Catalyst Summer 2004

The battle to reform one of the nation’s most restrictive mental illness treatment laws began five years ago. The lessons learned along the way can be instructive to those facing similar bad laws, and to those in states with good laws that have not taken the step that Florida will now take - widespread implementation and use.

In this issue of Catalyst, we bring you a snapshot of the road to reform that includes an overview of the effort; voices of bill sponsor Rep. David Simmons and principal advocate at the Florida Sheriffs Association Sheriff Donald F. Eslinger; and highlights of the extraordinary media support for bringing assisted outpatient treatment to Florida, now one of 42 states with that procedure. There are also two special advocates’ tools - an indepth fact sheet on assisted outpatient treatment and answers to frequently asked questions about Florida’s reform.

Feel free to print out a PDF copy of this newsletter for easier reading or to share at a conference or event. (Read more on our permissions policy.)

NOW WE CAN SAVE LIVES
by Treatment Advocacy Center President E. Fuller Torrey, M.D.

The Florida sheriffs, many local supporters of Baker Act reform, and TAC staff deserve accolades for helping to get the reform passed by the Florida legislature.

That was the critical step. Without it we had no hope. But now a new phase begins. The law must be implemented.

Implementing the law will improve and save the lives of individuals with severe psychiatric disorders, their families, and the community by decreasing hospitalizations, episodes of inappropriate jailing, homelessness, suicides, and episodes of violence.

Getting the law passed was not easy - opponents tried to stop the bill at every turn. Implementation could be just as challenging.

The statewide implementation of Kendra's Law in New York State proves that it can be done and clearly demonstrates that such laws can indeed be effective and can improve individual lives. That must be our goal in Florida as well, and if we succeed we will have so much more to celebrate.

This is not an academic exercise. The final goal of change must always be to secure lifesaving treatment for people with severe mental illnesses, and we should not be seduced by legislative victories alone. That has been TAC's purpose from the beginning, and we must always remember it.

NEW HELP, NEW HOPE IN FLORIDA
Landmark legislation makes Florida the 42nd state to authorize assisted outpatient treatment

On June 30, 2004, Gov. Jeb Bush signed SB 700 into law, the Florida Sheriffs Association’s legislation to reform that state’s mental illness treatment law, known as The Baker Act.

The law will allow court-ordered outpatient treatment for people with severe mental illnesses, like schizophrenia and bipolar disorder, who have a history of noncompliance combined with either repeated Baker Act admissions or serious violence. Sponsored by Representative David Simmons, Senator Durell Peaden, and Senator Rod Smith, the legislation becomes effective January 1, 2005.

Florida Governor Jeb Bush signed Baker Act reform into law June 30, 2004. He was joined by bill sponsor Senator Durell Peaden and representatives of the Florida Sheriffs Association (FSA), including four Florida sheriffs. Bringing assisted outpatient treatment to Florida was FSA’s top legislative priority.

Before passage of this law, Florida was one of only nine states that did not allow court-ordered outpatient treatment for people with severe mental illnesses who did not voluntarily accept treatment - inpatient commitment was the only choice.

“Court-ordered outpatient treatment is a less restrictive, less expensive treatment alternative for people who need intervention but do not require inpatient hospitalization,” said Treatment Advocacy Center Executive Director Mary T. Zdanowicz. “States with similar laws that implement them effectively have had well-documented successes in helping people whose brain diseases prevent them from making rational treatment decisions,” said Zdanowicz. [Read her full statement.]

Statistics on the first three years of New York state’s similar law revealed that for people placed in court-ordered outpatient treatment, 63 percent fewer were hospitalized, 55 percent fewer experienced homelessness, 75 percent fewer were arrested, and 69 percent fewer were incarcerated.

Seminole County Sheriff Donald F. Eslinger led the Florida Sheriffs Association’s effort to pass Baker Act reform. At a special ceremony at Sheriff Eslinger’s office on July 8, Rep. David Simmons, the bill’s sponsor, spoke about the law as a tribute to fallen officer Deputy Eugene Gregory. July 8 was the six-year anniversary of Deputy Gregory’s death in a standoff with a man with untreated schizophrenia. That tragedy sparked FSA’s reform effort.

Individuals in New York’s Kendra’s Law program were also more likely to regularly participate in services and take prescribed medication. The number of individuals exhibiting poor adherence to medication decreased 67 percent and those exhibiting poor engagement to services decreased 42 percent. Kendra’s Law has also had a marked effect on individuals with co-occurring substance abuse problems: participation in substance abuse services doubled.

Florida’s reform focuses on a small subgroup of those meeting existing involuntary examination criteria, recidivists who disproportionately use mental health, criminal justice, and court resources. In 2002, one person was Baker-Acted 41 times, costing approximately $81,000, not including court costs, law enforcement resources, or short-term treatment.

Recidivists’ Baker Act examinations increased 50 percent between 2000 and 2002; 540 people had eight or more Baker Act exams in one 24-month period (2000 to 2001), averaging at least one every three months.

Statement by Rep. David Simmons, the bill’s sponsor

Statement by Sheriff Donald Eslinger

Special tribute to Alan Singletary and Deputy Gregory

Oftentimes the unwillingness to stay in treatment is due not to denial or stubbornness, but to lack of insight. “Anosognosia, the neurological term for lack of awareness of illness, is the single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications,” said E. Fuller Torrey, MD, president of the Treatment Advocacy Center. “Caused by damage to specific parts of the brain, anosognosia affects about half of those with schizophrenia and bipolar disorder. People with anosognosia often will not accept medication unless they are court-ordered to do so. When asked retrospectively about their experience with court-ordered treatment, the majority of those ordered to treatment agreed that it was the right decision.”

This focus on the improved quality of life for consumers with untreated mental illnesses is an important point to everyone involved in passing this legislation, especially treatment providers. “Assisted treatment provides for early intervention to prevent a crisis, and, better still, empowers people with mental illnesses to take control of their symptoms and their lives,” explains Wayne Dreggors, President of Act Corporation and Chair of the Florida Council for Community Mental Health. “Having that legal avenue available in Florida can only serve the good of the people we serve, their families, and the community.”

Linda Gregory and Alice Petree know well the pain that can come from the unintended consequences of failing to treat a severe mental illness. Deputy Gene Gregory, Linda’s husband, and Alan Singletary, Alice’s brother, were both killed in a standoff six years ago resulting from Alan’s refusal to take medication for his schizophrenia. They worked together on passage of this legislation.

“We want other families to be able to get help for the people they love, before disaster strikes,” said Linda. “Alan didn’t believe he was sick,” said Alice. “If we could have gotten him the help he needed, he and Deputy Gregory might be with us today.”

There are certain stepping stones, each building on the next, that can increase the chance of a reform’s success. The lessons we learned in Florida may be useful to those in other states taking their first steps toward reform.

In 1999, a group of Florida advocates invited the Treatment Advocacy Center to meet with them. The advocates were struggling with the too-common dilemma faced by families who are unable to get treatment for a loved one with anosognosia, someone who is too sick to recognize that they are ill.

That meeting laid the first critical stepping stone on the road to reform - strong grassroots support for change. A group of individuals can spark reform. Members of the grassroots team in Florida wrote powerful letters to legislators, testified before committees, and bravely shared their stories with the media. Without them, the effort would never have roared to life. California’s similar effort was sparked by a grassroots task force made up of mental illness advocates, physicians, constitutional lawyers, social workers and law enforcement officials - they launched their work with a landmark white paper on the need for reform of California’s involuntary treatment law.

It is a fallacy that reform can only be launched by big organizations. Although it is desirable to have the backing of these groups, sometimes it is impossible until further down the road. The issue of assisted treatment can be misunderstood, so it can be hard for organizations to find consensus early in the process, which most groups understandably require before they lend their name to an initiative.

To start a campaign, the first stepping stone to place is grassroots support. Find others in your communities who seek reform by discussing it in your support groups, reaching out to people who have experienced tragedies, and talking to sympathetic professionals. Email is a great tool for organizing grassroots support. In Florida, New York, and California, email lists kept supporters updated on each bill’s progress, alerted subscribers to newspaper articles that needed response, and shared information on key actions.

In 2001, Seminole County Sheriff Donald F. Eslinger had already taken a leadership role in Florida advocating for new funding for mental illness and substance abuse services. Still, he knew enough to ask the question, “What can we do about someone who refuses services because they don’t think they are ill?” His personal and professional commitment to Baker Act reform was the next big step, and perhaps Florida’s most important.

Just as a broad grassroots base is critical, so is leadership, whether that is a passionate family member, like Sheree Spear in North Dakota, or an organization, like NAMI in Maryland.

Either way, a leader needs appreciation for and understanding of the problem, a personal interest, courage to take on what can be a contentious and difficult issue, political savvy, the time and energy to reach out to a wide variety of people, and tenacity. A successful leader also must be willing to invest in the process.

In Florida, Sheriff Eslinger was not only willing to devote his own time to the cause, but made the reform effort a priority for his staff, dedicating a liaison to focus solely on this issue. He also brought in the powerful Florida Sheriffs Association (FSA), of which he was legislative chair. FSA subsequently made Baker Act reform its top legislative priority, and its lobbyist did extraordinary work to ensure final passage.

To move to the leadership stepping stone in your state, consider candidates from law enforcement or corrections, judges, respected members of the community, renowned experts, and mental health professionals. Look for those who have taken a public position - in newspapers, on television, in a speech - about the need to provide treatment for people with severe mental illnesses who are otherwise homeless, in jail, or worse. Approach them with information about your coalition and your goals. You may be surprised at what happens.

Networking allows arguments to be aired and rebutted and brings good ideas to the table that can improve the effort. A meeting of stakeholders organized by an advocate in Ocala, Florida, presented a critical networking opportunity. Many in attendance later became critical partners for reform. Opponents in the crowd offered an invaluable opportunity: educate them and change their minds, or discover their arguments and strategy.

Big meetings allow coalitions to answer broad questions and generate interest. But some of the most important networking happens one-on-one, in conversations in the hallways and on the phone. Networking is about education and clarification. People have preconceived ideas or concerns that they may not raise in a public forum - a private conversation can allow an advocate to answer such questions in detail, in a way that might be prohibited in a meeting with a tight agenda.

For instance, when we heard of a law enforcement organization’s concern that reform would increase workload, we shared the data on how much of a burden the current law presented (law enforcement handled more Baker Acts cases than burglaries in 2000) and evidence that assisted outpatient treatment reduces arrests and emergency evaluations. We also made sure that those who had heard that misinformation had those facts.

It is not enough to network only with supporters - in fact, “preaching to the choir” can leave whole groups, who may be undecided, out in the cold. Don’t miss opportunities to dispel misconceptions and convert the naysayers. The earlier the opposition’s arguments can be addressed, the better. It is important to know what you are facing, because legislators and the media will hear opponent’s arguments, and the best way to disarm them is to be prepared.

When you find a group that wishes to support the effort, get it in writing, either with a formal resolution or a letter of support. Obtaining one of these documents is often easier if you offer to draft it - busy organizations are often grateful for the help.

The key rule for networking: Do not assume. Do not assume support, even when it is verbally offered. Do not assume someone is opposed until you speak to them and have a chance to outline your arguments. And do not assume that because someone is not being vocal in opposition that they are on your side. Until you see it in writing, you still have work to do.

The path your stepping stones are building to reform can only go so far without legislative leadership - there can be no bill without sponsors. Having multiple sponsors is wonderful, but a key sponsor must take ownership of the bill to shepherd it through the process.

In Florida, we learned the importance of having the right bill sponsors. Tenacity is key - a successful effort needs a sponsor willing to fight the inevitable opposition. Bipartisan support is ideal; if that is impossible, the lead sponsor should be in the majority party. It is useful if the sponsor chairs one of the substantive committees that will hear the bill.

The legislative leadership makes back-door decisions like which bills are scheduled for hearings, which bills bypass rules, and which bills are fast-tracked, so the higher up on the leadership ladder the sponsor is, the better. In Florida, the bill never would have beat the clock without the support of the Senate President, the House Speaker, and the Governor.

In states like Florida where efforts have been successful, bill sponsors were leaders. Minnesota Rep. Mindy Greiling, a family member, and California Rep. Helen Thomson, a former psychiatric nurse, engaged in countless hours of work convincing their colleagues to support bills in their respective states.

Florida’s new law is a legacy for far too many who lost their lives and inspired change. It is not unusual to learn that the person involved in a tragedy, either as perpetrator or victim, did not think they were ill, refused treatment, and had family members who tried unsuccessfully to get help. These tragedies are concrete examples of the need for reform that people can understand and relate to.

Violent tragedies - fewer in number but disproportionately reported by the media - are the root cause of stigma against people with severe mental illnesses. Educating the media and the public that untreated mental illnesses increase the risk of violence and victimization not only helps dispel some of this stigma, but it gains public support for reforms that increase access to treatment.

People who are affected often become the most impassioned and persuasive advocates. In Florida, Sheriff Eslinger lost a deputy in a standoff with a man with untreated schizophrenia. The deputy’s wife, Linda Gregory, and the man’s sister, Alice Petree, joined with the Sheriff to advocate for the new law. This tragedy both inspired these amazing people to advocacy and inspired those who heard them speak to support reform.

Everyone wishes that laws would be changed merely because they will save lives. The statistics on the value of assisted outpatient treatment laws are stunning and should be enough to convince anyone of their import. But stories touting those statistics usually primarily highlight a tragedy the law might have prevented.

Research is key to finding and compiling data that will help make the case for reform.

In Florida, there was an unusual abundance of data about Baker Act cases. Most helpful was data illustrating how ineffective the law was for engaging people in sustained community treatment.

For example, there were 540 individuals with eight or more Baker Act emergency examinations in one 24-month period, averaging at least one every three months. This information came from raw data buried in a report - it soon became an often-cited statistic by legislators and the media.

Of course, financial arguments resonate the most with legislators and administrators. For example, we determined that in 2002, one individual alone accounted for 41 Baker Act examinations at an approximate cost of $81,000 - not including court costs, law enforcement resources, or long-term treatment. Outpatient commitment would help such recidivist patients, as it has reduced hospitalization by up to as much as 74 percent. That data was broadly available, we pulled it into a formula that was understandable - and persuasive.

It is also critical to make information and data widely available. We posted everything on the internet, at www.bakeractreform.org.

Editorials and opinion pieces in support of reform

The editorial support in Florida for Baker Act reform has been tremendous. Editorials, written by the newspaper editorial board, represent the opinion of the newspaper. As of the end of July, 12 papers - including Florida’s five biggest - have written a stunning 33 editorials in support of the bill, reaching more than 6.6 million people.

Letters and opinion pieces written by advocates and family members were also critical. They appeared in papers across the state, reaching more than 7.4 million people.

A reform effort can rise or fall on media coverage. The most important tools in working with the media are detailed information and statistics, and willing and competent spokespeople. In Florida, families across the state were willing to share their personal stories.

Every day, newspaper stories make the case for reform - from articles about hospital closings to stories of preventable tragedies. When a story like this appeared, we alerted local families in case they wanted to submit a letter to the editor. Letters make a vital difference in educating readers, but also in educating newspaper editors, who gauge interest in a subject by the number of letters received. Although all the letters sent are not printed, they do make an impact.

Educating reporters is also vital. We reached out to those who wrote about a tragedy and educated them about the reform effort. The next time they wrote, they were likely to include information about anosognosia, assisted outpatient treatment, or the Florida legislation.

Members of the media appreciate clear information, well-spoken and available interviewees, and the truth. All of those were on our side. You can see from the sidebars throughout this issue of Catalyst (in PDF) that Florida media were quite responsive.

It is impossible to overstate the importance of understanding the legislative process and rules to ensure a smooth road for a bill. Without this stepping stone, the effort cannot make it to the end of the path.

In Florida, the legislative calendar is compressed into 60 days, not much time to get a bill through. The first year, the bill did not make it through its assigned committees by the end of the session. The second year, we were smarter. The bill made it the whole way to the floor of the House where it passed 113-2, an overwhelming victory. But timing kept it from being heard on the Senate floor, so despite widespread support, the bill died. In year three, we retooled. The legislation was introduced before the first day of the session. Even with this advantage, it took every moment of the short session for victory - the full body voted for passage on the very last possible day.

In California, there was actually one instance where the Senate left for summer vacation a week early, unexpectedly leaving that bill high and dry. The lesson is to watch the calendar carefully to ensure enough time to have your bill heard in its assigned committees, and to have an alternative plan if that fails. It is a frustrating thing to see your bill derailed on a technicality.

There are many strategies to derail a bill. For instance, the terms “pilot program,” “study,” and “workgroup” are often code words meaning “let’s stall the bill.” Statistics and data (to illustrate that the benefits of assisted outpatient treatment are well established) and preventable tragedies (to show that lives lie in the balance) are essential to establish that reform shouldn’t wait.

Convincing legislators is not enough. Legislative staff often have an inordinate amount of power, particularly in states with term limits, like Florida. Staff, who often predate and postdate elected legislators, work behind the scenes and know more ways to scuttle - or help - a bill than anybody. Educating key staffers can be the smartest thing you do.

Every year Floridians are faced with an overwhelming number of tragedies brought about by the consequences of untreated mental illness. Most of the people who will be helped by Baker Act reform do not understand they are ill; all have been shuttled through our courthouses, jails, receiving facilities, and hospitals multiple times.

The Governor and legislators in both the House and the Senate embraced this humane legislation precisely because it is intended to help people who are the sickest, people who cost the state an inordinate amount of money in services, from emergency response teams to court staff to crisis treatment facilities.

Before the Governor signed this measure into law, the only option available for people with severe mental illnesses who refused treatment was inpatient commitment. Yet Florida’s remaining public psychiatric hospitals routinely carry a waiting list exceeding 100. As inpatient beds continue to dwindle and hospitals continue to close, this often means that people who are in crisis end up in the streets or in jails instead of in treatment. If an inpatient bed is not available, there are no other options.

HB 463/SB 700 will allow a judge to commit someone to receive treatment in the community. This is a powerful way to ensure that existing services are used more wisely, and that scarce resources are not exhausted by people who continually enter and exit the system without gaining stability. These services - many of which could be actually helping others - are wasted when recidivist patients continue to refuse treatment. Each time they discontinue their medication, their disease worsens, they use more services, and the cycle continues.

This is a huge problem in Florida. For instance, in one 24-month period, 540 people were evaluated under the Baker Act eight or more times. That means eight or more times they reached the point of crisis. Not only is this dangerous and unproductive, it is prohibitively expensive. For example, in 2002, Florida spent $81,000 to Baker Act one individual 41 times.

Court-ordered outpatient treatment is not only effective and cost-efficient, it is also humane. In many instances, it is the only way to help someone in the grips of disease who believes that they are not sick, but being contacted by aliens through the television. It is interesting to note that when asked retrospectively about their experience with court-ordered treatment, the majority of mental health patients agreed that it was the right decision. Far from stripping people of their liberties, court-ordered treatment can restore people to free will.

I want to thank members of the House, especially Representative Murman and Speaker Byrd, for their support of this effort and their concern for people who are struggling with these diseases. I also want to thank my cosponsors in the Senate, Senator Peaden and Senator Smith, as well as the members of that body that voted unanimously for passage. I want to thank Governor Bush and his staff for their support. And I particularly want to thank and commend Sheriff Donald Eslinger and the members of the Florida Sheriffs Association, who made this legislation their top priority. Their concern for law enforcement officers and for people with mental illnesses is inspiring.

To those who are still struggling, Baker Act reform can bring hope. I know that everyone involved, from the Department of Children and Families to the mental health facility directors, will work together to ensure that this important law is implemented quickly and used broadly to help those whose brain disease prevents them from helping themselves.

The passage of Baker Act reform is a new beginning for Florida. As we pause to commend Gov. Jeb Bush, Rep. David Simmons, Senator Durell Peaden, Senator Rod Smith, and the legislature for passing this law, we at the Florida Sheriffs Association (FSA) know that much work lies ahead to ensure that it is fully implemented and used to save lives across the state.

The reform, initiated by FSA, will make Florida’s mental health treatment law more useful and compassionate for those with severe mental illnesses who are too sick to make rational treatment decisions. By giving courts the option of involuntary outpatient placement, also known as assisted outpatient treatment, we can ensure that those who are repeatedly Baker Acted for psychiatric evaluations, hospitalized, arrested, and incarcerated can stay in treatment and avoid that cycle.

This legislation will no doubt enhance mental health intervention and treatment services that will ultimately result in improved public safety for our communities.

Baker Act reform became FSA’s top legislative priority because of tragedies, personal and professional. Six years ago, the Seminole County Sheriff’s Office lost Deputy Eugene Gregory in an encounter with a man with untreated schizophrenia. In the 13-hour standoff, two other deputies were injured and the man with untreated mental illness, Alan Singletary, was killed.

We were all in shock. Gene was a family man, with a wife and three sons, an integral member of his community, with real compassion for the people he served. Amidst our grief, the same questions kept coming up: Why did this happen? What could we do to prevent it from happening again?

Seminole County Sheriff Donald F. Eslinger led the Florida Sheriffs Association’s effort to pass Baker Act reform.

Later, I found out Alan Singletary’s family was asking the same questions. Despite the fact that he had a long history of mental illness and a prior standoff with police, the law kept him from needed treatment.

In the quest to discover a reason for such a senseless loss, the consequences of failing to treat people with severe mental illnesses became clear.

According to a recent report by Human Rights Watch, there are three times as many people with mental illnesses in U.S. prisons as in state psychiatric hospitals. The U.S. Department of Justice put the number at 16 percent. In nearly every county in Florida, the jail holds more people with serious psychiatric disorders than any local psychiatric facility. The cost of this widespread incarceration of people with mental illnesses is enormous. For example, it costs Broward County taxpayers $78 per day to house a general population inmate, but it costs $125 per day to house an inmate with a mental illness. And jail is not the place to treat someone with a brain disease - people with mental illnesses who are incarcerated have high rates of victimization, assault, and suicide.

In 2000, there were 34 percent more Baker Act cases than DUI arrests. Florida law enforcement officers initiate nearly 100 Baker Act cases each day, comparable to the number of aggravated assault arrests in 2000 and 40 percent more than the arrests for burglary.

In 1998, officers were more likely to be killed by a person with mental illness than by an assailant with a prior arrest for assaulting police or resisting arrest. Compared to the general population, people with mental illnesses killed law enforcement officers at a rate 5.5 times greater. And people with mental illnesses are killed by police at a rate nearly four times greater than the general public.

The deaths of Deputy Gregory and Alan Singletary sparked a reform movement, but amending the law eventually became FSA’s top legislative priority because of what we see every day on the job. Officers initiate Baker Act emergency evaluations for people who have been Baker Acted before, and will likely be Baker Acted again. There is no resolution to the person’s pain and each call to their home increases the risk of a deadly encounter, as symptoms of their disease become more severe.

We are not mental health professionals. Despite important tools like crisis intervention training and the availability of less lethal weapons like Tasers, until now, Florida’s mental health treatment law prohibited the most important tool - a way to keep crises from escalating to the point where intervention techniques needed to be used. If someone didn’t qualify for one of the dwindling inpatient beds in a psychiatric facility, they were released. There was no way to ensure that after they were stabilized they would continue treatment. For far too many, that meant repeated trips in squad cars, repeated 911 calls from families desperate for help, repeated episodes of homelessness, repeated suicide threats, and repeated encounters with law enforcement.

Baker Act reform will give Florida access to an option already available in 41 other states. After six months in a similar program in New York, 63 percent fewer people experienced psychiatric hospitalizations; 75 percent fewer were arrested; 69 percent fewer were incarcerated; and 55 percent fewer experienced homelessness. These outcomes reduce unnecessary contact between law enforcement and people with severe mental illnesses and improve the outcomes for people who need treatment.

July 8, 1998, was a terrible day in Seminole County. But it is just one of many terrible days across Florida, before and since, that can be traced to people not getting treatment. We are pleased that this important law will be implemented in January and look forward to the day when people with mental illnesses can be assisted instead of arrested.

Regular readers of Catalyst know that we usually reserve this space to thank the people and organizations who make honorary or memorial donations. We are immensely grateful to those who choose to support the Treatment Advocacy Center’s mission. Your generous contributions allow us to continue our mission and are to be credited for this huge victory in Florida. Your names will appear in our next regular issue. For this special edition, we wanted to hear from some Florida stakeholders who recognize the benefit of this reform. We thank them and the many others across the country who recognize the benefits of and are willing to fight for treatment for those who do not know they need it.

GUARDIAN ADVOCATE: “As guardian advocates, we are pleased that the reform can provide more continuity for patients. It will be a tremendous benefit for guardian advocates to be able to continue supporting patients who are released from the hospital to involuntary outpatient placement. We wish this could have come sooner to prevent other tragedies, but are relieved that it will be there for others to benefit.” Bill and DiAnn Singletary, Ormond Beach.

FAMILY MEMBER AND ADVOCATE: “The option for court-ordered outpatient treatment can benefit the people with severe mental illnesses who suffer from lack of insight (anosognosia) and are not aware of their illness. This will help those who, because they do not think they are sick, refuse voluntary community-based services no matter how good they are.” Rachel Diaz, Miami.

SERVICE PROVIDER: “Assisted treatment provides for early intervention to prevent a crisis, and, better still, empowers people with mental illnesses to take control of their symptoms and their lives. Having that legal avenue available in Florida can only serve the good of the people we serve, their families, and the community.” Wayne Dreggors, President of Act Corporation and Chair of the Florida Council for Community Mental Health, Daytona Beach.

ASSISTED LIVING PROVIDER: “Some consider homelessness the least restrictive option available for people with severe mental illnesses; I believe it is the most restrictive... There are about 8,500 people living in the 623 limited mental health assisted living facilities in Florida. For those consumers living in the community who are most impaired by their illnesses, this reform will have a substantial, beneficial impact. Court-ordered outpatient treatment is a less restrictive alternative than has otherwise been available.” Doug Adkins, Dayspring Village, Hilliard.

STATE ATTORNEY: “Assistant State Attorney Angela Dixon says [Baker Act reform] is a big step forward. ‘We can’t hold them any longer so they’re released. This new law will allow us to ask the court to involuntarily commit them into outpatient.’ ” First Coast News, July 28, 2004.

NAMI FLORIDA: “The one thing NAMI Florida members could agree on about Baker Act reform is the provision for the court to allow relevant testimony from family members and friends about prior history and how it relates to a person’s current condition. Often times, family members and friends can provide meaningful first-hand information that should be considered in determining a loved one’s need for treatment.” Mike Mathes, president, NAMI Florida.

LAW ENFORCEMENT: “As a mental-health advocate the last three years of my career in law enforcement and corrections, I came into contact with hundreds of people with severe mental illnesses and their family members who welcome the proposed changes in Florida’s mental health laws. As a member of the criminal-justice community for 30 years, I have seen firsthand the effect that untreated mental illness has on the system and the community.” Larry Bacon, corrections consultant, Winter Park.

The answers to some basic questions about Florida’s new law follow. Much more information can be found at www.bakeractreform.org.

Live in Florida? This is good information to share with your local service provider.

Current law states that a mental health professional, law enforcement officer, or judge who issues an ex parte order can initiate an involuntary examination only when a person meets the following criteria:

[I]f there is reason to believe that he or she is mentally ill and because of his or her mental illness:

(a) 1. The person has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; or

2. The person is unable to determine for himself or herself whether the examination is necessary; and

(b) 1. Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services; or

2. There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior.

After the involuntary examination, if the person does not meet the criteria for involuntary inpatient treatment, he or she must be discharged from the receiving facility. If the person needs treatment and meets the criteria for involuntary inpatient placement, a petition can be filed with the court. The court holds a hearing; if it determines the person meets the criteria for involuntary inpatient placement, it can order treatment for up to six months.

The reform does not change the existing procedure for involuntary examinations. Right now, after an involuntary examination, if a person needs involuntary treatment, a petition can be filed for involuntary inpatient placement. The reform creates a new, less restrictive treatment alternative - involuntary outpatient placement. If, after an involuntary examination or a period of inpatient placement, a person is determined to need involuntary treatment in the community, a petition can be filed for involuntary outpatient placement. The court then holds a hearing and, if it determines that the person meets the nine-part criteria for involuntary outpatient placement, can order treatment for up to six months. This alternative will be available January 1, 2005.

IOP is a court order that mandates a treatment plan to be followed on an outpatient basis. In other states, it is sometimes called “assisted outpatient treatment” or “outpatient commitment.” Since the mid-1980s, Florida and 41 other states have adopted similar laws.

The IOP criteria applies only to those who have a history of noncompliance with prescribed treatment, combined with either repeated Baker Act admissions or serious violence - a small subgroup of the people who meet existing criteria for involuntary examination. A person can be considered for IOP only if all nine parts of the criteria are met:

(d) The person has a history of lack of compliance with treatment for mental illness;

1. At least twice within the immediately preceding 36 months been involuntarily admitted to a receiving facility or treatment facility as defined in s. 394.455, or has received mental health services in a forensic or correctional facility. The 36-month period does not include any period during which the person was admitted or incarcerated; or

2. Engaged in one or more acts of serious violent behavior toward self or others, or attempts at serious bodily harm to himself or herself or others, within the preceding 36 months;

(f) The person is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment plan and either he or she has refused voluntary placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment or he or she is unable to determine for himself or herself whether placement is necessary;

(g) In view of the person’s treatment history and current behavior, the person is in need of involuntary outpatient placement in order to prevent a relapse or deterioration that would be likely to result in serious bodily harm to himself or herself or others, or a substantial harm to his or her well-being as set forth in s. 394.463(1);

(h) It is likely that the person will benefit from involuntary outpatient placement; and

(i) All available less restrictive alternatives that would offer an opportunity for improvement of his or her condition have been judged to be inappropriate or unavailable.

A receiving facility administrator or a treatment facility administrator. A receiving facility administrator may file a petition for IOP if a person is examined at a receiving facility and is determined to meet the nine-part IOP criteria. A treatment facility administrator may initiate a petition for IOP if a person is at a treatment facility (i.e., a state hospital) and no longer needs inpatient placement, but could benefit from involuntary outpatient placement, and is determined to meet the nine-part IOP criteria. The petition is filed in circuit court and must include a proposed treatment plan for the individual, along with a certification from the community service provider that the services in the individual’s proposed treatment plan are available. If the services in the individual’s proposed treatment plan are not available, the petition cannot be filed.

The court shall allow testimony from individuals, including family members, deemed by the court to be relevant under state law, regarding the person’s prior history and how that prior history relates to the person’s current condition.

The patient may be brought to a receiving facility, to determine whether involuntary outpatient placement is still the least restrictive treatment alternative, if: in the clinical judgment of a physician, the patient has failed or has refused to comply with the treatment ordered by the court, efforts were made to solicit compliance, and the patient may meet the criteria for involuntary examination.

The reform maintains all safeguards that exist in the current law and provides some new patient protections: before IOP can be ordered, a nine-part criteria that applies to a very small, but specific group of people must be met; the patient is involved in creating the proposed treatment plan; an IOP order can be issued only if the recommended treatment services for the individual are available; the patient gets legal representation at the IOP hearing; and individuals with IOP orders are covered by the patient’s bill of rights.

In July 1998 in Sanford, Florida, Alan Singletary, 43, a man with untreated schizophrenia, killed Deputy Eugene Gregory during a landlord-tenant dispute that evolved into a 13-hour standoff between Singletary, Seminole sheriff's deputies, and SWAT team members. Singletary wounded two other law enforcement officers before being killed himself during the ensuing gunbattle.

Alan Singletary's family tried for years to get Alan help for paranoid schizophrenia, but were not successful. Alan’s sister, Alice Petree, is now an advocate for better treatment laws. “If we could have gotten him the help he needed, he and Deputy Gregory might be with us today,” she said.

Deputy Eugene Gregory’s widow, Linda, was instrumental in getting Baker Act reform passed. “We want other families to be able to get help for the people they love, before disaster strikes,” she said. Gene was a loving husband to Linda for 34 years and father to three sons who all work for sheriff’s offices.

The Treatment Advocacy Center does not accept funding from pharmaceutical companies or entities involved in the sale, marketing, or distribution of such products.

Without individual donors, TAC would not be able to support legislative efforts like the successful one in Florida described in this special edition of Catalyst. Your generous support enables us to build coalitions, create and implement media campaigns, and support legislation.

TAC's successes in states like Florida are only possible because of continued support from friends like you. Please consider a special donation today, perhaps in memory of someone lost to a severe mental illness, in honor of a strong advocate like Florida Sheriff Donald Eslinger, or in honor of your loved one who is surviving with a severe mental illness.

The battle for implementation is underway in Florida and across the nation - with your support, we can win.

Catalyst is a quarterly newsletter published as a public service by the Treatment Advocacy Center.

Board of Directors
E. Fuller Torrey, M.D., President
Fred Frese, Ph.D., Secretary
James Copple, Treasurer
Judge James D. Cayce
Ray Coleman
Thomas N. Faust
Carla Jacobs
D. J. Jaffe
Kenneth Kress, J.D., Ph.D.
Gerald Tarutis, Esq.

The Treatment Advocacy Center (TAC) is a national nonprofit organization dedicated to eliminating legal and clinical barriers to timely and humane treatment for millions of Americans with severe brain disorders who are not receiving appropriate medical care.

Since 1998, the Treatment Advocacy Center has served as a catalyst to achieve proper balance in judicial and legislative decisions that affect the lives of people with serious brain disorders. TAC works on the national, state, and local levels to decrease homelessness, incarceration, suicide, victimization, violence and other devastating consequences caused by lack of treatment.

The Treatment Advocacy Center is funded by individual donations and The Stanley Foundation. TAC does not accept funding from pharmaceutical companies or entities involved in the sale, marketing or distribution of such products.

Catalyst is a free quarterly hardcopy newsletter. TAC also produces a free weekly news roundup, sent via email to subscribers. To subscribe, send us an email or complete an online form.

Content in this newsletter may be reproduced for single use, or by nonprofit organizations for educational purposes only, if correct attribution is made to the Treatment Advocacy Center. To obtain multiple copies for distribution at a conference or meeting, visit our web site to print out a version in PDF, or call us at 703 294 6001.