Remarks prepared for the December 16, 1998 public hearing regarding Outpatient Civil Commitment in New York
by Howard Telson, M.D.
Director, Bellevue Outpatient Commitment Program and Clinical Assistant Professor of Psychiatry, New York University School of Medicine
It is an honor to be here today, for this great public discussion regarding outpatient commitment in New York. It has been my privilege to direct New York State’s Outpatient Commitment Pilot Program at Bellevue Hospital Center. I agreed to work on the project in early 1995 because it presented a new opportunity to help patients. The pilot was the culmination of years of efforts to make court ordered outpatient treatment available in New York. The Bellevue administration clearly envisioned it to be a clinical program which used a legal mechanism to improve compliance with outpatient treatment and services. It was viewed as a way to insure the delivery of the treatment and care in the least restrictive setting, and thus prevent decompensation and rehospitalization. In my own clinical experience I had certainly encountered resistance to and refusal of necessary and appropriate outpatient treatment which I watched result in relapse and which I imagined could have been helped by the availability of outpatient commitment.
Outpatient commitment has been used in many parts of the United States over the past few decades, and has grown directly in proportion to the implementation of deinstitutionalization. The effectiveness of deinstitutionalization was predicated on the availability of effective treatment in the community and on the willingness of patients to receive the treatment voluntarily. As a result of deinstitutionalization many patients were able to leave the large state hospitals and have decent lives in the community. In many cases, however, the assumptions underlying deinstitutionalization were incorrect. Community mental health services were never developed in the way that was originally planned. In addition, many individuals lacked the capacity to seek treatment or rejected treatment due to their illness. They had hallucinations, delusions, paranoia, disturbances of mood and thinking, and problems with motivation, concentration, judgement and insight that interfered with their ability to seek treatment. And in many cases patients not only neglected but actively rejected outpatient psychiatric care due to the symptoms of mental illness.
As deinstitutionalization was being implemented most states amended their commitment laws to require dangerousness to self or others before involuntary inpatient treatment was permitted. The traditional standard of need for treatment was eliminated from most state laws, making it difficult to access care for many very ill, but not dangerous, individuals. By the late 1970’s the problems of deinstitutionalization and stricter commitment laws resulted in a new phenomenon known as the “revolving door syndrome.” This occurred both among formerly institutionalized patients as well as in young chronic patients who never had spent long periods in hospitals. These patients could often be treated effectively, and stabilized in the hospital. However, upon discharge they could not access or became noncompliant with outpatient treatment, and deteriorated to the point of becoming homeless, or becoming dangerous and requiring involuntary hospitalization.
Outpatient commitment is one of a number of interventions, which were specifically developed to address the problems of noncompliance in the community and the revolving door syndrome. Outpatient commitment occurs when a judge formally orders a patient to comply with a plan for outpatient psychiatric treatment and services in the community in order to prevent deterioration that may result in hospitalization. It reintroduces a need for treatment standard into civil commitment, and thus re-asserts a clinical as opposed to a criminal basis for the court’s intervention.
Outpatient commitment became increasingly widespread in the 1970’s and ‘80’s. It is now formally available in 35 states and the District of Columbia. Almost a decade ago Dr. Jeffrey Geller outlined a set of clinical guidelines for the use of outpatient commitment which have been widely accepted, and which have guided the development of the Bellevue program. First, there are a number of conditions regarding the patient. The patient must have a history of failing in the community and must currently express an interest in living in the community. The patient must have that degree of competence necessary to understand and abide by the stipulations of the outpatient commitment order. Finally, the patient must not be dangerous when complying with the ordered treatment.
The guidelines also define a set of requirements for the service system, which also must make, if you will, an outpatient commitment. The treatments being ordered must have demonstrated efficacy when used properly with that individual patient. The outpatient system must be capable of delivering the necessary outpatient services, which must be sufficient for the patient’s needs and necessary to sustain community tenure. The psychiatric outpatient system must be capable and willing to provide, monitor and enforce compliance to the ordered treatment. And, finally, the public sector inpatient system must support the outpatient system’s participation in the provision of involuntary community treatment.
Much of the published research has shown that outpatient commitment is effective. It suggests that outpatient commitment contributes to reducing the rate of hospitalization, the length of stay of hospitalizations and dangerousness in the community. Unfortunately, most studies have had limited value due to the small numbers of patients, short follow up periods and a lack of controls, or nonequivalent controls. Many outpatient commitment programs were put into place with enhanced community services, and the study designs did not distinguish the effects of the court order and the related legal intervention from those of enhanced care and treatment.
Because it was available in so many other states, and because much of the research suggested that outpatient commitment was effective, the State legislature agreed to test outpatient commitment in New York, and to specifically study the effects of both enhanced services and of the court order. Section 9.61 of the Mental Hygiene Law was passed in 1994, and called for a three year pilot program and a study to determine the program’s effectiveness in preventing rehospitalization and improving patient quality of life in the community. The legislation also required that the study assess participant satisfaction with the program. In 1997 the pilot was extended for one year.
The program began in July 1995 and is administered through a Coordinating Team which consists of two psychiatrists, a coordinating manager who is also a social worker, a staff social worker, and part time attorney. The team functions as a community forensic psychiatric consultation service, and is responsible for implementing the clinical program in full compliance with the requirements of Section 9.61.
I and the rest of the staff of the Bellevue Outpatient Commitment Program have enjoyed this opportunity to develop and promote a new intervention and to help seriously ill patients do better in the community. This has been an especially challenging project because as a pilot, all the forms, procedures and interventions have had to be newly developed. Because the pilot was operated out of one site in the entire state, most consumers, providers and family members were unfamiliar with its theory and practice, and a massive educational program was found to be necessary for the project to even materialize. The job of developing, implementing, and helping to study outpatient commitment in New York has been complex but rewarding.
You will be hearing from Policy Research Associates regarding their evaluation of the program. I would like to take this opportunity to share what we at Bellevue have learned in developing and implementing the pilot program.
We learned, first, that good, comprehensive, coordinated treatment and care can, as has been seen elsewhere, substantially improve the quality of life of consumers and help them to stay out of the hospital. We were fortunate to be able to offer patients a wide range of individual, day treatment and case management programs, assertive community treatment teams, and transitional and supported housing options. We are also proud of the model that the Coordinating Team has created: the system can, indeed, increase accountability as well as efficiency. A team such as ours, which has a clinical focus that operates across all systems and advocates for the best available treatment for each individual consumer can really make a difference in people’s lives. We strongly believe that the authority granted to the Coordinating Team by its accountability to the judicial system was responsible for a good part of its success in negotiating difficult problems with consumers as well as with providers and families.
Second, we learned that many providers strongly believed that outpatient commitment had a necessary place in the care of seriously ill patients with histories of noncompliance and subsequent hospitalization. In the past years we have worked with over sixty provider agencies throughout New York City to develop individualized treatment plans that offered quality care to difficult to serve clients. Only two provider programs refused to offer services in the context of an outpatient commitment order. Most providers found the coordination of services and additional assistance provided by the Coordinating Team to be helpful. Yet they also clearly stated, again and again, that the court order offered leverage in working with very ill patients, which permitted the continuous delivery of services and prevented relapse. Renewals of outpatient commitment orders were commonly requested because they were perceived to assist providers in negotiating treatment with consumers; and orders were sometimes described as “safety nets,” both by providers and by consumers in the program.
Third, we saw that as community awareness regarding the pilot program grew, we received more and more requests from families and providers to access outpatient commitment. Although the program was conceived as a pilot that would only include patients currently hospitalized at Bellevue, it became clear that there was a strong feeling that court ordered outpatient treatment could be beneficial to many others individuals.
Fourth, we learned that the Legislature left much of the enforcement of outpatient commitment orders to clinical judgement, and we also learned that operationalizing the enforcement mechanisms of Section 9.61 required careful negotiation and consensus building. Considering that outpatient commitment was indeed new territory, it was imperative that each step was taken carefully and correctly, and this took more time than was originally anticipated. The Guidelines for the Administration of Medication over Objection in the Community were completed almost one year into the project. The procedures to transport noncompliant patients who might be dangerous to the Bellevue emergency room were finalized only in October of this year, really just a few weeks ago. Families and providers consistently expressed the desire that the law had more “teeth,” that is, that the enforcement mechanisms were clear and available.
The slowness of the process of creating the new enforcement mechanisms, as well as the many questions related to enforcement which had to go unanswered, unfortunately limits the value of the PRA study. During the 26 months during which patients were enrolled as subjects in the PRA study, the group who received court orders did not experience outpatient commitment as the New York State Legislature intended it to be implemented. For this and a variety of other reasons, PRA’s court and control groups were too similar to actually test the impact of outpatient commitment on hospital days, experience of coercion or consumer and provider satisfaction.
Fifth, we learned that the outpatient commitment orders did appear to assist many individuals to stay in outpatient treatment, and thus stay out of the hospital, in spite of the limited enforcement mechanisms. The PRA report shows that patients with outpatient commitment orders, as compared to those with enhanced, coordinated services and no court order, were easier to locate upon followup, became homeless less often, and spent less total time in acute and state hospitals. Although PRA has indicated that their finding are not statistically significant to a degree that offers scientific certainly, their data indicate strong trends which very much validate our clinical experience. Even mentally ill chemical abusers seem to spend less time in the hospital with outpatient commitment, often because they continue taking medication in spite of abusing drugs.
Sixth, we have seen outpatient commitment increase feelings of accountability on the part of consumers, providers and families. The outpatient commitment process and the way the court order has been used respects the autonomy of the individual patient while acknowledging his or her specific impairments. Families and providers value the court orders because they are a focus around which service coordination and mobilization pivot. Providers find the orders helpful in negotiating treatment with consumers who are often profoundly ambivalent because of their illnesses. And we have seen that consumers, providers and families view outpatient commitment not an alternative to complete freedom and liberty, but rather as an alternative to relapse, homelessness and longer stays in the hospital.
Finally, we have seen that the hospital and the Mental Hygiene Legal Service can cooperate to insure good outcomes for patients. In his 1986 American Journal of Psychiatry editorial called “Outpatient Commitment: The Problems and the Promise” Professor Paul Appelbaum wrote the following: “Whether the problems with outpatient commitment can ever be successfully resolved will depend in large part on the attitude of lawyers who specialize in mental health issues.” He goes on to note that “such patient-oriented cooperation is demonstrated today in several jurisdictions in which outpatient commitment is being accomplished by agreements negotiated between patients’ attorneys and the mental health system with court supervision.” This is precisely the experience that emerged during this pilot. The Mental Hygiene Legal Service has held the hospital accountable for every detail of the outpatient commitment program; and we all learned that by following the law, and working for the best interest of the patient, that more often than not a complete, appropriate treatment plan could be developed that would satisfy the consumer, the hospital and the court. There were indeed a number of patients who did not consent to the order, and the Mental Hygiene Legal Service was vigilant in representing them in contested hearings. For the most part, though, we understood the fact that patients so often consented to the orders to mean that we were doing our job correctly. Commitment to treatment was not necessarily perceived or experienced as coercion.
This has been a unique experience. For now I want to thank the Outpatient Commitment Program staff at Bellevue, present and past, and everyone at Bellevue, the Health and Hospitals Corporation, the Department of Mental Health, Mental Retardation and Alcoholism Services, and the State Office of Mental Health who participated in the pilot. I also want to thank all of the providers who offered their services in conjunction with the pilot. I want to thank all of the patients in the program; they largely understood that outpatient commitment was designed to help them stay well in the community, and not in any way to hurt or punish them. This program has been observed by many very closely; I hope that the value of legal intervention in the context of good clinical care shines through any misunderstanding of its intentions. I certainly hope that outpatient commitment continues in New York, and is made available to as many individuals as can benefit from it. And I hope that the discussion in the next few months focuses on how to implement the best outpatient commitment program in the country. Thank you all for coming, and for sharing your opinions regarding this very important subject. (Posted 2/1999)
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