Rewire Article: Advocates Say Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Article over at Rewire about H.R. 2646 (“Murphy Bill”):

Advocates say that U.S. Rep. Tim Murphy’s “Helping Families in Mental Health Crisis Act,” purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

Topics include privacy concerns, the difficulties patients face when trying to have their concerns taken seriously, the need for trauma-informed care, and the implications for the LGBTQ community.

Great quotations from Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force and #RealMHChange’s own Leah Harris.

The article is worth reading in full.

Senate Markup of Mental Health Bill Today! Watch it Live

Most progressive mental health groups are supporting this version of the Senate bill, as it does not include the rights and dignity violations in the House version.

Markup of Mental Health Reform Act of 2016

Wednesday, March 16, 2016, 10:00 AM

Link to Webcast – should go live approximately 15 minutes prior to the mark-up.

Senate discussion draft bill – announcement from HELP Committee
Bill is link at the bottom of announcement.

Summary of draft
Full text of the draft

Press on the bill
The Hill: Here is a link to an article that reports that the author of proposed mental health legislation in the House has criticized the bipartisan U.S. Senate bill.

Morning Consult – Rep. Murphy Hits HELP Committee’s Mental Health Bill

Roll Call: Amid ‘Crisis,’ Senate Bill Seeks Boost Access to Mental Health Care

The Tennessean: Lamar Alexander Takes on Mental Health ‘Crisis’ (Real MH Change quoted here)

Thank you to the National Disability Rights Network for compiling this information.

What you can do:
We invite you to engage on social media during the markup, if you cannot be there in person. Let these committees know what you think of the conversation and what should and should not be a part of mental health legislation. Please use the hashtag #realmhchange. We will be Tweeting from @realmhchange.

Tweet your thoughts to the HELP Committee:

@LamarAlexander (Chair)
@PattyMurray (Ranking Member)
@GOPHELP
@HELPCmteDems

 

 

 

ACTION ALERT: “The Mermaid” Film Promotes Stereotypes and Force

sdavidowBy Sera Davidow

It’s Murphy Bill season, and every last article, video and sound bite that’s circling counts in the court of public opinion. Tim Murphy reportedly has admitted that manipulation of information for public consumption is a necessary evil in order to push his agenda. Apparently he feels his self-righteous cause justifies his means. But, the swirl of misguided media leaves the rest of us needing to be all the more attentive to the messages flying around.

Unfortunately, Murphy has plenty of unwitting subjects to further his desired message, and one of them is Italome Ohikhuare who wrote and produced ‘The Mermaid’. ‘The Mermaid’ is a about a young woman and her relationship with her brother who is diagnosed with schizophrenia. It is reportedly based on Italome’s real-life experiences with her real-life brother, for whom she claims this piece is a ‘gift’.

The film is an unfortunate 13-minute advertisement for Involuntary Outpatient Commitment (aka Assisted Outpatient Treatment, AOT, or Murphy’s favorite pet), that attempts to paint itself as a “moving love story about a young woman torn between her blossoming relationship with her boyfriend and her chaotic but endearing relationship with her brother.”

‘Love’ is the furthest thing from my mind as I watch the main character (Sirah) interacting with her boyfriend (Jay) who’s attempting to manipulate her into bed, or her violent and erratic brother (Deji) who she screams repeatedly “just needs his pills.” In fact, this film is troubling at many levels both from a standpoint of racism and psychiatric oppression. Here’s a brief list of the whys:

  • The film re-enforces dangerous racial stereotypes: Deji is a young black man *wearing a hoodie* and is repeatedly painted as violent and frightening, particularly toward Jay (who is a white man). There is little that could make this film any less racially sensitive given today’s climate.
  • Except this: Jay (the white, professionally dressed lawyer boyfriend who is physically attacked by Deji) rescues him from drowning at the end of the film.
  • The film promotes significant misunderstandings about how psychiatric drugs work in both the short and long-term: Sirah screams (more than once) that Deji will be alright if he just gets his pills. However, unless we’re speaking of tranquilizer darts (or other heavy sedatives) and unless we’re defining ‘alright’ as ‘incapacitated by sleep’, there is no pill that would have such immediate effect. Furthermore, Sirah’s screechy insistence re-enforces the erroneous belief that psychotropics are the key, ignoring all the research that now suggests that they often lead to little improvement and not infrequently can make things worse.
  • The film promotes the idea that people with psychiatric diagnoses like schizophrenia are scary and dangerous: Although there’s little real-word research to suggest that people with psychiatric diagnoses are at greater risk of violence than the average person, Deji has his hands around Jay’s throat three times within the first five minutes of the Mermaid. This is followed immediately by Jay yelling that he needs to be “Baker Acted” and suggesting that he’s going to “kill someone”.
  • The film promotes hopelessness and perpetuates the idea that people with diagnoses like schizophrenia will forever be tormented and dangerous: Hopeless statistics and propaganda about the schizophrenia diagnosis are tacked on to the end of the film, and the promotional website spouts this little gem at the conclusion of its ‘about’ section: “But the most unexpected moment comes at the end of the film, when they’re all confronted with…the tragic reality that this story, just like schizophrenia, can’t have a happy ending.” (See the film’s full website here: http://www.themermaidfilm.com )
  • The film perpetuates the idea that there’s psychiatric drugs and hospitalization or there’s nothing, and that force is an inevitability: Apparently, Sirah’s been trying to support Deji in almost complete isolation, and the film (however unintentionally) paints that and the forced hospitalization he experiences by the end not as two extremes on a fairly broad spectrum, but as point A to point B on a two-point scale. In fact, her boyfriend reassures her that she “did the right thing,” and had “no other choice”. The truth is, though, that there are many choices in how to support people who are going through extreme states, and great harm done through the use of force. Meanwhile, the use of force, while often an act of desperation by otherwise decent people, represents a failure of the system, and not an inevitability of some hopeless ‘brain disease’. This film does a real disservice by failing to represent any of that.
  • As an added bonus, it paints women as shrill and helpless sex objects: Jay seems to be angling to get Sirah into bed at the start of the film. By its conclusion, as Sirah is once again helplessly screaming, Jay must come to her rescue not once (when her brother is drowning), but twice (when she’s crying inconsolably and invites him to spend the night as he’d clearly wanted to do right from the start). Sure, she also has a moment (after Deji is rescued from the ocean by Jay) where she slaps and pins her brother to the ground, but that moment is so unbelievable it’s just plain bizarre.

‘The Mermaid’ is currently being promoted via the Mental health Channel (MHC), as the winner of the Jury Award in their Film Festival. I recently spoke with Managing Director, Harry Lynch, regarding my concerns about the film (among other elements of MHC), and although he said he heard some of my concerns, he didn’t feel that they could take action to remove the film unless they heard from more than just me that it was problematic.

I am hoping that you will hear his words as a call to action and ask MHC directly to remove this film.

Remember, it all counts. Every message going out to the public counts. The messages put forth in ‘The Mermaid’ count (and not in a good way). And, if Harry Lynch speaks truth, so does your voice.

I hope you’ll use it.

You can see ‘The Mermaid’ here: https://vimeo.com/139278058

You can reach the Mental Health Channel here: mhc@arcosfilms.com

Sera Davidow is a mother, an advocate, an activist and a filmmaker who devotes much of her time to the Western Massachusetts Recovery Learning Community (http://www.westernmassrlc.org). She entered the mental health system as a teenager and cites “non-compliance” as part of what saved her from a very different path that surely would not have included the freedom she now enjoys from all psychiatric labels and medications.

ACTION ALERT: #HousingNotAsylums! Monday, December 14

On Monday December 14, at 11:00 AM Eastern Time, the National Alliance on Mental Illness (NAMI), the American Psychiatric Association (APA), and the National Association of Psychiatric Health Systems (NAPHS) will host a briefing on Capitol Hill entitled “Nowhere to Go: How Restrictions on Psychiatric Beds Harm People with Serious Mental Illness.” The topic of the briefing is repealing the IMD exclusion in Medicaid.

What is the IMD Exclusion?

The “Helping Families in Mental Health Crisis Act” would largely repeal a Medicaid rule that prohibits federal Medicaid funds from going to individuals under 65 served in “institutions for mental diseases.” These institutions are facilities of more than 16 beds that primarily serve individuals diagnosed with mental illnesses. The IMD rule applies only to freestanding psychiatric facilities. Psychiatric inpatient care in general hospitals is covered by the Medicaid program. Psychiatric inpatient services for children 21 and under are also covered under the Medicaid program.

What’s wrong with hospital beds? Shouldn’t Medicaid pay for this?

In the 1960s, we shut down many mental institutions because they were breeding grounds for neglect, abuse, and death. Sadly, the “One Flew Over the Cuckoo’s Nest” days are not over. Chilling reports coming out of Western State Hospital in Washington State as well as Florida state mental hospitals show that large institutions can be unsafe places for people with psychiatric disabilities. The Service Employees International Union (SEIU), has created a website “Behind Closed Doors” documenting abuses by Universal Health Services Inc. (UHS), America’s largest provider of inpatient behavioral health care. If we repeal the IMD exclusion, we can expect more of these horrific reports.

The IMD rule, which has been in effect since the beginning of the Medicaid program, was designed to limit the warehousing of people with mental health disabilities in psychiatric institutions. This Medicaid rule was enacted two years after the 1963 Community Mental Health Centers Act, at a time when the country had begun to shift away from large psychiatric institutions and develop community-based mental health services. It has been an important incentive for mental health systems to develop community services rather than relying solely on institutional care.

Who would benefit from repeal of the IMD exclusion?

Definitely not people diagnosed with mental health conditions, their families, or people who work in psychiatric hospitals. Who WOULD benefit is the National Association of Psychiatric Health Systems (NAPHS), who is a co-sponsor of this briefing and whose leadership is composed of the top brass in the psychiatric institution industry, including UHS. They would stand to gain billions from this repeal, and are lobbying hard to have it passed.

So if repealing the IMD Exclusion isn’t the answer, what is?

The root of the problem with the mental health system is the lack of comprehensive community-based services that help prevent crisis in the first place. Too often, people cannot obtain services until they are in crisis. Then, they are usually taken to a general hospital (usually an emergency room) or have an encounter with law enforcement. After their hospitalization or involvement with the criminal justice system (often including incarceration), they return to the community without needed services. The response to this vicious cycle is not to build more inpatient beds or to keep incarcerating people, but instead to invest in intensive community-based services that avoid and de-escalate crises, prevent hospitalization, and help people returning to the community to get the support they need. The mental health system needs more funding for services such as mobile crisis teams, crisis respite houses, family and peer supports, and supportive housing — not more institutions. According to the Corporation for Supportive Housing, “cost studies in six different states and cities found that supportive housing results in tenants’ decreased use of homeless shelters, hospitals, emergency rooms, jails and prisons.”

What you can do:

Starting at 11:00 AM on Monday, December 14, Tweet to your member of Congress or post to their Facebook wall and tell them #HousingNotAsylums!

Our Twitter accounts: @RealMHChange; @NDRNAdvocates

Sponsors’ Twitter accounts: @APAPsychiatric; @NAMICommunicate

Use HashTags: #RealMHChange #protectPAIMI #HousingNotAsylums

Sample Tweets:

  • We need #HousingNotAsylums! Community not institutions!
  • Repealing the IMD exclusion will line corporate pockets, while our communities stay impoverished.
  • #HR2646 is a rollback to One Flew Over the Cuckoo’s Nest, NOT the #realmhchange we need! #housingnotasylums
  • #RealMHChange is crisis respite services that help people and save money — NOT #HR2646
  • “I’d rather die than go back to the hospital.” Crisis respite houses are a great alternative. http://bit.ly/1jV3ukZ
  • Spend $$ on community-based #mentalhealth services that work, not institutions. #realmhchange
  • Crisis respites save lives and dollars! http://www.gjcpp.org/pdfs/2013-007-final-20130930.pdf #housingnotasylums
  • Move #mentalhealth services closer to the community, not farther away into hospitals. #HousingNotAsylums
  • #HR2646 promotes hospitalization for #mentalhealth needs best cared for in the community. #RealMHChange
  • Over-reliance on hospitalization is expensive & less effective than community-based mental health care. #RealMHChange
  • #RealMHChange is funding prevention of crisis. #HR2646 would fuel a crisis based system.

ACTION ALERT: Tell Dan Rather He is Wrong on Mental Health Reform!

On December 6, a report ran in the Herald-Tribune covering a panel discussion featuring former CBS anchorman Dan Rather. You may watch the video of his remarks here.

According to the article, Mr. Rather said the following concerning things:

  • “Rather traced the crisis back to a failure of follow-through in the 1960s, after a national consensus was reached across party lines to close psychiatric hospitals in favor of community-based outpatient treatment.”
  • “Rather said he believes early detection and treatment — including the easing of doctor/patient confidentiality laws that prevent families from seeking help for a loved one until it’s too late — would be one step in the right direction.”
  • “We can’t eliminate mass killings, but we can curb some of the gun violence by addressing the mental health crisis.”
  • “Rather said to reach a national consensus on what should be done would take a willingness for people on all sides of the political and ideological spectrum to acknowledge the magnitude of the problem and coordinate on potential solutions. He specifically cited the inclusion of the National Rifle Association in that consensus, an organization he said ‘tends to be demonized.'”

What you can do:

  • Send a letter to the Herald-Tribune using this form. If you send a letter, please try to do it in the next day or so to maximize opportunities for publication. Tips on sending effective letters to the editor can be found here. You may use our talking points below, or use your own.
  • Leave comment at the bottom of the Herald-Tribune article.
  • Post to Dan Rather’s Facebook page: https://www.facebook.com/theDanRather
  • Tweet to Dan Rather: https://twitter.com/DanRather
  • Use the hashtags #realmhchange #protectpaimi and #stopmurphybill
  • Links you can Tweet or share on Facebook:
    Collected Statements from the Campaign for Real Change in Mental Health Policy http://bit.ly/1IVAhwZ
    “Mental Illness, Mass Shootings, and the Politics of American Firearms” by Jonathan M. Metzl, MD, PhD, and Kenneth T. MacLeish, PhD http://bit.ly/1y5qbJl
    “Paul Ryan blames mass shootings on mental health laws” by David Perry http://bit.ly/1Ncb5pT
    “Mental illness: an easy scapegoat for those who won’t point fingers elsewhere” by Ari Ne’eman http://bit.ly/1QXtwSV

Talking points:

  • We should not blame de-institutionalization for the current state of affairs. The reason for today’s broken system is that states haven’t fully funded — and continue to underfund — community-based services that can prevent homelessness, institutionalization, and incarceration. According to a recent NAMI report, “funding for mental health services fell in more states than it grew. This is the third year in a row the number of states willing to increase spending on mental health shrank.”
  • Regarding health privacy, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is clear that information can be shared with caregivers in case of an emergency. Providers need to be better educated as to how HIPAA works. We do not need to change the law. Weakening HIPAA privacy protections will scare people away from seeking help. We should not support health privacy discrimination against people with mental health issues.
  • Reforming the mental health system will not “curb gun violence.” The research is clear that people with mental health conditions are not responsible for the vast majority of gun violence in our nation. Only 3-5% of violent acts in America can be traced to a person with a psychiatric diagnosis. In fact, they are 11 times more likely to be the victims of violence than the perpetrators. The known risks for gun violence include: access to guns, substance use, poverty, and a history of violence. For more information, see this excellent review of the evidence.
  • Given that mental health conditions are not a significant risk factor for gun violence, reform of the mental health system should be discussed separately from gun reform. Therefore, the NRA is not a relevant partner for discussion on mental health reform. To reach consensus, we should include the perspectives of people with mental health issues themselves, who are often left out of the discussion on national policy matters.

A Psychiatrist Opposes H.R. 2646: Here’s Why

Screen Shot 2015-12-05 at 2.50.08 PMDear 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

Action Alert: Tell NYT Columnist Nicholas Kristof that Mental Health and Gun Violence are Not Connected!

On Thursday, December 3, 2015, New York Times Op-Ed Columnist Nicholas Kristof, usually a strong proponent of human rights, recklessly stated that mental health and gun violence are connected and supported the Murphy bill – the Helping Families in Mental Health Crisis Act (H.R. 2646).

Among other things, Kristof stated that: “As for mental health, Republicans are right that it is sometimes related to gun violence. But it’s also true that in some cases their budget cuts have reduced mental health services. To his credit, Representative Tim Murphy, a Pennsylvania Republican, has introduced a bill that would improve our disastrous mental health system, perhaps reducing the number of people who snap and turn to violence. Yet some Democrats are wary of the bill because Republicans like it. That’s absurd: We need better mental health services just as we need universal background checks.”

You can read the entire piece here:

What you can do:

  • Email Kristof at:  Kristof@nytimes.com
  • Tweet to Kristof @NickKristof
  • Write a letter to the editor to the New York Times. Their guidelines for submitting a letter to the editor can be found here.

Let him/NYT know the following:

  • He is incorrect about the connection between mental health issues and gun violence.
  • The Murphy bill will undermine the human rights of people with psychiatric disabilities.
  • The Murphy bill fails to addres gaps in community-based services that are the root of the problems in the mental health system.
  • Direct him to Rep. Paul Tonko’s recent blog post. Rep. Tonko gets it: “Study after study has shown that there is no connection between those w/#mentalillness & violence” – @RepPaulTonko
  • Direct him to this letter by the Bazelon Center on the false link between mass shootings and mental health.
  • For more information and talking points, see the excellent sample email (below) by Susan Rogers or Sera Davidow’s statement on gun violence and psychiatric diagnosis.

Thank you for taking action today!
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SAMPLE EMAIL:

Dear Mr. Kristof,

First, let me say that you are my favorite New York Times columnist and I read your column religiously. In the past, I have quoted some of the facts you have included in your columns about gun control, such as statistics from your excellent column “The Killer Who Supports Gun Control.”

So I was very disappointed to read in your recent column that you support Rep. Tim Murphy’s misguided bill, H.R. 2646, the Helping Families in Mental Health Crisis Act.

Rep. Murphy is promoting his bill – which, if passed, would be harmful to individuals with mental health conditions, such as myself, by hamstringing the federal protection and advocacy system, violating people’s privacy rights, and promoting force rather than choice in treatment – by linking mental health conditions and violence.

Rep. Murphy is wrong. Many studies, such as one by researchers at Vanderbilt University, have found that “mental illness is the wrong scapegoat after mass shootings.” I also urge you to read Rep. Paul Tonko’s excellent piece on this subject, “Why Equating Mental Illness with Violence Harms Us All.”

Here is a quote from a Vox.com report: “When economist Richard Florida took a look at gun deaths and other social indicators, he found that higher populations, more stress, more immigrants, and more mental illness didn’t correlate with more gun deaths. But he did find one telling correlation: States with tighter gun control laws have fewer gun-related deaths.”

Mr. Kristof, again, I admire your work enormously, and I appreciate your educating me about important charitable organizations such as the Fistula Foundation, which I have been donating to ever since reading about their work in more than one of your columns.

I also appreciate your focus on gun control. I hope that, in another column, you will write to indicate that you were wrong to promote Rep. Tim Murphy’s bill, H.R. 2646, the Helping Families in Mental Health Crisis Act.

Thank you again for all you do,

Susan Rogers
Director
National Mental Health Consumers’ Self-Help Clearinghouse
https://twitter.com/SusanRogersMH