MAKING IT EASIER TO COMMIT THE MENTALLY ILL
Laws are changing, but that may not be the best solution.
By Jonathan Walters
GOVERNING
MARCH, 1990
As a crime, her daughter's was minimal: harassing a man for whom she had a "fatal attraction, says Nancy K. Terry. But as a strain on the family, the problem was all-consuming.
When Terry, who lives in Eugene, Oregon, looked into having her daughter committed to a state hospital where she might get intensive psychiatric help, she discovered that it was virtually impossible. Under Oregon law, unless her daughter did something to prove she was an immediate danger to herself or others, the institution's doors were closed to her
The only alternative would have been to have her criminally prosecuted, but then "she'd have been sentenced to two years [in jail] and would have gotten out in a day," says Terry. Worse, she would have received no kind of psychiatric evaluation or help.
It's the classic Catch-22 of most state laws on involuntary civil commitment of the mentally ill, say those in a growing movement to change those laws. "Basically you have to wait until the person commits a crime to get them help," says Jim Havel, deputy director of the National Alliance for the Mentally III, founded by families of the mentally ill to push for changes in state mental health systems and commitment procedures. And by the time someone commits a crime, adds Terry, "they've deteriorated to a very difficult point."
"For a very long time it was very easy to get people committed," says Leslie Scallet, executive director of the Mental Health Policy Resource Center "Then during the 1970s, there was a considerable effort to tighten up commitment criteria.'' Now the pendulum is swinging hack the other way, she says. ''But the overall trend. from 1950 to the present is that it's still a whole lot harder [to commit] now than then, and there's very little chance that that will change in any drastic way.''
But changing incrementally it is. In the past decade, nearly 20 states have broadened the criteria for commitment to state hospitals. From Washington state to New Jersey, the impetus has been to get help for individuals and families before the crisis hits.
As the pendulum swings back, however, more specialists in the mental health field are beginning to view broadening the criteria as a simplistic solution to a complex problem, a solution that in the long run may cause more problems than it solves. The immediate effect is that state hospitals are forced to discharge patients prematurely in order to find space for the increased numbers of newly committed patients.
But the fundamental approach is wrong as well, say many mental health specialists, because it ignores what they see as a serious need to improve community mental health services, which can deliver help before problems become acute and commitment becomes necessary.
Terry's experience with her daughter prompted her to join a task force to look into broadening the criteria for involuntary commitment in Oregon. It wasn't a popular cause. Civil libertarians viewed it as an effort to turn the clock back to the days when hen commitments could be ordered on the flimsiest of grounds. The state, at the same time, wasn't anxious to open its doors to more wards.
Despite the conflicts, the task force recommended a modification of the criteria that was acceptable to opponents. The change, which vent into effect in 1987, was narrow Any person v, ho had been committed twice in the previous three years and who was beginning to show renewed symptoms of mental illness could be committed without proof that they were a danger to themselves or others.
States essentially use three different criteria to determine whether an individual should be forced into a state hospital, says John Parry, staff director for the American Bar Association's Commission on the Mentally Disabled. The first and strictest test allows commitment only of individuals who have proved themselves dangerous. The second, broader test applies when someone is unable to provide for his or her own life support—a standard that includes inability to hold a job or to clothe, house or feed one's self. Oregon's new law represents the third test, committing an individual based on mental health history.
Many states still adhere staunchly to the first-tier test—danger to oneself or others—partly because they've been pushed there by civil libertarians and partly, say the critics, because it is a way of avoiding the costs of handling the additional patient load state institutions could expect if the criteria for commitment were broadened. "States are not interested in accepting any more responsibility than they already have," says Dr. E. Fuller Torrey, author of a number of books critical of present mental health care practices.
Torrey's charge is a bum rap, says Dr. Richard C. Lippincott, administrator of Oregon's Mental Health and Developmental Disability Services Division in the Department of Human Resources. He believes the level of support for mental. health in any state is a direct reflection of the compassion with which the mentally ill are viewed by the population at large. "The finger of responsibility needs to be brought down to the public`" Lippincott says.
What happens when a state does broaden commitment criteria? Washington did it in 1979. A study covering the 10 following years showed that the number of commitments increased significantly, and care got worse. "These statutes change, and not a thought is given to planning for what will happen, says Susan Stefan, staff attorney with the Mental Health Law Project, a patients' rights advocacy organization.
When laws are e eased but the mental health system doesn't get the funds to cope with the influx, ''you're getting overcrowding and understaffing and horrible conditions," she says. She wants to see more money put into prevention. "Fund adequate and appropriate c community service to help people before they have to be institutionalized," she says.
A growing number of people in the mental health care field agree. "The thinking now is that intervening before [a patient] has seriously deteriorated—getting them into treatment, finding them housing, jobs—is the more cost-effective way to go, says Danna Mauch, executive director of mental health and community support services for Rhode Island.
Comparing the c cost of community-based health care versus hospital care isn't easy to do, however, notes Stephen Leff, a psychologist and vice president at Human Services Research Institute, which specializes in providing planning and evaluation and technical assistance to state and local governments in the area of mental health care. ''There is no option more cost effective or morally acceptable than good community-based care. There are a lot o' options that are less costly, but not morally acceptable. Among those unacceptable options, Leff ranks top-notch hospital care that isn't accompanied by decent community-based care after a patient is discharged.
Community-based care is the direction a number of states are heading, however, as a less expensive option than expanded acute care. ''In areas without a range of services, people naturally look to commitment as the solution to their problems," says Mauch. ''In our system, while hardly perfect, you can access care in other ways than commitment, and so you don't hear much talk about 'if commitment law were looser it would be easier to get help.'"
Besides community-based counseling services, outpatient care, crisis intervention and family counseling, Rhode Island has recently set up three mobile treatment units, which will target at-risk young adults before care requirements become acute. Currently the state is working with 5,800 mentally ill patients at the community level and only 200 in its state hospital Naturally. money for these programs has been a key, says Mauch. The state has expanded its mental health budget from $33 million in 1985 to $56 million in 1990. Underlying the fiscal support, says Mauch, is a motivated and involved core of community activists concerned with improving (he entire mental health care system.
Rhode Island may be on to something. In Oregon, where statutory reform arrived in 1987 hand in hand with an extra $7 million to boost community services. mental health director Lippincott says there hasn't been an increase in admissions to state hospitals.
Still, reform of commitment statutes may simply be a much easier route to go than trying to extract money and system overhauls from state legislatures. Mental health care specialists estimate that most states v, would have to double, triple or even quadruple what they now spend on community-based care to bring their systems UK, to an adequate level.
And in states other than ones like Rhode Island, where health care needs are concentrated in a small geographical area and where community support for mental health care is strong, commitment may be the only real health care option for families in crisis. ''It's a very frightening and confusing situation when you have a person who needs hospitalization and can't get it,' says Havel. ''Two-thirds of the mentally ill out there who need help right now are living with their families. It becomes a very stressful situation, extraordinarily stressful.
But Stefan, along with other health care specialists, thinks that states need to look anew at their overall mental health care policies and programs, and not just commitment laws. "States have basically gotten out of the mental health care business; they've pushed people out [of hospitals], yet they haven't funded community services, and that has left the parents holding the bag, and that's not fair But it's equally unfair to dump people back into institutions who really don't need to be there."
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