Dear Congressman Upton:
As a psychiatrist and an American who abhors senseless violations of individuals’ liberty, I implore you NOT to support the Murphy bill or any other legislation that encourages the use of involuntary outpatient commitment for psychiatric treatment. For 9 years, I trained and worked in Wisconsin where involuntary outpatient commitment has been used to force people into treatment for over 30 years, and I can tell you first hand, it does far more harm than good to individuals, it is very expensive, and it does not address the public health and safety issues that people hope it will.
First, let’s be clear about the verbiage that is being put forth to describe involuntary outpatient commitment. The term “Assisted Outpatient Treatment” sounds very humane and appealing, but AOT is neither assisted nor is it treatment. It’s a court order to force people to undergo medical intervention, and primarily that means that they are forcibly medicated. It means that people will be subjected to drugs and procedures that they object to.
Proponents of the Murphy bill will point out that virtually all the states have outpatient commitment laws. However, very few states actually implement them. There are many reasons for this. These laws are impractical, cumbersome for the judicial system and law enforcement, and they entail additional fiscal resources for court process, court-ordered evaluation, and expert testimony. Enforcement of such laws poses difficult practical dilemmas of such magnitude that most states choose to ignore them. For example, if an individual does not come to the clinic for his injection of medications, will police seek him out, apprehend him, and restrain him while he is brought to the clinic and forcibly injected with medications (as is usually specified in outpatient commitment laws)? Do our law enforcement agencies have the resources to assume additional responsibilities with respect to mental health treatment, or feel that it is an appropriate role for them to be, essentially, an arm of the mental health system? In most states, the answer has been a resounding “No.”
Proponents of outpatient commitment usually assert its efficacy, but it should be kept in mind that the actual research in this area has shown very mixed results. Most studies do show that you can decrease the use of inpatient services and homelessness using outpatient commitment. But one has to ask – how does it do that? Is it because individuals are effectively treated, less symptomatic, healthier, and recovering? Consumers have been saying for years that this is not the case – that it is because they are overly sedated by medications, incapacitated, and therefore no longer perceived to be “a problem” to others. There are certainly research findings that support their observations. Outpatient commitment has not been shown in any studies to improve social functioning or to increase individuals’ ability to return to work, and some studies suggest that individuals who receive involuntary outpatient commitment are not even less symptomatic than others receiving voluntary services, even if their voluntary participation in treatment is sporadic.
Most of the evidence in support of involuntary outpatient commitment comes from New York state and the implementation of Kendra’s law. The key piece of information that proponents of outpatient commitment omit is that Kendra’s law has shown some positive outcomes largely due to the fact that, at the time the law was enacted, the governor of New York pumped an additional $200 million into mental health services. We know from research that people participate more in treatment and need less acute hospitalization when consumers are offered expanded outpatient treatment options, so it is highly probable that New York achieved these outcomes not through involuntary outpatient commitment but by adequately funding overall mental health services.
Another important consideration is that the National Association of State Mental Health Program Directors (NASMHPD) cautions against enacting outpatient commitment in an environment where there are not robust resources for community mental health treatment. We know that in many states the mental health system has been stripped down to a grossly substandard condition. Consistently, national surveys by NAMI and other mental health advocacy groups grade 27 states’ mental health services as D, D-, or F and NAMI gave the US as a whole a rating of D. Mental health care has never achieved parity with other medical services and state mental health systems face massive gaps in services, inadequate workforce, and insufficient funding. We do not have sufficient resources to provide adequate mental health services to the many citizens who are voluntarily seeking treatment, so what are we really offering the individual who gets “assisted treatment”? I believe the answer is clear. Outpatient commitment for the vast majority of Americans means only one thing – they will be medicated excessively against their will so that they no longer pose an inconvenience to the community. Essentially they are being incarcerated in a chemical jail.
Invariably, those who seek to impose outpatient commitment laws put forward a number of individuals giving personal testimony to the helpfulness of such laws. I do not doubt that these citizens managed to derive benefit from having been forced into treatment, much as some people manage to derive benefit from time in prison. However, I believe we all know that we should not enact law based only upon anecdotal evidence, as it does not represent the full spectrum of the impact of such laws and is easily manipulated. Legislators rarely get to hear first hand from the individuals who are harmed by outpatient commitment because these individuals generally face insurmountable barriers to being able to come forward to present testimony on their own behalf: they are often severely disabled, they are impoverished, they are not supported by such organizations as NAMI or the “Treatment Advocacy” groups, and sometimes they are simply incapacitated by the treatment they are being administered. I appreciate the personal experience of those who feel that forced treatment was helpful to them; however, I can also say that I have personally known many individuals who felt that forced treatment was dehumanizing and decimated their motivation to pursue recovery due to the overwhelming sense of oppression they felt from being forcibly medicated. For two of these individuals, the excruciating and permanent adverse effects of these medications were a significant factor in their eventual suicides.
It is also important to realize that many family members of individuals having psychiatric disability harbor the fantasy that “if only we had had a law” their family member would have accepted treatment sooner and had a better life or averted some painful event. In practice this just doesn’t happen. Based upon my lengthy experience with outpatient commitment in Wisconsin, I can assure you that people who are forced to take medications that make them feel horrible do not develop insight about how helpful the treatment is and graduate to voluntary treatment. Instead, they understandably focus on the injustice of the situation, blame family and treatment providers, and do what they can to protest and subvert the treatment process. In most instances, people only gain insight and motivation to stick with these very difficult treatments when they have had the opportunity to make attempts to live without mental health intervention and learn from the outcomes.
We need to keep in mind that involuntary treatment in public health is generally reserved for situations in which the disease is common, communicable, and has a high potential to be lethal, and in which the cause of the disease is known and the legally required treatment is associated with low risk. Examples would be the tetanus or pertussus vaccines for children, or screening for tuberculosis. Mental health diagnoses and treatments simply do not meet this profile. While many mental health professionals cite “chemical imbalances in the brain” as the cause for psychiatric disturbance and the justification for psychotropic medications, the fact is that such imbalances have never been consistently demonstrated by research. Most recently, a number of alternative theories have emerged that implicate viral genetic material and autoimmune reactions in the central nervous system or generalized inflammation in the etiology of mental illnesses. These novel models of mental illness are promising, but they also call our current treatment practices into question. The fact is, we don’t know what causes mental health disorders, and as a result we don’t know whether the treatments we would force on people are scientifically justifiable or even relevant.
Even more important, the medications that we would require individuals to take are far from benign. Most people who take them experience some degree of fatigue, poor attention, flattened emotion, tremor or restlessness, and gastrointestinal side effects such as constipation and heartburn. More than half experience severe weight gain, which may be in excess of 50 pounds. The antipsychotic medications also commonly cause many other medically serious adverse effects such as seizures, permanent neurological dysfunction, diabetes, heat stroke, heart failure, and other potentially life threatening conditions. One injectable medication has been given special monitoring requirements by the FDA because it can cause sudden unexplained coma. We know that taking these medications over the long term, as many people having psychiatric disability do, erodes people’s health. Due largely to the adverse effects of psychotropic medications, people having psychiatric disabilities have a life expectancy that is 25 years less than the average population.
This is not to say that medications do not help many people. We must ensure that the full range of psychotropic medications is made available in the mental health armamentarium. However, we also need to acknowledge that, generally, the people who get a good response to medications are not the people who are targeted for outpatient commitment. About a third of people will have a significant improvement from medications. They tend to recover, go on to have a full life, and are usually highly motivated to continue treatment. Roughly another third may have a partial response but struggle with significant side effects, and they are understandably ambivalent about treatment. The final third have no significant reduction in their symptoms, though they frequently do have severe adverse effects, and their motivation to pursue treatment with medications is, understandably, very low. Thus many people who are forced to take medications in outpatient commitment are those who derive very little therapeutic benefit from them, though, from the perspective of social control, others may perceive them to be improved because they are more sedated or chemically restrained.
A serious problem with involuntary commitment statutes is that no safeguards are put in place to ensure that the individual receives quality treatment, rather than being indiscriminately subjected to chemical restraint. It is admittedly difficult to incorporate adequate provisions in legislation to ensure that the mandated services are effective and that risks associated with treatment are adequately managed. To my knowledge, no outpatient commitment law includes a requirement for the treating facility to comprehensively assess the individual’s risk for adverse effects, empirically document an improvement in symptoms and functioning using standardized rating tools, or to examine for and document the intensity of adverse effects. Nor do these laws mandate medical monitoring and treatment for the adverse effects of medications, or specify a threshold for risk. For example, if under involuntary treatment, an individual gains 50 pounds and develops diabetes, the treating facility is under no obligation to modify the treatment approach or to provide the appropriate medical care, even though the treatment is now causing potentially life-threatening adverse effects. Lastly, these laws give no guarantee that the treatment that is forced upon the individual meets generally accepted standards of care. Given that more than half of our state mental health systems are inadequate, with gaping deficiencies in the continuum of care, involuntary treatment obligates individuals to undergo substandard treatment. To me, all of this is simply unconscionable.
We also need to critically examine our motivations in enacting outpatient commitment laws. As is the case with the Murphy bill, proponents of outpatient commitment often cite public safety issues and roll out the rare but dramatic examples of situations where individuals having psychiatric symptoms engaged in heinous homicidal acts in response to psychotic beliefs. Such incidents are vanishingly rare though they receive a lot of publicity. Homicides precipitated by psychosis constitute a minute percentage of homicides in the US. Nor is it clear that forced outpatient treatment would have prevented these tragedies. In some instances, the individuals who perpetrated these crimes were already mandated to receive outpatient psychiatric services and this was ineffective, as was the case for Seung Hui Cho at Virginia Tech in 2007. In other cases, the individual had never been identified to need psychiatric intervention. In the case of Adam Lanza of the Sandy Hook shooting, which is one of the incidents prompting the Murphy bill, treatment was recommended when he was a minor, but was declined by his mother, and no evidence of psychosis or incipient violence had been identified during an extensive psychiatric evaluation. We know that mental health professionals cannot predict future behavior. We know that treatment with medications does not eliminate the possibility that an individual can have a recurrence of symptoms or, like any other citizen, become violent for other reasons. Also, we have laws that allow for involuntary commitment in the event that a person is a danger, and past behavior can be factored into the determination that the individual meets criteria for dangerousness. In view of all this, it should be obvious that outpatient commitment laws, no matter how they are worded, are ineffective tools for improving public safety and add nothing to our current tools for intervening in the event of dangerousness.
Another common motivation for supporting outpatient commitment is the belief that such laws reduce mental health expenditures for individuals who are frequent hospital recidivists or who otherwise consume a disproportionate amount of public resources. However, when one examines the bigger picture, most studies have found that outpatient commitment drains funds from mental health to pay for court mandated evaluations, court process, expert testimony, and other expenses associated with the legal process. Further, in many cases, hospital recidivism is not caused by consumer non-compliance, but, rather, results from poor coordination of care, lack of timely access to care, a lack of community support services, and inadequate treatment options. Forcing medications on individuals will not resolve recidivism due to these deficits in the system of care. However, it is likely that many of these individuals will be unfairly labeled as treatment failures and inappropriately subjected to outpatient commitment when, in fact, the system of care has failed them.
Outpatient commitment is a simplistic way to give the false impression of “doing something” to solve complex and disconcerting social problems. The core clinical problem is simply that we don’t have effective and easily tolerated cures for mental disorders. But neither will outpatient commitment address the prevailing social concerns surrounding mental health treatment. From a public health perspective, at the risk of being provocative, if the goal of such legislation is really to reduce the incidence of aberrant public behavior, what we need instead is a law that prohibits the consumption of alcohol; if the goal is really to reduce healthcare costs, what we need instead is a law to force diabetics to comply with recommended treatment; if the goal is really to decrease the risk of gun-related deaths, what we need instead is a law to keep firearms out of the hands of males. Obviously few people would ever consider legislating these violations of people’s rights even though these changes would make a significant impact on these important public health problems. I would put it to you that the reason we are even considering violating the rights of individuals having psychiatric disabilities is because they constitute a small, highly stigmatized, and vulnerable group who will generate little push-back.
Lastly, we need to consider the devastating impact of involuntary outpatient commitment on our ability to provide people mental health care. The single most important therapeutic tool that mental health professionals have is the trusting relationship we have with our clients. People need to be able to tell us their innermost thoughts and fears, and trust that we will treat them in a fair and respectful manner. In my experience, the threat of involuntary outpatient commitment undermines that relationship and deters people from seeking the help they need.
In summary, I sincerely hope you will reject any legislation that seeks to expand or incentivize outpatient commitment for psychiatric treatment. Forced outpatient treatment is never the short-cut to recovery that proponents claim it will be. Forcing someone to be injected with medications does not promote insight, improve functioning, improve quality of life, save money, or promote public safety. Most of the proponents of this bill are individuals and professionals who have had very limited, if any, experience with the actual implementation of involuntary outpatient commitment. It is understandable that the concept sounds appealing to them; however, the issues are just not that simple and, as a result, involuntary outpatient commitment is not the tool they imagine it will be. Involuntary outpatient commitment is harmful, not helpful to the goals of getting people into treatment, fostering recovery, promoting safety, and containing mental health costs. If we truly wish to assist citizens having refractory psychiatric concerns, we must fund mental health adequately, ensure that all state mental health systems meet the prevailing standard of care, and encourage strengths-based, individualized approaches to recovery that de-stigmatize mental health concerns.
Sincere thanks for your attention to this issue,
Coni Kalinowski, MD
Medical Director, Mojave Adult, Child, and Family Services
University of Nevada School of Medicine