TREATMENT ADVOCACY CENTER
Visit our web site www.psychlaws.org
August 23, 2002
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1. MENTALLY ILL COULD BE
COMMITTED - The Whittier Daily News, August 14,2002
2. STOLEN FREEDOM
- The Orange County Register, August 21, 2002
3. STUMBLING INTO THE
UNKNOWN - The Santa Fe New Mexican, March 18, 2002
4. ON FORMULATING MENTAL HEALTH CODES
FOR THE WORLD -- Psychiatric Times, July 2002
1. THE WHITTIER DAILY
NEWS, August 14, 2002
[Editor's Note: For three years advocates have feverishly striven
to reform California's treatment laws, which are among the country's worst.
Their goal is in sight.
On Wednesday, the Appropriations Committee of the California Senate passed AB
1421 (a version of New York's assistant outpatient treatment law) to the Senate
Floor. The full Senate will vote on the measure next week. The state's Assembly
has already approved the bill. AB 1421's next stop, if passed by the Senate,
will be the desk of California's Governor.
Between AB 1421 and a failed predecessor, the effort for this reform has
entailed nine committee and two floor votes, thousands of letters and phone
calls, and scores of personal visits. And now the members of the California
Treatment Advocacy Coalition are that close. We wish them the fortune that they
have so rightly earned.
Please note that the article below was written before AB 1421 passed the
Appropriations Committee.]
MENTALLY ILL COULD BE COMMITTED
By Chris Rizo, Correspondent
SACRAMENTO - A controversial bill that could allow judges to sentence mentally
ill people to take their medication or face involuntary commitment passed a key
legislative hurdle Tuesday, with the help of one local lawmaker. Aimed at
keeping mentally ill patients out of jails and hospital emergency rooms, the
proposal AB 1421 would begin a pilot program in which counties could allow
judges to order people diagnosed with mental illnesses to comply with their
treatment plans or face involuntarily commitment to a mental health facility for
up to 180 days.
While critics argue the bill would trample the civil liberties of the mentally
ill, members of the Senate Judiciary Committee voted 4-2 for the proposal, after
several amendments were offered by the bill's author, Assemblywoman Helen
Thomson, D-Davis.
"I hated this bill when it was first introduced four years ago," said local
state Sen. Martha Escutia, D-Norwalk, chairwoman of the powerful committee.
"But, now I am confident that the due process protections are there at every
step of the way to protect their rights."
For decades, the Lanterman-Petris-Short Act has been used to protect the
mentally ill. Under that law, certain medical professionals can involuntary
detain for up to 72 hours those who, as a result of a mental disorder, are a
danger to themselves or others.
But, unfortunately, current law doesn't do anything for the people who "are too
sick to know that they are sick," Monrovia police Chief Joseph Santoro said in
an earlier interview.
The bill is named "Laura's Law," for 19-year-old Laura Wilcox, who was killed
last year when a diagnosed schizophrenic allegedly not taking his medicines
burst into a Northern California mental health clinic where she was
volunteering, opened fire, and killed three.
"We understand this bill raises significant civil rights issues," said Laura's
mother, Amanda Wilcox, at Tuesday's hearing. "But when an individual's right not
to take medication infringes so drastically on another family, then perhaps the
civil liberties of mental health clients have gone too far."
Forcing mentally ill patients to comply with court-ordered treatment, she said,
seems to be "a relatively benign measure" to balance the public's safety with
the individual freedoms of the mentally ill.
Assemblywoman Thomson added, "This is not about stigma, blame or stereotypes,
it's about getting assistance to those that need it."
Opponents, however, say forced treatment actually harms recalcitrant patients
more than it helps.
"The very experience of forced treatment and cohesion, and the lack of respect
and dignity, actually causes people to avoid treatment," said Sally Zinman,
executive director of the Berkeley-based California Network of Mental Health
Clients.
"Recovery is based on self-determination and choice," she continued. "That is
what we are all fighting for here."
The Senate Appropriations Committee will hear the bill later this month.
2. THE ORANGE COUNTY
REGISTER, August 21, 2002
[Editor's Note: In every state considering treatment law reform,
there always seems to be one of them. In California it is Senator Ray Haynes.
Please do not assume that his depictions of AB 1421 are legally accurate. His
grasp on the effects of severe mental illness, you can judge for yourself.]
Commentary
STOLEN FREEDOM
With new bill government could label dissidents 'mentally ill' and control
them
RAY HAYNES
State Sen. Haynes represents the 36th Senate District,
which includes western Riverside County and northern San Diego County. He is
also the Senate Republican whip.
Individual liberty is the fragile thread that holds the fabric of a free society
together. All fabric has unsightly loose threads, but if those threads are
removed incorrectly, the fabric can unravel and destroy the garment. A
commitment to individual liberty will leave a lot of loose threads in a society.
One of the loose threads in a free society is the plight of the mentally ill.
They always have trouble "fitting in." Left to their own, some end up homeless,
others burden their families. There are some individuals that people think are
crazy, but who are really just offbeat. Some mental health professionals have
defined people with strong religious convictions as "mentally ill." Hitler
justified incarcerating Jews on the grounds that their belief in Judaism was
evidence of mental illness.
If the mentally ill become violent, it is easy for
government to justify removing them from society. But, what if they don't?
Should we be able to lock up someone whose only crime is being mentally ill, if
they pose no threat to their own physical safety or the safety of others? In
California we have said no.
A.B. 1421, a bill before the Legislature, may change that. Under current law, a
person is free to refuse medical help that is offered but not wanted. If a
doctor thinks you need an appendectomy, or even an aspirin, you can say no
without fear of being arrested. If you happen to suffer from a mental illness or
disability, you can refuse treatment for that illness or disability as long as
no one else is harmed by your refusal. That is how things work in a free
society.
If A.B. 1421 becomes law, you can be incarcerated if you "fail to follow" the
treatment plan some psychiatrist has prescribed for your mental illness or
disability, even if you are not dangerous. If government thinks someone has a
mental illness, the doctor's program is forced on him or her.
That is how dissidents are treated in a totalitarian government. The government
declares the dissident insane, and then prescribes a treatment plan that either
involves mind-numbing drugs or jail. Castro controls his people with
psychiatrists and involuntarily commits those who disagree with him politically
on the grounds that they are mentally deficient, and then he treats them with
drugs that render them unable to function. His psychiatrists use the power of
government to enforce their "treatment plans" for the political dissidents.
The people who support A.B. 1421 will tell you that they only want what's good
for the mentally ill. They even have a "good" name for those who will "receive
help," calling it "assisted outpatient treatment." It is assistance, however,
given at the end of a gun, with threats of incarceration if the person getting
the assistance refuses. Under the guise of helping the mentally ill, A.B. 1421
steals not just their freedom, but the freedom of each and every one of us.
Civil liberties are important. A government that doesn't have to prove that you
are dangerous or will do something bad before it locks you up is totalitarian.
A.B. 1421 will allow the government to lock you up if the government thinks you
are mentally ill and you won't do what some government psychiatrist tells you to
do, even when you don't pose a danger to yourself or anyone else.
A government that allows that to occur is not a government
that values liberty and is only a step away from totalitarianism. We have every
reason to fear a government that would allow such a thing to occur. This is the
first step down a very slippery slope.
3. THE SANTA FE NEW
MEXICAN, March 18, 2002
[Editor's Note: Unlike most illnesses, psychiatric disorders
affect not just people but whole families, and for decades. We thank the New
Mexican for giving voice to those living with mental illness who don't show up
in any NIMH statistics.]
STUMBLING INTO THE UNKNOWN
Deborah Davis
Relatives of the mentally ill enter a system they know little about; often, they
must take on the burden of care for their loved one
Without family support, Frank Clyde believes his son, Ryan, would be homeless.
Navigating through the bureaucracy of the mental-health system has been
difficult enough for Clyde, who is retired. He can't imagine how people with
mental illnesses could ever be capable of accessing services on their own.
After Ryan Clyde was diagnosed with bipolar disorder, which causes a person to
have episodes of mania and depression, the Clydes stumbled into a world they
knew nothing about. "What happened to this son of ours who had so much going for
him and is now stalled in his tracks?" Clyde said. "We're still looking for
answers. We needed help, lots of help, and that's when we realized we had to
find out everything on our own."
The behavioral-health system is huge and complex, to the point that Mary Eloisa,
who has worked in the system for nine years, said she still doesn't understand
it.
It is not unusual for the family to be the key support for a mentally ill
person, according to Fred Sandoval, a member of NAMI's (National Alliance for
Mentally Ill) local chapter.
As someone who responds to emergencies through Crisis Response of Santa Fe,
Eloisa encounters many families who have adult children living with them; she
also sees a high level of burnout and frustration. When a family member becomes
mentally ill, the family is typically at a loss as to what to do. Sometimes
family members deny there is a problem.
"It can be absolutely devastating to see someone you love dearly going through
this kind of pain," Eloisa said. "It is devastating to see them have a huge
obstacle in their life, and it can be very frustrating because you don't know
what to do."
The Clydes were stunned when their 20-year-old son began to talk about having
AIDS and getting it cured by aliens.
"We thought he was on drugs, his brain snapped," Clyde said.
Frances Jones, whose youngest daughter was diagnosed as schizoaffective, tried
to balance her sick daughter's needs with the needs of her three other children.
"We tried to go about as normally as possible, but it definitely affects the
family," said Jones, a Santa Fe resident. "Everybody became very protective of
her, afraid something would happen to her."
Even Eloisa, who has years of training and experience working with mentally ill
people, was powerless when her daughter was diagnosed with paranoid
schizophrenia.
"This is my baby, and she was hurting so bad," Eloisa said. "How can I help
her?"
Not only do the parents have to research illnesses and hunt for services, they
also deal with a person who doesn't necessarily appreciate their help and a
society that usually doesn't understand.
"Oftentimes a person will become angry at the safest person to direct their
anger to," Eloisa said. "It's hard to not take it on, to understand this person
is sick. It wears people thin to deal with all the pieces and then be the
target."
Clyde grew agitated as he described seeing his son walk into court for a hearing
to decide whether he needed hospitalization for 30 days. He had stayed at St.
Vincent Hospital for seven days before the hearing.
He was brought in wearing handcuffs and shackles around his ankles. It is a
common story among people who are mentally ill and an example of the stigma
against mental illness. When Clyde questioned the police officers who
transported his son, they told him it was procedure. Yet in other states, the
courts come to the hospital to pick up the patients.
"This is a kid whose only crime is mental illness," Clyde said. "You take
someone with diabetes, and you wouldn't transport them that way."
Faced with scarce housing for the mentally ill, families often have to house the
ill family member, or the person winds up in jail, the hospital or on the
streets.
"It's probably in the best interest for everyone if the person can live in a
supportive situation," Eloisa said. "Unfortunately there's not a lot available."
The Clydes considered residential homes, but Ryan does not want to move out of
Santa Fe, and he didn't want to stay at the city's only group home, Casa Milagro.
"You're dealing with someone who doesn't want to be restricted, so you have to
negotiate and watch what you say," Clyde said.
Having Ryan Clyde in his own apartment while staying with his parents five days
a week is temporary, according to Frank Clyde. But he has no idea what the next
step could be.
They figured out that living arrangement after Ryan Clyde had stopped taking his
medication and spiraled into illegal drugs and unsafe behavior.
"The frustration is there is no outline to follow, no plan, no degree of
certainty. No one has helped us," Clyde said.
Parents are forced into becoming fierce advocates for their children. Both Jones
and Albuquerque resident Charlotte Back started housing programs in response to
their children's needs.
"I started doing this because there just wasn't housing where people understood
the mental-health factor," Back said. "The first place my son went to in
Albuquerque they made him leave because he was acting mentally ill. This was a
place for the mentally ill."
While she's trying to start another housing project in Northern New Mexico,
Back, 73, is ready to call it quits.
"But you do what you gotta do," she said.
4. PSYCHIATRIC TIMES, July 2002
[Editor's Note: With all the anguish that inflexible treatment
laws hinging on eligibility standards based solely on imminent danger have
caused over the latest three decades in the United States, how could anyone
suggest that such laws be the world-wide model? According to Dr. Alan Stone,
that is just what the World Health Organization plans on proposing.
Realizing that they mandate tragedy, state after state with such laws has
forsaken them. Indeed, the Treatment Advocacy Center is dedicated to the reform
of these antiquated legal frameworks. That a leading health organization should
encourage the world to embrace them is unfathomable.]
Commentary
ON FORMULATING MENTAL HEALTH CODES FOR THE WORLD
by Alan A. Stone, M.D.
The World Health Organization (WHO) has distributed for comments the draft of a
Manual on Mental Health Legislation as a guide for all the countries of the
world. It is to serve as a model for new legislation and as a guide for
countries amending their legislation. Given the different legal systems, the
cultural diversity and the vast inequalities in economic resources among the
nations of the world, one can certainly question the wisdom of the WHO's
top-down approach. In addition, everyone who knows the scarcity of competent
mental health care professionals and the limited resources in third world
countries will recognize that most of the proposals are quite unrealistic. How
can nations who cannot feed their poor or meet the basic necessities of public
health measures and primary care be expected to provide "incompetent" mental
patients with counsel (lawyers) and independent tribunals (courts) before they
begin to treat them?
The draft is described as "the collective views of an international group of
[unnamed] experts," but it seems rather to be the work of lawyers who have been
trapped in a time warp since the 1970s. This draft of the manual would impose on
the rest of the world the complex array of legal restrictions and red tape that
antipsychiatry ideologues imposed on American psychiatry back in that era.
The chief goal of antipsychiatry legal reform in the United States was to
protect the "rights" of the mentally ill, even if that meant that their needs
were never met. At that time, there was widespread distrust of psychiatric
medications, and many legal rights advocates failed to recognize the medical
reality of mental illness. Efficacious treatments for psychotic disorders were
portrayed as mind-altering drugs. Reform-minded advocates argued that delusions
and hallucinations were protected speech under the First Amendment. They refused
to believe that lack of insight was the hallmark of serious mental disorder.
Lawyers promoting this rights-driven approach were also distrustful of families,
who _were constantly portrayed in mental health legislation as acting against
the interests of mentally ill family members. Since neither mental health care
professionals nor families could be trusted to act in the patients' best
interests, lawyers camped on the doorstep of psychiatric hospitals to contest
every intervention. The draft takes the same approach and displays the same
suspicious attitude toward families of the mentally ill seeking treatment for a
member of their family. Parents and spouses who know the patient best have no
standing to request treatment for an incompetent relative. But families are
specifically permitted by the draft to protest and appeal against psychiatric
treatment, even after two independent mental health care professionals and an
independent court-like authority have concluded that the patient is incompetent
and that treatment is necessary. This is only one example of many provisions
that make it clear that the draft's experts have the same basic goal as the
antipsychiatry legal advocates of the 1970s. Every psychiatric intervention is
to be contested on legal grounds. One can find lots of verbiage in the draft
about the importance of families, about the plague of mental illness and about
the need for treatment. But the actual provisions come straight from the most
radical rights-driven models of the 1970s. The underlying rationale in the 1970s
was skepticism about the reality of mental disorders and the efficacy and risks
of psychotropic drugs. Thirty years later, this skepticism, often based on
ignorance and bias, cannot be justified. The WHO's own goal is to promote
greater access to efficacious mental health treatments. The draft prepared by
their experts, if unchanged and implemented, would be the single greatest
obstacle to access for the sickest patients who typically have no insight into
their condition, but have a real chance of being helped by appropriate
medication. Lawyers may have a different perspective, but physicians usually
look to the available empirical evidence and insist on proof that a method
works. The legal reforms proposed by the draft for the rest of the world have
been tested in America and Europe, and the results are nothing to cheer about.
The financial and resource costs of the rights-driven approach have been
documented. As one of the original legal advocates of this reform later
conceded, "The law is a blunt instrument. We could bring it crashing down on the
old system but we could not create a new one." America is one of the wealthiest
nations in the world, but, even here, many jurisdictions cannot afford the costs
of the expensive and time-consuming legal procedures that the draft requires.
Instead, officials typically abandon the efforts to hospitalize or treat the
seriously mentally ill who lack insight into their condition. Since legal
barriers have restricted psychiatric hospitalization in the United States, the
mentally ill have been increasingly shunted into jails and prisons. This shift
has occurred despite billions of dollars in government funding of alternatives
to hospitalization: disability insurance, housing subsidies and various other
kinds of community-based services. Over 1 million nursing home beds were created
to deal with geriatric patients who had previously been cared for in state
mental hospitals. What evidence-based health policy would urge third world
nations to adopt even the more radically restrictive laws of the draft when they
do not have the resources for any of these alternatives? The most startling
example of the draft's radicalism and bias is its prohibition of mandatory
outpatient treatment. The draft's experts adopted the U.S. constitutional
doctrine of the "least restrictive alternative." This idea is that when the
state interferes with an important constitutional right-the "alleged" patient's
liberty-it should interfere in the least restrictive fashion. Mandatory
outpatient treatment is often the only feasible alternative available in the
United States. Its underlying purpose is to provide and insure compliance with
antipsychotic medication. There is conflicting empirical evidence about the
value of mandatory outpatient treatment, but the outright prohibition
demonstrates the draft's bias against psychiatric intervention.
In the United States, the families of people with serious mental illnesses
eventually organized the National Alliance for the Mentally Ill (NAMI) to lobby
for better care and to modify the 1970s' laws and provisions that prevented
patients from receiving treatment. The American Psychiatric Association spent
years canvassing its members and preparing a model statute that balanced legal
rights and needs. The U.S. Supreme Court and other federal courts have backed
away from their earlier support of the radical rights-driven approach. The
experts who prepared the draft have dismissed the efforts of NAMI and the APA.
They have considered none of the negative consequences of the reforms they
propose. And they have ignored the changing legal climate in the United States
courts that is most familiar with the rights-driven model. This is not the way
the most important health organization in the world should behave.
It is difficult to justify the WHO's decision to allocate its own limited
resources to this ill-conceived project of formulating mental health codes for
the entire world, but perhaps it can be explained. There is growing
international solidarity around the ideal of universal human rights. That
progressive effort deserves support and recognition by everyone. However, even
John Stewart Mill, the patron saint of human rights, recognized that children
and (those he called) the "insane" posed a special problem for any universal
notion of liberty and human rights. The U.S. lawyers of the 1970s unfortunately
refused to believe in the reality of insanity or mental illness. Instead of
recognizing the special problem Mill described, they declared the mentally ill
as the paradigm victims of human rights abuse. Success in protecting a client
with schizophrenia from appropriate and efficacious treatment was, in their
biased view, as much a victory for autonomy and human rights as protecting a
political dissident from improper and inappropriate treatment. But delusions and
hallucinations are not a manifestation of human autonomy; they are symptoms of a
serious malfunction of the human brain. So these legal victories were not a
victory for patients with schizophrenia or their families, or for anyone else
who recognizes the realities of mental illness. Given the advances in
neurosciences and our understanding of the biological dimensions of mental
illness, psychiatrists should recognize the fallacy of that outmoded approach.
Yet it is the misguided view of these biased lawyers and the outmoded legal
precedents they set that the draft is mistakenly following in the name of human
rights. The director general of WHO has recognized that, around the world, most
people with serious mental illnesses are not being provided treatment. There is
documentation that conditions in some mental hospitals in India and elsewhere
are truly appalling and appropriate legal change should begin there. The
proposed Manual on Mental Health Legislation should be rejected. It will add to
the woes of those suffering people and will divert precious resources away from
their care.
Dr. Stone is Touroff-Glueck Professor of Law and Psychiatry in
the faculty of law and the faculty of medicine at Harvard University.
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