General Resources / Legal Resources / Medical Resources / Briefing Papers / State Activity    
Hospital Closures / Preventable Tragedies / Press Room / Search Our Site / Home

New England Psychologist

April 2005

Reprinted with permission. All rights reserved.

A commuter pushed under a train by a homeless man. An 11-year-old boy murdered in the woods near his home. When violent stories make the news, there's an immediate public uproar especially when it's revealed that the perpetrators are mentally ill. In these incidents, the murderer was a man diagnosed with paranoid schizophrenia who didn't take medication.

The families in both of these cases have pushed for a change in state laws to allow judges to order mentally ill patients to follow prescribed medication plans. Those laws, Kendra's Law in New York and Gregory's Law in New Jersey (now being reviewed), are known as involuntary outpatient commitment (IOC) laws.

Currently, there are IOC laws in 42 states although not all are actively used. Of the eight states without IOC laws, three are in New England: Massachusetts, Maine and Connecticut.

If Maine State Senator John Nutting (D) has his way, there will be one less New England state on that list. Last month, the state's Health and Human Services Committee of the Maine state legislature held a hearing on his proposed bill.

"The hearing went quite well," he says. "Now we have to go through due process to work out the parameters of the bill."

A 10-person review committee made up of professionals in the mental health field, legislators and advocate groups will meet to work out those parameters. At the end of April, they will present their findings to the committee.

At first glance, it appears obvious that an individual who could be that dangerous to others, or indeed to himself, should be forced to comply with medical treatment that could alleviate the situation. But, the issue is not that simple. As Brian Rines, Ph.D., a forensic psychologist who handles nearly half of Maine's court-ordered mental health evaluations, points out, there are issues to consider before any bill is passed.

"This is the only time in our culture where you can force treatment on someone just because they are odd or strange," he says. "Whatever you do, you have to be real sure to protect people's rights."

"I am not opposed to the law. The current bill allows people to live in the community who could profit from anti-psychotic medication but are not at the threshold to meet our involuntary commitment standards. Since the time I worked at the state hospital in '63 as a college student, I have witnessed the state of Maine go through three stages of deinstitutionalization. But the money doesn't follow the patients. In most cases we are tossing these people onto the street and wishing them well," Rines says.

The Maine Psychological Association has taken a guarded stand. Members recommend additional study to determine how the law would be implemented, who would be affected and how individual patients would be protected from infringements of legal rights, says Kendra Bryant, Ph.D., MePA president elect and legislative committee chairperson.

"There didn't appear to be a lot of clinician input into how this law would be implemented," Bryant says. "On the other hand, in Maine it is difficult to get an order to do medication without the person's approval even for inpatient commitment. This could be an improvement but not necessarily the way it is now written."

Nationwide, involuntary outpatient commitment is a hot-button issue. The Treatment Advocacy Center (TAC) in Washington, D.C., a national nonprofit organization working to "eliminate barriers to timely treatment of severe mental illness," has put a great deal of resources behind the issue across the country. Executive Director Mary T. Zdanowicz, Esq., appeared at Maine's recent legislative hearing.

At the hearing, she explained that many people with severe mental illness often experience anosognosia, a neurological deficit that impairs the ability to recognize the illness.

"It's a complex issue," Zdanowitz tells New England Psychologist. "The major opposition that people have is that people have the right to make their own choices. That's okay except when illness makes them incapable of making their own decisions."

Zdanowitz prepared a brief for the hearing that outlined the IOC laws' effectiveness. The New York program resulted in 63% less hospitalizations, 65% fewer episodes of homelessness and 75% fewer arrests.

TAC also points to a study done by Duke University of mentally ill patients who were offered mental health services. Those who were offered the services combined with a court order requiring participation had lower hospitalization rates (up to 74 %), fewer arrests (74%), reduced violence and improved treatment compliance (58%).

In a paper on the study published in the "American Journal of Psychiatry" (Dec. 1999), its authors said, "Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective."

These same studies are used by opponents to show why the laws should not be passed or enforced. The Bazelon Center for Mental Health Law in D.C., says that "the studies [in New York and at Duke University], clearly show that [IOC] confers no benefit beyond access to effective community services - access that is too often nonexistent on a voluntary basis."

There are questions, say opponents, of the ethicality of coercing someone to take antipsychotic drugs, especially because of the side effects. Then there are questions about how one would enforce such a law.

"This is a huge issue," says Wayne Daily, public information officer for the Connecticut Department of Mental Health and Addiction Services. "Even though 42 states have these laws on their books, few implement them. There are aspects that make them difficult to implement. What if someone refuses the medication? Are you going to wrestle them down in their living room?"

The National Mental Health Association calls IOC a "simplistic response to a complex problem." Instead, it recommends increasing funding for community-based mental health resources and advance directive legislation that would allow a patient to make a choice in his/her treatment.

Studies conducted by the MacArthur Foundation have shown that people with mental illness are usually competent to make their own decisions.

In Connecticut, a study was done in 1995 to determine the efficacy of an IOC bill. The task force recommended an alternative to the IOC law including having the DMHAS create a systematic approach to address the needs of the population at risk and to enhance relationships with other agencies.

"The issue is that this could become a way in which we are excused of doing the hard work of engaging these people in treatment," Daily says.

In Massachusetts, although there is currently no IOC law, courts have been using a 1983 court case, known as the Rogers Decision, to impose a substituted judgment decision in order to enforce compliance.

The Massachusetts Department of Mental Health does not support IOC legislation.

"There are a number of aspects of outpatient commitment that the department has concerns about," says Lester Blumberg, chief of staff. "What we really need to do is increase compliance and enhance access and reduce stigma. The research that we have seen doesn't establish that outpatient commitment would do any of those."

In New Hampshire, the IOC law is not used as often as conditional release. In 1998, a retrospective study of 26 patients released from the New Hampshire State Hospital showed that conditional discharge resulted in significant improvements for medication compliance, substance abuse and violence in the two years following release. There was also improvement, but only in the first year, in number of days in the hospital, number of moves per year and months of employment.

In Rhode Island, the IOC laws state that a court may order mandatory medication compliance if it finds that otherwise, because of mental illness, the person may cause harm if left unsupervised. In addition, any alternative programs must be investigated first.

Vermont's law states that the court may order a person who is deemed to be in "need of treatment" to follow a specific plan of treatment outside inpatient hospitalization.

While the debate rages around the country, the state of Maine will have to decide for itself. It won't be an easy decision, but Rines feels it can be done properly.

"If I were to write this bill," he suggests, "I would be sure that some kind of choice would be allowed to the patient. They can follow the medication plan or stay in the hospital. You put the onus of choice on the patient."