being admitted to area mental health facilities without insurance."
The one alternative they can always count on is jail," she says.
And jails and prisons are often the worst place for mentally ill people to be,
experts say, because offenders are sometimes punished for symptoms of their
illness -- being noisy, refusing orders -- and end up staying longer.
"Mentally ill prisoners are more likely than others to end up housed in
especially harsh conditions, such as isolation," according to a recent study by
Human Rights Watch. "That can push them over the edge into acute psychosis."
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3. MILWAUKEE JOURNAL SENTINEL, January 17, 2006
[Editor’s Note: One way in which to help ensure that those in need of
psychiatric care stay in the mental health system is to increase the skills and
awareness of the gatekeepers of the criminal justice one, i.e., police officers
and sheriff’s deputies.]
PROGRAM TEACHES OFFICERS THE SKILLS TO DEAL WITH MENTALLY ILL
Empathy Seen As Key To Defusing Violent Situations
By Annysa Johnson
Earl Ingram gets angry when he thinks about the day he drove his son to a
Milwaukee police station, hoping officers would take him for commitment to the
Milwaukee County Mental Health Complex.
Diagnosed at 24 with bipolar disorder, Ingram's son, now 28, had been setting
fires at his mother's house, and Ingram feared for the safety of the young man
and others.
Rather than let him bring his son in, Ingram said, four officers with billy
clubs went out to the car, handcuffed his son and hauled him in.
And instead of being taken to the Mental Health Complex, Ingram said, his son
was arrested on an outstanding warrant for driving after revocation and booked
into the jail, where he sat for two weeks without his court-ordered medications.
"It was overkill . . . one of the coldest responses I've ever seen," said
Ingram, a radio talk show host who will share his family's experiences as part
of a new Milwaukee police training program that started this month.
The Crisis Intervention Team program is designed to give police officers the
information and skills they need to improve their responses to situations
involving people with mental illness. That's of grave importance, say mental
health professionals, who voiced outrage in recent years over fatal police
shootings of individuals in mental health crises.
"It doesn't eliminate all tragedies," said Sandy Pasch, former president of the
National Alliance for the Mentally Ill of Greater Milwaukee, who helped bring
the program to the city. "But it greatly reduces them."
Thirty Milwaukee police officers have volunteered to take the 40 hours of
training, after which they'll be dispatched as first responders on calls
involving mental health issues. The goal, said Lt. Carianne Yerkes, is to have
at least a quarter of the department's 1,800 officers participate in the
training.
'The Importance of Empathy'
The weeklong program, offered at no cost by local mental health professionals
and advocates, will cover a host of issues - from the types of disorders and the
drugs used to treat them to community resources and techniques for de-escalating
potentially violent situations.
"That is a major component," said Pasch, who rode along with officers last year
in Memphis, where the program was developed in the 1980s.
"They learn the value of talking to people - what questions to ask, the
importance of empathy," she said. "When you show you're a human being responding
to them, instead of an officer, it takes the fear level down."
The crisis intervention program, or some variation, has been implemented in a
number of cities around the country, including Denver, Indianapolis, and
Appleton, Wis.
The Milwaukee program is taking elements from all those but will most resemble
Memphis' effort in that it's voluntary. In addition, Pasch said, Milwaukee's
program will attempt to address the cultural component - how different ethnic
groups tend to deal with mental health issues - a topic most communities have
avoided because of its complexity.
Pasch said she hopes to see the training expanded to other police departments -
the Milwaukee County Sheriff's Department and some suburban departments have
shown interest - and hospital emergency room personnel.
Yerkes, speaking with the volunteer presenters recently, said she was encouraged
by the comments of officers who applied for the first round of training.
"Many of them have family members or friends who suffer from mental illness, and
have seen the system break down in how they're handled," she said.
Giving Officers Options
The new training comes as many of the resources available for people with mental
illness have shut down or scaled back their services.
As a result, "so many officers believe there are only two options out there: I
can do nothing or take them in for an involuntary commitment," said Steve
Dykstra, a psychologist in the Milwaukee County Behavioral Health System.
"We need to do a better job of developing those options, and letting police know
what else is out there," he said.
Already in place are programs such as Our Space, in which individuals with
mental illness help others work through crises or maneuver through the system,
and mobile teams of mental health professionals who can be called in as needed.
But advocates are hoping to create a crisis resource center where individuals
who are not a danger to themselves or others can go for help.
"In most cases, people don't need hospitalization," Pasch said. "They need
someone to talk to, who can hook them up with services or medication, or just
listen to them. It would be the equivalent of an urgent care center in
medicine."
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4. ASHEBORO COURIER TRIBUNE (NC), January 9, 2006
[Editor’s Note: It happened in most states sometime in the 1970’s, as
commitment standards were vastly restricted to require that a person must be an
immediate and demonstrable physical danger to himself or others before being
placed in a treatment facility. That legal change left law enforcement officers
powerless to help thousands of individuals who were psychotic and obviously in
need of care in a psychiatric facility. To protect and help such individuals,
some officers decided it was wiser to bring them to jail than to allow them to
remain on the streets. The term “mercy booking” was thus born.
Reflecting North Carolina’s shrinking inpatient capacity and some apparently
laggardly processes, officers in Asheboro were spending an average of five hours
on each commitment. And that did not even include the time needed for
transportation to a psychiatric hospital. We can’t help but wonder how many
people with a severe mental illness in Asheboro were brought to a booking room
rather than a treatment facility mainly because of time considerations. In many
parts of our nation a new term may now be applicable – “convenience booking.”]
INVOLUNTARY COMMITMENTS STRAIN POLICE MANPOWER
By Mark Brumley -- Staff Writer, The Courier-Tribune
ASHEBORO — Several weeks ago, Asheboro police were called to a home in the city
where a 22-year-old man had gotten drunk and cut his left wrist.
The man was passed out when officers arrived early that Saturday morning, a
report stated. But by the time an ambulance got him to Randolph Hospital for an
involuntary mental commitment, he was combative.
It took four officers to control the man, who later that day was sent to another
hospital for treatment. All told, the reporting officer spent 11 1/2 hours on
the case, records showed.
Such involuntary mental commitments are a common, time-consuming, disturbing and
sometimes dangerous aspect of a law enforcement officer’s job, but it’s not one
that gets much attention. They frequently involve alcohol and drugs, which
complicates and extends the process for police, mental health counselors and
health-care workers.
“We’re all concerned about the time that it’s taking for commitments,” said
Bonita Porter, the Randolph access manager for the Sandhills Center for Mental
Health, Development Disabilities and Substance Abuse Services in Asheboro.
Asheboro Police Chief Gary Mason said his officers are averaging 20 involuntary
commitments per month, according to a recent analysis conducted by the
department. The average length of time for each call is five hours, which is
almost half of an officer’s 12-hour shift. But Mason said it’s not unusual for
calls to take 11 or 12 hours. And one recent commitment took 21 hours.
“It is certainly a big weight around our necks,” Mason said. “What that does is
it takes an officer off of the street and takes them away from being able to
answer calls.”
The burden of involuntary commitments is not just a local issue, Mason said.
“The commitment problem is really growing, and it’s not just here, it’s all over
the state,” said Mason, who has discussed the issue with other law enforcement
officials at professional conferences. “It’s a problem we’re all facing.”
With the average length of time that officers spend on involuntary commitment
calls expected to increase, Mason said his department sat down last summer and
came up with a new system to keep officers on the streets rather than in a chair
waiting while involuntary commitments take place.
“We’ve had to strategize and try to do some different things,” Mason said. “It’s
really helping us. We feel like it is utilizing our personnel to the best of our
ability.
The Process
Porter said involuntary commitments get started in a number of different ways.
In some cases, she said, a mental client comes in for a routine counseling
session and it becomes obvious to the case worker that the individual has become
“psychiatrically debilitated.” If the client is still fairly clear headed, the
counselor might be able to talk the patient into going voluntarily to a hospital
for treatment.
Family members, neighbors or friends might also bring involuntary commitments to
the attention of police or mental health workers by reporting that an individual
is acting strangely, Porter said. In other cases, police may encounter mentally
or emotionally imbalanced people as a result of attempted suicide and armed
standoff calls.
Regardless of the circumstances, the involuntary commitment process is basically
the same.
If it comes up during business hours, the person is taken to the mental center.
If it’s after hours or on weekends, the person is taken to the Randolph Hospital
emergency room.
During those times, counselors are paged through Moses Cone Memorial Hospital in
Greensboro under a contract with Sandhills Center. If the counselors do not live
in the area, their travel time to Asheboro extends involuntary commitments for
police. During a 21-hour involuntary commitment last year, a counselor took 12
hours to arrive from Greensboro to do the evaluation, Mason said.
The first step is an assessment by counselors who try to determine if
individuals need to be committed. Porter said counselors typically look for any
significant changes that have occurred in people’s lives, whether or not they
are oriented to time and place and if they are at risk of harming themselves or
others. If the people have been drinking or taking drugs, the assessments can be
more difficult and take longer, Porter said. She said family members, if they
are available, can often give counselors valuable information for their
assessments.
If a counselor determines that a person needs to be committed, the next step is
getting a psychiatrist, a psychologist with a Ph.D. or a medical doctor to
approve the commitment. Porter said they will typically go along with the
counselor’s assessment, and the next step is to ask a magistrate for a
transportation order to send the person to a mental hospital or a substance
abuse treatment facility.
“It’s interesting that, really, the last word is sort of left with the
magistrate,” Porter said. “He or she could say I disagree. ... It happens very
rarely, but it has happened.”
Finding A Hospital
Porter said the next step is usually the most time consuming: Finding a hospital
that will accept the patient for a stay of three-seven days.
“That waiting time begins to extend because we’re now dealing with something out
of our control that’s beyond us,” Porter said. “That’s typically where the clock
goes longest.”
On good days, when everything “clicks,” Porter said, the entire process of
finding a hospital takes three to five hours. On other days, it can take much
longer, occupying not only police officers but also mental health workers.
“It’s a domino effect that goes beyond your local community,” Porter said. “Of
course, we are majority affected by that.”
Committing a patient is not as easy as just shipping the person off to Dorothea
Dix Hospital, the state mental hospital in Raleigh. Porter said Dix is usually
“on diversion” on weekends, which means the hospital won’t accept new patients.
During those times, the patients may be sent to private facilities that have
contracts with Dix, including Holly Hill Hospital in Raleigh and Bryn-Mar
Hospital in Jacksonville.
If Dix is accepting patients, Porter said the hospital requires them to sober up
before being admitted, due to health risks. That means officers often must wait
until a patient’s blood alcohol content drops below .08, the state level for a
driving while impaired charge.
Dix is usually the only option for uninsured patients with no money, Porter
said. Even if patients have insurance, a hospital might not accept them if they
are too unstable or violent, Porter said. She said the hospital might already
have a high number of problem patients, making the unit more difficult to
manage.
If a patient has insurance, Porter said, Dix requires mental health workers to
call at least five other centers before checking for a bed there. She said
mental health workers usually check with nearby hospitals offering with
in-patient psychiatric services before calling outside the area. Those hospitals
include Moses Cone Memorial Hospital in Greensboro, High Point Regional
Hospital, FirstHealth Moore Regional in Pinehurst, Alamance Regional Medical
Center in Burlington and Stanly Memorial Hospital in Albemarle.
“They (Dix) want to know that all of those hospitals said ‘no’ to us,” Porter
said. “That takes time.”
Placing a patient in an area hospital might not be possible, Porter said. In
those cases, mental health workers start to look outside the area to facilities
such as Holly Hill, Bryn-Mar and Coastal Plains Hospital in Rocky Mount.
“They’re not very close to Randolph County at all,” Porter said.
Fewer Hospital Beds
Also making it more difficult to place mental patients has been the declining
number of private hospital beds set aside for them. Porter said there just isn’t
a lot of money for hospitals in mental health and substance abuse treatment. The
services are costly, she said, and the insurance services are relatively low.
“Many of them have just cut back on the number of beds that they have,” Porter
said. “We saw that trend happening a lot five or six years ago.”
Porter said mental health advocates are working to reverse that trend, but
another change on the way is the pending merger of Dix with John Umstead
Hospital, a state mental facility in Butner.
“A lot of beds are going to be depleted because of that,” Porter said.
That’s one reason police expect their average wait on involuntary commitment
calls to increase to six or seven hours in coming years.
As mental health workers make calls to try to find a hospital, the clock ticks
away for police, and the risk that some patients will become violent increases.
“We’re concerned that this may escalate while we’re waiting to get to that ...
psychiatric evaluation, getting papers over to the magistrate and so forth,”
Porter said.
Mason said he’s had firsthand experience with such cases.
“You’ll have some people that can get very violent and will fight you or could
hurt you and might not even be aware of their behavior,” Mason said. “It can be
very dangerous. Over the years, we’ve had several instances where it could have
been a very bad situation.”
He remembered on one call at a local doctor’s office where he found himself in a
struggle for his life with a mental patient who seemed to have “amazing
strength.” Mason said the man had already assaulted one of his parents and torn
up the doctor’s office by the time police were dispatched. He said he ended up
on the floor wrestling with the man and trying to keep him from taking his
handgun. Eventually, the man was placed in handcuffs and leg irons and taken to
mental health.
“That could have been a life-or-death situation that was a commitment order,”
Mason said. “You have to go in knowing that you may get hold of someone who is
very unstable, somebody that could be very strong that could not be thinking
with a rational mind and could hurt you and others.”
In extreme cases, Porter said, counselors can ask for an emergency certificate,
which allows a patient to be committed more quickly.
Impact On Law Enforcement
Asheboro police officials already knew that patrolmen were spending an
extraordinary amount of time on involuntary commitment calls when they sat down
in June 2005 to analyze the numbers. But even they were surprised at some of
their findings.
In addition to determining that they were averaging 20 involuntary commitment
calls per month at five hours per call, Mason said, they learned that 75 percent
of those calls came in during the peak hours of 11 a.m.-11 p.m. That’s when
officers get 65 percent of their daily 911 calls for service.
And about three times per month, Mason said, officers have two or more
involuntary commitments taking place at the same time. Days like that can cut a
five-officer patrol team’s effectiveness in half, Mason said. And if an officer
is standing by with an involuntary commitment at the end of his or her shift,
and officer from the next shift must take over regardless of whether the team is
already shorthanded, Mason said.
“That’s where it’s hitting us, and it’s really straining our manpower, “ Mason
said. “What that does is it takes an officer off of the street and takes them
away from being able to answer calls.”
Involuntary commitments also take a toll on the Randolph County Sheriff’s
Office, where deputies are responsible for driving patients to mental health and
substance abuse treatment facilities all over the state after magistrates issue
transportation orders.
Maj. Allen McNeill said deputies transported patients 457 times in 2004. He said
that doesn’t include the times that the patients got weekend passes from the
facilities where they were being treated and deputies were required to drive
them home and then return them to the facilities.
The state recommends that sheriffs transport involuntary commitments in unmarked
cars driven by plain-clothes officers to avoid the appearance that mental health
patients are criminals, but that’s not always possible, McNeill said. He said
the sheriff’s office has to give the assignments to whoever is available for
them. McNeill said patrol deputies, civil deputies and jailers all do the
transports, depending on the time of day.
McNeill said sheriff’s officials agree that most mental health patients aren’t
criminals, and that’s why they do not believe that deputies should have to
transport them. It shouldn’t be a law enforcement responsibility, he said.
“That’s just part of our job that we get stuck with,” McNeill said.
No Cutting And Running
The quickest way to reduce the amount of time police officers spend on
involuntary commitment calls would be to no longer require them to stand by
while the process take place.
Some departments around the state have already started allowing officers to walk
away from involuntary commitments after picking up the patients and taking them
to a mental health center or hospital, Mason said. That may save officers’ time,
but it could also put counselors and health-care workers in danger if a patient
becomes violent. It could also expose the police department to greater
liability.
So cutting and running is not an option for Asheboro police officers, Mason
said.
“There’s a growing number of departments across the state that are doing that,”
he said. “However, we feel like, based on the legal advice that we’ve got and
from the opinions given by the Attorney General’s Office ... we just don’t feel
like legally that’s the proper thing for us to do. So we keep our people with
the commitments until we feel like our duty and obligation have been fulfilled.”
But Mason said the department had to find a way to keep patrol officers from
spending hours on involuntary commitment calls.
“We just felt like it was getting to the point that we had to look at doing to
some different things because it’s absolutely killing us out in the field,” he
said.
Coming Up With An Answer
With the city’s approval, Asheboro police devised a plan last summer to handle
lengthy involuntary commitment calls.
The plan involved establishing a roster of officers willing to come in to work
on their days off to standby at mental health or the hospital to relieve on-duty
officers so they can get back on the streets. Supervisors begin calling officers
on the roster only if it appears that a commitment will take longer than a few
hours. The officers aren’t required to come in to work, but if they do they
receive overtime pay. Mason said the money comes out of the department’s special
assignments budget, which is typically used for license checks and other
operations.
“This gets an officer back in the field,” Mason said. “We feel like it’s good
utilization of the taxpayers’ money and the money that’s been allocated to our
department. It is relieving officers and getting them back into their cars.”
After implementing the system, police officials studied it in July 2005 to see
how it worked, Mason said.
That month, the department responded to 15 involuntary commitment calls. Six of
those did not require an off-duty officer to be called out. The total amount of
time that officers spent on those calls was 16 hours, 10 minutes.
The total time spent on the other nine calls was 56 hours, 30 minutes. On-call
officers stood by for a total of 46 hours, 15 minutes, on those calls. They were
paid a total of $1,300 for overtime.
“So far it is really helping us,” Mason said. “What it’s done is it has relieved
us of our manpower being tied up as much. We’re still have a lot of commitments
that we’re dealing with but it is giving us some help in keeping sufficient
numbers of officers out in the field.”
******************************
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March 10, 2006
******************************
1. OUTPATIENT COMMITMENT OVERVIEW - Harvard Mental Health Letter, March 2006
2. STATE PSYCHIATRIC HOSPITALS DWINDLE - South Bend Tribune, February 20, 2006
3. PROGRAM TEACHES OFFICERS THE SKILLS TO DEAL WITH MENTALLY ILL - Milwaukee
Journal Sentinel, January 17, 2006
4. INVOLUNTARY COMMITMENTS STRAIN POLICE MANPOWER - Asheboro Courier Tribune,
January 9, 2006
******************************
1. HARVARD MENTAL HEALTH LETTER, March 2006
[Editor’s Note: This month’s Harvard Mental Health Letter offers an overview of
assisted outpatient treatment. It is a balanced and, given its length,
insightful summary of the treatment mechanism.
In noting that it “included only a small number of patients, none of whom were
violent, and there was no effective enforcement mechanism,” the newsletter
accurately describes some of the limitations of the Bellevue Study – one of the
very few (of many) examinations to find no statistically significant beneficial
effect of AOT. It does not mention, however, that members of the control group
were hospitalized for a median 101 days in 11 months while the median person
under an AOT order experienced only 43 days of hospitalization. Because of the
small size of the study, this seemingly dramatic result did not reach the level
of statistical significance; as it stands, it was certainly significant for the
participants.]
Outpatient Commitment.
The emptying of mental hospitals began a half-century ago with the hope that
effective treatment would be available on the outside, and patients would be
willing to accept it. But for many neither of those conditions has been met.
Many thousands of so-called revolving-door patients consume a disproportionate
share of the resources of the health care and criminal justice systems as they
move between jails, prisons, emergency rooms, psychiatric hospitals, rented
rooms, group homes, and the street.
At any given time, a third to half of people with schizophrenia or bipolar
disorder are not receiving treatment, and a third of the homeless are mentally
ill. Many are too discouraged or disorganized to take any initiative. Some will
not agree to treatment because they are isolated and withdrawn, or paranoid and
suspicious. Others refuse help because they wrongly believe they are doing well
enough without it. Court-ordered treatment -- known as outpatient commitment,
mandatory outpatient treatment, or assisted outpatient treatment -- has been
proposed as a partial solution to this problem.
What Are The Standards?
The laws of more than 40 states permit outpatient commitment, mainly for
patients who are actually or potentially dangerous to themselves or others. The
best-known state law is Kendra’s Law, passed in New York in 1999 after a woman
was pushed under a subway train by a man with schizophrenia. Under the New York
law, which is fairly typical, assisted outpatient treatment is authorized for
people who, because of failure to comply with treatment, have been in a mental
hospital, prison, or jail within the last three years or have committed an act
of violence in the last four years. To be committed, they have to be in danger
of relapse or deterioration that would result in physical harm to themselves or
others.
Many mental health professionals believe the standards should be less strict,
with a focus on deterioration alone. A study group appointed by the American
Psychiatric Association issued a report in 1999 recommending outpatient
commitment to prevent relapse or severe deterioration that would make patients
either dangerous or unable to care for themselves.
It’s much simpler to require mandatory treatment for the mentally ill if they
use illicit drugs or (less often) commit other minor crimes. No formal judgments
about dangerousness or deterioration are necessary. Addicts can be sentenced to
drug treatment in lieu of or in addition to imprisonment. In some places, courts
arrange to provide treatment for mentally ill lawbreakers. In mental health
courts, defendants who plead guilty are assigned to outpatient treatment instead
of prison.
The Debate
Critics say that outpatient commitment is an attack on privacy, autonomy, and
the right to travel. They also say that it undermines the therapeutic
relationship, reduces the long-term potential for independent living, drives
patients away from seeking treatment, and diverts resources from voluntary
patients. They insist that the dragnet of outpatient commitment will entrap
people who don’t need it.
Defenders of mandatory outpatient treatment say that it promotes compliance,
especially regular use of medications; mobilizes support services; lowers the
risk of homelessness, psychiatric hospitalization, and substance abuse; and
makes it less likely that patients will be victims or perpetrators of violence.
They say there is no evidence that people are prevented from seeking treatment
and point out that patients and their families rarely raise objections. They say
outpatient commitment will not divert resources as long as extra funding is
supplied. It will not be authorized for people who don’t need it if they have
legal representation, regularly scheduled reviews, and the right to appeal
decisions. In response to the argument that outpatient commitment infringes on
civil liberties, its defenders argue that people are not free when their minds
are in thrall to illness.
Apart from these issues, enforcement is a problem. In some states, patients who
do not comply can be brought to a clinic by police. Some think this should be
allowed when it is authorized by a judge based on evidence presented by a
clinician; others think there should be a formal hearing. Involuntary
hospitalization is a solution only for patients who present an imminent danger.
Telling them that they will be hospitalized unless they take their medications
may sometimes be impractical because resources are limited.
What The Studies Show
The New York State Office of Mental Health issued a report on Kendra’s Law in
2005 and pronounced it a success. From 1999 to 2004, nearly 4,000 court orders
were issued, usually for six months, and in two-thirds of cases the orders were
renewed. About 70% of the patients committed under the statute had schizophrenia
and 13% had bipolar disorder. The report found that after commitment these
patients were more likely to take their medications and less likely to be
homeless, arrested, or hospitalized. In interviews, nearly two-thirds of the
patients said they thought that the court order had been good for them.
There are other favorable reports about outpatient commitment but only two
controlled studies. In a trial conducted at Duke University, patients discharged
from a psychiatric hospital were assigned at random to community treatment alone
or to outpatient commitment with community treatment. The researchers found that
after a year, patients assigned to outpatient commitment had a better quality of
life because they were more likely to comply with treatment and less likely to
be victims of violence. The rate of psychiatric hospitalization was the same in
both groups under the original three-month commitment order. Most of the
advantage for outpatient commitment arose after that three-month period, when
the study was no longer controlled.
The second controlled study, a three-year pilot project at Bellevue Hospital in
New York City, found that outpatient commitment made no difference in the
effectiveness of intensive community treatment. The study included only a small
number of patients, none of whom were violent, and there was no effective
enforcement mechanism.
In an independent analysis for the Cochrane Collaboration, reviewers in 2005
concluded that the only strong evidence for the value of outpatient commitment
came from the findings of the Duke study on the risk of criminal victimization.
Willingness to accept treatment is only one side of the problem that has led to
calls for outpatient commitment; the availability of treatment is the other
side. Everyone agrees that mandatory outpatient treatment requires a plan that
includes intensive services. But often those services are not available because
the public mental health system is poorly organized and underfunded. Mandatory
treatment laws, taken seriously, could be an incentive to provide the needed
organization and funding. But it’s also possible that if better services were
available, outpatient commitment would become a less important issue.
References
American Psychiatric Association Council on Psychiatry and Law. Mandatory
Outpatient Treatment Resource Document. American Psychiatric Association,
December 1999.
Cornwell JK, et al. "Exposing the Myths Surrounding Preventive Outpatient
Commitment for Individuals with Chronic Mental Illness," Psychology, Public
Policy, and Law (March-June 2003): Vol. 9, No. 1-2, pp. 209-32.
Hiday VA. "Outpatient Commitment: The State of Empirical Research on Its
Outcomes," Psychology, Public Policy, and Law (March-June 2003): Vol. 9, No.
1-2, pp. 8-32.
New York State Office of Mental Health. Kendra’s Law: Final Report on the Status
of Assisted Outpatient Treatment, March 2005.
Torrey EF, et al. "Outpatient Commitment: What, Why, and for Whom," Psychiatric
Services (March 2001): Vol. 52, No. 3, pp. 337-41
******************************
2. SOUTH BEND TRIBUNE (IN), February 20, 2006
[Editor’s Note: Whether for long-term care or a shorter period after an acute
episode, people overcome by severe mental illnesses can need placement in a
secure setting – for their own welfare and, at times, for that of those around
them. While improvements in outpatient care can mitigate that need, modalities
for secure inpatient care remain essential and will be long into the foreseeable
future.
Currently, there are two types of inpatient facilities available for people with
serious psychiatric disorders – psychiatric and correctional. Psychiatric care
should be supervised by mental health professionals rather than correctional
ones, whether this goal is fostered through rational commitment standards that
permit treatment interventions before the symptoms of an untreated illness lead
to a criminal act or by programs like mental health courts that offer diversion
once the person has entered the criminal system.
Yet, before a person in crisis because of a mental illness can receive care in a
hospital bed rather than a jail cell, there must be a hospital bed available.]
STATE PSYCHIATRIC HOSPITALS DWINDLE
Fewer Options Left For Housing The Mentally Ill.
By Alicia Gallegos
It's 10 p.m. on a Tuesday night.
Someone is standing in the middle of a busy road, careening in and out of
traffic, mumbling incoherently.
A "10-96" goes over the radio, police code for a "mental subject." Officers
arrive and usher the person away from the street.
Police then have three choices, according to a 2000 report from the National
Institute of Justice journal: arrest the person, take him or her to a mental
hospital, or resolve the matter informally.
But officers know that in reality, their alternatives are even more limited,
says Maj. Sam Cochran with the Memphis Police Department. Officers can wait
hours trying to have a person admitted to an area mental health facility, he
explains, only to find the subject doesn't meet commitment standards or must
voluntarily enter the facility.
Throw in unruly, violent behavior, and their options dwindle further.
"Arrest often was the only step available to the officer in situations where
individuals were not sufficiently disturbed to be accepted by the hospital but
were too public in their deviance to be ignored," professor Linda A. Teplin
writes in the NJI article.
For the many untreated mentally ill, the criminal justice system now becomes the
entry point into the mental health system.
"We don't want to put people in jail," says Elkhart County Sheriff Michael
Books. "(But) we have a responsibility to deal with those folks, (especially) if
we have a violent person." The majority of mentally ill offenders are in jail or
on probation for a property or public-order offense, according to a recent study
by the Bureau of Justice Statistics.
The study also found a high rate of homelessness for mentally ill inmates, along
with unemployment, alcohol and drug use and physical and sexual abuse before
their incarcerations.
A lack of state psychiatric hospital beds contributes to the problem, experts
say.
From 1972 to 1990, available beds decreased by more than 70 percent because of
hospital closures, according to the National Association of State Mental Health
Program Directors Research Institute.
In the 1990s, 44 hospitals closed nationwide. From 2000 to 2003, two state
hospitals closed, and a report cited five states that planned to close hospitals
in 2004 and 2005. In Indiana, the last state hospital to close was Central
Indianapolis Hospital 11 years ago, according to Indiana Family and Social
Services Administration.
Indiana was actually the only state listed that planned to increase the size of
one of its hospitals when the closure report came out in 2004.
A new unit was created at Logansport State Hospital this past summer,
specifically designed for patients involved in the criminal justice system, said
Dennis Rosebrough, FSSA communications director. The hospital also has a new
wing in the works that will open even more beds.
Nationwide, general hospital specialty unit psychiatric beds also have
decreased, according to the report. From 1998 to 2003, 23 of 38 states have
experienced declines in their specialty beds.
The reason for the shortages is multifaceted, says Mary Zdanowicz, executive
director of the Treatment Advocacy Center, a national nonprofit agency dedicated
to helping Americans with severe mental illness. Of course, one major reason is
money, she says.
The Institutions with Mental Disease exclusion was implemented in 1965 by
Congress and prevents state psychiatric hospitals from receiving federal
Medicaid funding.
Without that money, many hospitals have closed.
Although the push of mental health care into more community-based solutions is
well-meaning, she says, it doesn't work for everyone.
Some people with mental illness need long-term, structured care. Others have a
harder time being admitted to area mental health facilities without insurance."
The one alternative they can always count on is jail," she says.
And jails and prisons are often the worst place for mentally ill people to be,
experts say, because offenders are sometimes punished for symptoms of their
illness -- being noisy, refusing orders -- and end up staying longer.
"Mentally ill prisoners are more likely than others to end up housed in
especially harsh conditions, such as isolation," according to a recent study by
Human Rights Watch. "That can push them over the edge into acute psychosis."
******************************
3. MILWAUKEE JOURNAL SENTINEL, January 17, 2006
[Editor’s Note: One way in which to help ensure that those in need of
psychiatric care stay in the mental health system is to increase the skills and
awareness of the gatekeepers of the criminal justice one, i.e., police officers
and sheriff’s deputies.]
PROGRAM TEACHES OFFICERS THE SKILLS TO DEAL WITH MENTALLY ILL
Empathy Seen As Key To Defusing Violent Situations
By Annysa Johnson
Earl Ingram gets angry when he thinks about the day he drove his son to a
Milwaukee police station, hoping officers would take him for commitment to the
Milwaukee County Mental Health Complex.
Diagnosed at 24 with bipolar disorder, Ingram's son, now 28, had been setting
fires at his mother's house, and Ingram feared for the safety of the young man
and others.
Rather than let him bring his son in, Ingram said, four officers with billy
clubs went out to the car, handcuffed his son and hauled him in.
And instead of being taken to the Mental Health Complex, Ingram said, his son
was arrested on an outstanding warrant for driving after revocation and booked
into the jail, where he sat for two weeks without his court-ordered medications.
"It was overkill . . . one of the coldest responses I've ever seen," said
Ingram, a radio talk show host who will share his family's experiences as part
of a new Milwaukee police training program that started this month.
The Crisis Intervention Team program is designed to give police officers the
information and skills they need to improve their responses to situations
involving people with mental illness. That's of grave importance, say mental
health professionals, who voiced outrage in recent years over fatal police
shootings of individuals in mental health crises.
"It doesn't eliminate all tragedies," said Sandy Pasch, former president of the
National Alliance for the Mentally Ill of Greater Milwaukee, who helped bring
the program to the city. "But it greatly reduces them."
Thirty Milwaukee police officers have volunteered to take the 40 hours of
training, after which they'll be dispatched as first responders on calls
involving mental health issues. The goal, said Lt. Carianne Yerkes, is to have
at least a quarter of the department's 1,800 officers participate in the
training.
'The Importance of Empathy'
The weeklong program, offered at no cost by local mental health professionals
and advocates, will cover a host of issues - from the types of disorders and the
drugs used to treat them to community resources and techniques for de-escalating
potentially violent situations.
"That is a major component," said Pasch, who rode along with officers last year
in Memphis, where the program was developed in the 1980s.
"They learn the value of talking to people - what questions to ask, the
importance of empathy," she said. "When you show you're a human being responding
to them, instead of an officer, it takes the fear level down."
The crisis intervention program, or some variation, has been implemented in a
number of cities around the country, including Denver, Indianapolis, and
Appleton, Wis.
The Milwaukee program is taking elements from all those but will most resemble
Memphis' effort in that it's voluntary. In addition, Pasch said, Milwaukee's
program will attempt to address the cultural component - how different ethnic
groups tend to deal with mental health issues - a topic most communities have
avoided because of its complexity.
Pasch said she hopes to see the training expanded to other police departments -
the Milwaukee County Sheriff's Department and some suburban departments have
shown interest - and hospital emergency room personnel.
Yerkes, speaking with the volunteer presenters recently, said she was encouraged
by the comments of officers who applied for the first round of training.
"Many of them have family members or friends who suffer from mental illness, and
have seen the system break down in how they're handled," she said.
Giving Officers Options
The new training comes as many of the resources available for people with mental
illness have shut down or scaled back their services.
As a result, "so many officers believe there are only two options out there: I
can do nothing or take them in for an involuntary commitment," said Steve
Dykstra, a psychologist in the Milwaukee County Behavioral Health System.
"We need to do a better job of developing those options, and letting police know
what else is out there," he said.
Already in place are programs such as Our Space, in which individuals with
mental illness help others work through crises or maneuver through the system,
and mobile teams of mental health professionals who can be called in as needed.
But advocates are hoping to create a crisis resource center where individuals
who are not a danger to themselves or others can go for help.
"In most cases, people don't need hospitalization," Pasch said. "They need
someone to talk to, who can hook them up with services or medication, or just
listen to them. It would be the equivalent of an urgent care center in
medicine."
******************************
4. ASHEBORO COURIER TRIBUNE (NC), January 9, 2006
[Editor’s Note: It happened in most states sometime in the 1970’s, as
commitment standards were vastly restricted to require that a person must be an
immediate and demonstrable physical danger to himself or others before being
placed in a treatment facility. That legal change left law enforcement officers
powerless to help thousands of individuals who were psychotic and obviously in
need of care in a psychiatric facility. To protect and help such individuals,
some officers decided it was wiser to bring them to jail than to allow them to
remain on the streets. The term “mercy booking” was thus born.
Reflecting North Carolina’s shrinking inpatient capacity and some apparently
laggardly processes, officers in Asheboro were spending an average of five hours
on each commitment. And that did not even include the time needed for
transportation to a psychiatric hospital. We can’t help but wonder how many
people with a severe mental illness in Asheboro were brought to a booking room
rather than a treatment facility mainly because of time considerations. In many
parts of our nation a new term may now be applicable – “convenience booking.”]
INVOLUNTARY COMMITMENTS STRAIN POLICE MANPOWER
By Mark Brumley -- Staff Writer, The Courier-Tribune
ASHEBORO — Several weeks ago, Asheboro police were called to a home in the city
where a 22-year-old man had gotten drunk and cut his left wrist.
The man was passed out when officers arrived early that Saturday morning, a
report stated. But by the time an ambulance got him to Randolph Hospital for an
involuntary mental commitment, he was combative.
It took four officers to control the man, who later that day was sent to another
hospital for treatment. All told, the reporting officer spent 11 1/2 hours on
the case, records showed.
Such involuntary mental commitments are a common, time-consuming, disturbing and
sometimes dangerous aspect of a law enforcement officer’s job, but it’s not one
that gets much attention. They frequently involve alcohol and drugs, which
complicates and extends the process for police, mental health counselors and
health-care workers.
“We’re all concerned about the time that it’s taking for commitments,” said
Bonita Porter, the Randolph access manager for the Sandhills Center for Mental
Health, Development Disabilities and Substance Abuse Services in Asheboro.
Asheboro Police Chief Gary Mason said his officers are averaging 20 involuntary
commitments per month, according to a recent analysis conducted by the
department. The average length of time for each call is five hours, which is
almost half of an officer’s 12-hour shift. But Mason said it’s not unusual for
calls to take 11 or 12 hours. And one recent commitment took 21 hours.
“It is certainly a big weight around our necks,” Mason said. “What that does is
it takes an officer off of the street and takes them away from being able to
answer calls.”
The burden of involuntary commitments is not just a local issue, Mason said.
“The commitment problem is really growing, and it’s not just here, it’s all over
the state,” said Mason, who has discussed the issue with other law enforcement
officials at professional conferences. “It’s a problem we’re all facing.”
With the average length of time that officers spend on involuntary commitment
calls expected to increase, Mason said his department sat down last summer and
came up with a new system to keep officers on the streets rather than in a chair
waiting while involuntary commitments take place.
“We’ve had to strategize and try to do some different things,” Mason said. “It’s
really helping us. We feel like it is utilizing our personnel to the best of our
ability.
The Process
Porter said involuntary commitments get started in a number of different ways.
In some cases, she said, a mental client comes in for a routine counseling
session and it becomes obvious to the case worker that the individual has become
“psychiatrically debilitated.” If the client is still fairly clear headed, the
counselor might be able to talk the patient into going voluntarily to a hospital
for treatment.
Family members, neighbors or friends might also bring involuntary commitments to
the attention of police or mental health workers by reporting that an individual
is acting strangely, Porter said. In other cases, police may encounter mentally
or emotionally imbalanced people as a result of attempted suicide and armed
standoff calls.
Regardless of the circumstances, the involuntary commitment process is basically
the same.
If it comes up during business hours, the person is taken to the mental center.
If it’s after hours or on weekends, the person is taken to the Randolph Hospital
emergency room.
During those times, counselors are paged through Moses Cone Memorial Hospital in
Greensboro under a contract with Sandhills Center. If the counselors do not live
in the area, their travel time to Asheboro extends involuntary commitments for
police. During a 21-hour involuntary commitment last year, a counselor took 12
hours to arrive from Greensboro to do the evaluation, Mason said.
The first step is an assessment by counselors who try to determine if
individuals need to be committed. Porter said counselors typically look for any
significant changes that have occurred in people’s lives, whether or not they
are oriented to time and place and if they are at risk of harming themselves or
others. If the people have been drinking or taking drugs, the assessments can be
more difficult and take longer, Porter said. She said family members, if they
are available, can often give counselors valuable information for their
assessments.
If a counselor determines that a person needs to be committed, the next step is
getting a psychiatrist, a psychologist with a Ph.D. or a medical doctor to
approve the commitment. Porter said they will typically go along with the
counselor’s assessment, and the next step is to ask a magistrate for a
transportation order to send the person to a mental hospital or a substance
abuse treatment facility.
“It’s interesting that, really, the last word is sort of left with the
magistrate,” Porter said. “He or she could say I disagree. ... It happens very
rarely, but it has happened.”
Finding A Hospital
Porter said the next step is usually the most time consuming: Finding a hospital
that will accept the patient for a stay of three-seven days.
“That waiting time begins to extend because we’re now dealing with something out
of our control that’s beyond us,” Porter said. “That’s typically where the clock
goes longest.”
On good days, when everything “clicks,” Porter said, the entire process of
finding a hospital takes three to five hours. On other days, it can take much
longer, occupying not only police officers but also mental health workers.
“It’s a domino effect that goes beyond your local community,” Porter said. “Of
course, we are majority affected by that.”
Committing a patient is not as easy as just shipping the person off to Dorothea
Dix Hospital, the state mental hospital in Raleigh. Porter said Dix is usually
“on diversion” on weekends, which means the hospital won’t accept new patients.
During those times, the patients may be sent to private facilities that have
contracts with Dix, including Holly Hill Hospital in Raleigh and Bryn-Mar
Hospital in Jacksonville.
If Dix is accepting patients, Porter said the hospital requires them to sober up
before being admitted, due to health risks. That means officers often must wait
until a patient’s blood alcohol content drops below .08, the state level for a
driving while impaired charge.
Dix is usually the only option for uninsured patients with no money, Porter
said. Even if patients have insurance, a hospital might not accept them if they
are too unstable or violent, Porter said. She said the hospital might already
have a high number of problem patients, making the unit more difficult to
manage.
If a patient has insurance, Porter said, Dix requires mental health workers to
call at least five other centers before checking for a bed there. She said
mental health workers usually check with nearby hospitals offering with
in-patient psychiatric services before calling outside the area. Those hospitals
include Moses Cone Memorial Hospital in Greensboro, High Point Regional
Hospital, FirstHealth Moore Regional in Pinehurst, Alamance Regional Medical
Center in Burlington and Stanly Memorial Hospital in Albemarle.
“They (Dix) want to know that all of those hospitals said ‘no’ to us,” Porter
said. “That takes time.”
Placing a patient in an area hospital might not be possible, Porter said. In
those cases, mental health workers start to look outside the area to facilities
such as Holly Hill, Bryn-Mar and Coastal Plains Hospital in Rocky Mount.
“They’re not very close to Randolph County at all,” Porter said.
Fewer Hospital Beds
Also making it more difficult to place mental patients has been the declining
number of private hospital beds set aside for them. Porter said there just isn’t
a lot of money for hospitals in mental health and substance abuse treatment. The
services are costly, she said, and the insurance services are relatively low.
“Many of them have just cut back on the number of beds that they have,” Porter
said. “We saw that trend happening a lot five or six years ago.”
Porter said mental health advocates are working to reverse that trend, but
another change on the way is the pending merger of Dix with John Umstead
Hospital, a state mental facility in Butner.
“A lot of beds are going to be depleted because of that,” Porter said.
That’s one reason police expect their average wait on involuntary commitment
calls to increase to six or seven hours in coming years.
As mental health workers make calls to try to find a hospital, the clock ticks
away for police, and the risk that some patients will become violent increases.
“We’re concerned that this may escalate while we’re waiting to get to that ...
psychiatric evaluation, getting papers over to the magistrate and so forth,”
Porter said.
Mason said he’s had firsthand experience with such cases.
“You’ll have some people that can get very violent and will fight you or could
hurt you and might not even be aware of their behavior,” Mason said. “It can be
very dangerous. Over the years, we’ve had several instances where it could have
been a very bad situation.”
He remembered on one call at a local doctor’s office where he found himself in a
struggle for his life with a mental patient who seemed to have “amazing
strength.” Mason said the man had already assaulted one of his parents and torn
up the doctor’s office by the time police were dispatched. He said he ended up
on the floor wrestling with the man and trying to keep him from taking his
handgun. Eventually, the man was placed in handcuffs and leg irons and taken to
mental health.
“That could have been a life-or-death situation that was a commitment order,”
Mason said. “You have to go in knowing that you may get hold of someone who is
very unstable, somebody that could be very strong that could not be thinking
with a rational mind and could hurt you and others.”
In extreme cases, Porter said, counselors can ask for an emergency certificate,
which allows a patient to be committed more quickly.
Impact On Law Enforcement
Asheboro police officials already knew that patrolmen were spending an
extraordinary amount of time on involuntary commitment calls when they sat down
in June 2005 to analyze the numbers. But even they were surprised at some of
their findings.
In addition to determining that they were averaging 20 involuntary commitment
calls per month at five hours per call, Mason said, they learned that 75 percent
of those calls came in during the peak hours of 11 a.m.-11 p.m. That’s when
officers get 65 percent of their daily 911 calls for service.
And about three times per month, Mason said, officers have two or more
involuntary commitments taking place at the same time. Days like that can cut a
five-officer patrol team’s effectiveness in half, Mason said. And if an officer
is standing by with an involuntary commitment at the end of his or her shift,
and officer from the next shift must take over regardless of whether the team is
already shorthanded, Mason said.
“That’s where it’s hitting us, and it’s really straining our manpower, “ Mason
said. “What that does is it takes an officer off of the street and takes them
away from being able to answer calls.”
Involuntary commitments also take a toll on the Randolph County Sheriff’s
Office, where deputies are responsible for driving patients to mental health and
substance abuse treatment facilities all over the state after magistrates issue
transportation orders.
Maj. Allen McNeill said deputies transported patients 457 times in 2004. He said
that doesn’t include the times that the patients got weekend passes from the
facilities where they were being treated and deputies were required to drive
them home and then return them to the facilities.
The state recommends that sheriffs transport involuntary commitments in unmarked
cars driven by plain-clothes officers to avoid the appearance that mental health
patients are criminals, but that’s not always possible, McNeill said. He said
the sheriff’s office has to give the assignments to whoever is available for
them. McNeill said patrol deputies, civil deputies and jailers all do the
transports, depending on the time of day.
McNeill said sheriff’s officials agree that most mental health patients aren’t
criminals, and that’s why they do not believe that deputies should have to
transport them. It shouldn’t be a law enforcement responsibility, he said.
“That’s just part of our job that we get stuck with,” McNeill said.
No Cutting And Running
The quickest way to reduce the amount of time police officers spend on
involuntary commitment calls would be to no longer require them to stand by
while the process take place.
Some departments around the state have already started allowing officers to walk
away from involuntary commitments after picking up the patients and taking them
to a mental health center or hospital, Mason said. That may save officers’ time,
but it could also put counselors and health-care workers in danger if a patient
becomes violent. It could also expose the police department to greater
liability.
So cutting and running is not an option for Asheboro police officers, Mason
said.
“There’s a growing number of departments across the state that are doing that,”
he said. “However, we feel like, based on the legal advice that we’ve got and
from the opinions given by the Attorney General’s Office ... we just don’t feel
like legally that’s the proper thing for us to do. So we keep our people with
the commitments until we feel like our duty and obligation have been fulfilled.”
But Mason said the department had to find a way to keep patrol officers from
spending hours on involuntary commitment calls.
“We just felt like it was getting to the point that we had to look at doing to
some different things because it’s absolutely killing us out in the field,” he
said.
Coming Up With An Answer
With the city’s approval, Asheboro police devised a plan last summer to handle
lengthy involuntary commitment calls.
The plan involved establishing a roster of officers willing to come in to work
on their days off to standby at mental health or the hospital to relieve on-duty
officers so they can get back on the streets. Supervisors begin calling officers
on the roster only if it appears that a commitment will take longer than a few
hours. The officers aren’t required to come in to work, but if they do they
receive overtime pay. Mason said the money comes out of the department’s special
assignments budget, which is typically used for license checks and other
operations.
“This gets an officer back in the field,” Mason said. “We feel like it’s good
utilization of the taxpayers’ money and the money that’s been allocated to our
department. It is relieving officers and getting them back into their cars.”
After implementing the system, police officials studied it in July 2005 to see
how it worked, Mason said.
That month, the department responded to 15 involuntary commitment calls. Six of
those did not require an off-duty officer to be called out. The total amount of
time that officers spent on those calls was 16 hours, 10 minutes.
The total time spent on the other nine calls was 56 hours, 30 minutes. On-call
officers stood by for a total of 46 hours, 15 minutes, on those calls. They were
paid a total of $1,300 for overtime.
“So far it is really helping us,” Mason said. “What it’s done is it has relieved
us of our manpower being tied up as much. We’re still have a lot of commitments
that we’re dealing with but it is giving us some help in keeping sufficient
numbers of officers out in the field.”
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