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Health & Fitness

Forced Medication No Solution for Violence in Our Society

Connecticut should beef up the existing behavioral health system, one of the best in the nation, rather than waste limited resources on flawed proposals that are proven to be ineffective.

Last week marked the passage of exactly two months since the tragic killings of 20 children and six staff members at Sandy Hook Elementary School.  Although there’s still no solid evidence that the gunman, Adam Lanza, had a psychiatric diagnosis, many in the general public, along with a large contingent of policy makers, remain convinced that mental illness is to blame for the December 14th tragedy in Newtown.  This belief has led to a lot of “magical thinking” that we can prevent another tragedy of such magnitude by creating policies that “protect” the public from those with mental illnesses.

One such proposal is “involuntary outpatient commitment”, also known as “assisted outpatient treatment” by its proponents, and as “forced treatment” by the advocacy community, which opposes the concept.  Whatever the label, it’s no panacea, and there’s a great deal of danger in rushing to take action—any action—in order to be seen as doing something to “fix” the problem.

Outpatient commitment refers to laws that exist in all but six states (including Connecticut), allowing the courts to order mandatory, community-based treatment of individuals with serious mental illness who have repeated hospitalizations and criminal justice contacts, and are found to be “non-compliant” with medication regimes.  The most famous of these laws is New York State’s Kendra’s Law, enacted in 1999.  An editorial published in Connecticut’s very own Hartford Courant that year condemned the law as a “kneejerk reaction” that would “foment unwarranted fear of the mentally ill” and sidetrack efforts to address the larger problem of providing adequate community services for those wishing to access them. 

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At a January 29th hearing of the Connecticut General Assembly’s Bipartisan Task Force on Gun Violence Prevention and Child Safety, Jan Van Tassel, Executive Director of the Connecticut Legal Rights Project said that outpatient commitment orders “have nothing whatsoever to do with preventing violence.”  She added that outpatient commitment could even create a sense of false assurance in the community, given that perpetrators of past acts of violence, including the Virginia Tech shootings, were under outpatient commitment orders.  Worse, such a law will perpetuate the myth associating mental illness with violence.  In reality, according to multiple studies, a person with a mental illness is no more prone to violence than someone from the general population.  Sadly, people with mental illnesses are far more likely to be victimized by others than to be violent themselves.

Also testifying at the January 29th task force hearing, Department of Mental Health and Addiction Services Commissioner Patricia Rehmer said that, due to fragmentation and severe underfunding of their mental health systems, many states with outpatient commitment laws haven’t implemented them. In fact, only 12 states with laws in place are currently able to enforce them.  In its first year of implementation, Kendra’s Law cost the State of New York $32 million for enforcement alone, in addition to the $125,000 million appropriated for housing and behavioral health services. 

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Given the shortage of funding for existing mental health services, it’s highly unlikely that Connecticut could afford to enforce a law mandating outpatient treatment.  In order to do so, it would have to divert monies from an already desperately overburdened mental health system.  Consider this:  in the past five years, state-funded non-profits, which provide the bulk of state-sponsored social services, have received a mere one-half of one percent cost of living adjustment in the past five years.  With sharp hikes in the costs of gas, heating oil, and food, agencies have been forced to cut programs and staffing.  The average private nonprofit worker earns about half of what a comparable state employee is paid.  As a result, many private nonprofit workers rely on public assistance to survive, and community-based agencies face a chronic problem with high turnover and vacant positions. 

Successful treatment relationships rely on trust, which is particularly difficult to build with trauma survivors.  For such a person, an outpatient commitment order is just another betrayal in a long line of betrayals, and creates an adversarial relationship between provider and client that will make the client less likely to engage in services in the future, wreaking perhaps irreparable damage on the recovery process.

In the 14 years since Kendra’s Law was enacted, there has been no concrete scientific evidence that clearly shows the efficacy of court-mandated treatment, and there is no reliable evidence about the comparative effectiveness of involuntary versus voluntary treatment.  In fact, scientifically controlled studies show the same benefits with enhanced voluntary community outpatient services as with involuntary outpatient commitment.

Connecticut already has one of the best mental health systems in the country, receiving one of only six B’s in a 2009 report from the National Alliance on Mental Illness entitled “Grading the States: A Report on America’s Mental Health Care System for Serious Mental Illness”.  The national average was a “D”.  Why should Connecticut follow the example of other states in establishing flawed mental health policies that don’t help people succeed in their communities, when we’re already a national leader in providing effective mental health services? We should instead build on the demonstrated strengths of Connecticut’s system, investing available resources on practices that have a proven track record in helping people with severe mental illnesses to live more successfully in their communities. 

Community based services that pair an array of supports with clinical services and medication are vital to helping those with mental illnesses rebuild their lives.  Safe and stable housing, in conjunction with wrap-around supports like educational and vocational supports, case management, and the teaching of basic living skills, greatly reduce shelter use, ER visits, hospitalizations, arrests and jail time, saving the public untold amounts of money.   

This model works for several reasons.  Clients build meaningful relationships with staff members, along the mutual respect and trust that come from regular interactions.  They have access to trained peer specialists (persons in recovery from mental illness), who not only understand and personally relate to their unique challenges, but also offer pragmatic advice and perspectives based on their own experiences, along with hope, possibly the most crucial element in the recovery process. 

As President Bush stated in the Executive Order establishing the President’s New Freedom Commission on Mental Health, “the desired outcomes of mental health care…are to attain each individual’s maximum level of employment, self-care, interpersonal relationships, and community participation.”    The Commission made its final report in 2003, but as Michael Hogan, PhD, who chaired the commission, has said, we’re still “spending too much on mental illness in all the wrong places”—the costs of untreated or poorly treated mental illness are painfully evident in the disability system, in the criminal justice system, and on the streets. Federal expenditures on benefits for people disabled by mental illness exceed the actual budgets of any of the state mental health agencies.  The number of prison and jail inmates with mental health problems has more than quadrupled to 1.25 million since 1998.

Devoting adequate funding for Connecticut’s highly effective and collaborative system of supports and requiring private insurance companies to cover these services for their clients is a worthwhile investment in our state’s future.  Where involuntary outpatient commitment is an expensive proposition that is unlikely to have any long term positive effect on the lives of the limited number of people it would serve, using our limited fiscal resources to expand and improve Connecticut’s community-based mental health system will help countless individuals become fully functioning members of society.  The ultimate return for the state of Connecticut is huge—fully independent people in recovery not only stop using expensive services, they also give back as they become employed and purchase goods and services, thereby supporting local businesses and creating new revenues for the state.

It’s long past time to address the inadequacies of our behavioral health system, but we shouldn’t rush to implement proposals that offer empty promises.   Involuntary outpatient commitment is one such proposal that can neither eliminate violence in our society, nor ensure decent, accessible behavioral health services for all.

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