Commitment law won't help the mentally ill

Commitment law won't help the mentally ill

By Marylou Sudders, 6/12/2002

SOME MENTAL health specialists argue that outpatient commitment and forcing people with mental illness to take medications would improve the Commonwealth's mental health system. But the argument is simplistic and flawed.

It is a topic that draws vitriolic reactions from all sides and threatens to pull asunder the fragile alliance that currently exists in Massachusetts among the mental health constituency, composed of family members, individuals with mental illness, community and hospital providers, advocates, and practitioners. Moreover, it is the wrong issue at this time.

The real issue is the lack of a comprehensive mental health system that provides treatment, rehabilitation, and opportunity for recovery. Our society has never entered into a social contract for individuals with mental illness.

The human stories of mental illness are heartbreaking. In much of our country, jails, the streets, and child custody agencies are the de facto mental health system. For years, we have blamed individuals with mental illness and their families for their illnesses. We have allowed the illness to define individuals, robbing them of their humanity. We have conveyed no hope of recovery. Stigma and discrimination have defined our attitudes, justifying the low priority for services and funding.

For real gains to be realized, we must acknowledge that mental disorders are illnesses and that individuals with mental illness and their loved ones deserve to be treated with dignity and respect. Will this social contract cost money? Absolutely, and much more than is provided in state and federal budgets. A true social contract acknowledges the worth and value of the individual, engages in relevant research, and invests in services.

Mental health has for years been the stepchild of our health care and human services systems. Decisions on helping those desperate for services too often are determined by inadequate funding streams rather than coherent public policy. It should surprise no one that government-funded mental health systems are fragmented and cannot meet demand.

Given that there are never enough resources to meet the need, how would outpatient commitment work? In Massachusetts, there are long wait lists for publicly funded mental health case management and residential services. The waiting time for outpatient services, including appointments to see a psychiatrist, is months not weeks. Many mental health practitioners do not accept any insurance. Outpatient commitment does not guarantee access to care or compliance with treatment.

The call for outpatient commitment comes out of frustration. In some cases, the frustration of seeing a loved one suffer; for others, the inability to locate care and treatment. Although Massachusetts does not have an outpatient commitment law, more than 4,500 people in the Commonwealth take their psychiatric medications under court orders. Known as Rogers guardianships, these orders specify which medications are prescribed and how often they are taken.

Our mental health system must be built upon a foundation of respect and collaboration. The use of coercion in treatment and outpatient commitment has significant consequences and perpetuates the stigma associated with mental illness. Many states with outpatient commitment laws on the books seldom use them. Studies show that the fear of forced treatment drives many people away from the very treatment that they need. Another study compared the treatment outcomes for patients with outpatient commitment orders with patients receiving voluntary services; there were no differences in treatment outcomes. Other studies point out that individuals with mental illness are not more prone to violence. Individuals with mental illness account for a fraction of the violent acts committed in our country.

Outpatient commitment cannot be used as a shortcut for good treatment. For instance, clozapine is the ''gold standard'' medication for the most severe symptoms of schizophrenia. It does not come in a one-time injection - it is a pill that must be taken daily for years. Clozapine can help transform lives, but it has powerful side effects. It takes a trusting relationship with a psychiatrist to take this step. Nothing can substitute for trust. This truth underlies the clinical adage ''no alliance, no compliance.''

There are well-researched voluntary programs that demonstrate impressive treatment outcomes, including symptom relief and medication compliance. These include Programs for Assertive Community Treatment. Existing in other parts of the country for years, they have been slow to develop in Massachusetts. I have been implementing these teams as scant resources have allowed. In addition, persons with mental illness benefit greatly from peer support through psychosocial rehabilitation clubs and peer education models. It is through these progressive, voluntary treatment models that even the most severely mentally ill individuals can become more productive members of society.

Massachusetts has much to be proud of. We have a framework of a comprehensive mental health system. It needs to be fully realized and sustained. The mental health community must seize the opportunity to chart a different course. We must ensure that the provision of mental health care and treatment is not primarily a public function. We must ensure that private insurers end their historic segregation of mental health services and provide the parity now required under law. And, we must draw upon the strength that united 2,500 people in April and 1,000 in November, all demanding that mental health services be available. That is the issue, not outpatient commitment.

Marylou Sudders is commissioner of mental health for Massachusetts.