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MARYLAND 2002 - SB 645/HB 923
Testimony supporting SB 645

Senate Education, Health, and Environmental Affairs Committee
Chairman: Clarence W. Blount
March 12, 2002, 1pm

Testimony by Rosanna Esposito, JD
Treatment Advocacy Center

Senate Bill 645 - Mental Hygiene - Involuntary Admission,
Emergency Evaluation, and Clinical Review - Standards
Position: Support

The Treatment Advocacy Center is a national non-profit organization, located in Arlington, Virginia. Our mission is to eliminate barriers to treatment for people with severe mental illnesses such as schizophrenia and bipolar disorder. The Center is particularly concerned about state laws that require "dangerousness" as the basis for medical interventions for people who do not recognize their own need for treatment. I have been asked today to speak about how Maryland's "dangerous" standard compares to other treatment laws and to share experiences from other states that have updated their treatment standards.

When was the last time Maryland revised its treatment criteria? 

Maryland last revised its treatment criteria in 1982, at the tail end of a national trend where states changed their laws to require a court finding of dangerousness before treatment could be provided to those incapable of recognizing their need for it. While well intentioned, reform efforts meant to protect people with mental illnesses resulted in many of the most severely ill going without needed treatment. In too many cases waiting for "danger" has resulted in people becoming homeless, incarcerated, suicidal, victimized or prone to violent episodes.

How does Maryland's treatment law compare to other state treatment laws? 

Here we are again, at the tail end of another trend where states have updated their treatment laws to allow earlier intervention. Maryland now has one of the strictest criterions for treatment in the nation. A chart summarizing the criteria for all 50 states is attached to this testimony.

How does Senate Bill 645 compare to other state treatment laws? 

44 states have modernized their laws over the past twenty years to allow medical intervention before a person reaches the point of "imminent dangerousness." These reforms recognized that dangerousness-based criteria often resulted in tragedies that were preventable. The revisions were also meant to bring the treatment laws more in line with terrific advances in scientific understanding and ability to treat severe mental illnesses. The majority of states have criteria along the lines of the 'gravely disabled' language proposed in Senate Bill 645. Several states are even more progressive. Please see the attached selection of comparable criterions.

Is the 'gravely disabled' criterion unconstitutional? 

Since Washington State first passed its 'gravely disabled' standard in 1976, such narrowly tailored standards have been routinely upheld in constitutional challenges in state courts. The U.S. Supreme Court has never even decided to accept or hear a challenge to a 'gravely disabled' standard.

Does the U.S. Supreme Court require 'dangerousness' in order for the state to order a person into treatment? 

The argument that O'Connor v. Donaldson requires dangerousness for civil commitment misreads the holding of that case. What the Court did rule was that a nondangerous person could not be confined if there was no treatment being given. According to Kenneth Kress, a prominent Mental Health Law professor from the University of Iowa who has published articles on the subject, "Scholarly opinion recognizes the parens patriae power to constitutionally commit and require coerced medication under three conditions: 

(1) mental illness; 
(2) incapacity to make informed treatment decisions; and 
(3) treatment is provided." 

Senate Bill 645 satisfies these requirements.

Should the law allow non-dangerous people to select their own course of medical treatment? 

Absolutely. The Center supports the rights of non-dangerous people with severe mental illnesses who have the capacity to make an informed medical decision to make treatment decisions for themselves. The proposed 'gravely disabled' criterion in Senate Bill 645 upholds those rights because it is specifically tailored to apply only to those who are incapable of making an informed decision about treatment.

Why is the incapacity to make an informed decision a key element of the reform proposal? 

It is commonly claimed that, "if you make the psychiatric services attractive enough and culturally relevant, then individuals with serious mental illnesses will utilize them." This appears to not be true. There have been nearly 100 studies in recent years that address the question of "anasognosia" or lack of insight in people with severe mental illnesses. The research shows that nearly half of the people with schizophrenia or bipolar disorder do lack insight into their illness. In a recently published study, the greatest reason for non-treatment was the person's lack of awareness of their illness. Very few of those polled in the study cited "not satisfied with available services," "could not get appointment," "language problem," etc., as a reason why they were not in treatment. Such individuals will not voluntarily utilize psychiatric services, no matter how attractive those services are, because they do not believe that they have an illness.

Do people who are treated involuntarily refuse to be treated on a voluntary basis in the future? 

The claim that involuntary treatment scares many away from even voluntary services appears to be unfounded. Studies demonstrate that the majority of individuals who refuse treatment accept it after being told that they must. Furthermore, the majority of patients who initially object to hospitalization or medication retrospectively agree with the decision to hospitalize or treat them. Research also suggests that, "attitudes toward treatment can improve over longer periods of time, and that previously committed patients tend to voluntarily seek treatment later."

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