3 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

I would like to begin by saying that although I have paranoid schizophrenia, and am also a recovering alcoholic and drug addict, I do not blame anyone. It was not the case, but I could have come from the nicest, most normal family in the world, and given my genetic makeup, and then my experiences, I would have still needed psychiatric, and 12-Step help. I thank God that both are available today.

I was born on August 31, 1961. Until I was around five or six years of age, I was sexually abused by some sick individuals who also took it upon themselves to give me drugs, alcohol and cigarettes. I knew that I did not like the abuse, but that I did like the "buzz" of the intoxicants. Therefore, today I believe that even then, I was an alcoholic and addict. I have learned that a hallmark trait of the alcoholic is the idea that, "I want what I want, when I want it," and that was me.

When I was in my early teens, I began to abuse alcohol and drugs of my own volition. I also felt different, but do not know if this was the onset of my mental illness. I smoked a lot of marijuana, which can make one paranoid, and can "kick in" the symptoms, but I had slowed down the usage before my first episode.

In 1985, I had lost my license to drive and therefore my job; and in addition, my family had moved to Taylor, Michigan. I began to isolate, and got very paranoid. I felt that evil people were going to kill me so I decided to kill myself. After an unsuccessful attempt, I was admitted to a private hospital in Ann Arbor, Michigan. I was released after only about eight days and was told to go to outpatient treatment. I did this and was for the first time put on psychotropic medication.

After about six months, I returned to work at a service station, and shortly after that I was actively using drugs and alcohol. I changed jobs a couple of times, and on Christmas of 1986, I decided to quit taking my medication, and soon thereafter, quit seeing my therapists. I was to learn that I had a total lack of insight into my illness.

By March of 1987, I was for the first time experiencing hallucinations in the form of hearing a voice. My boss told me to go home in early April and get some help, as he was aware that I suffered from some type of mental illness. My parents came to take me to their home in Toledo, Ohio, after a hospital in Michigan gave me a prescription and sent me home.

As morning broke on April 29, 1987, the soothing sound of a train's whistle was intoxicating, only to be shattered by a voice screaming profane obscenities and commanding me to kill my parents. (Only I heard the voice because, as I was to learn, it was a command hallucination). I had no insight into this nor any other aspect of my mental illness. In fact, a classic symptom is that I had stopped taking my meds by choice, and felt no need to start taking them again. Today this is not an issue because I receive an injection of prolyxin.

I did kill my father and was first sent to jail and then to what was then called Dayton Forensic Hospital. Later, after being found not guilty by reason of insanity, I was sent to a civil mental hospital in Toledo.

There, I usually received more than adequate care by mostly outstanding staff. I worked at a job in the hospital's commissary as part of my therapy. The pastoral care staff went above and beyond the call of duty. Subsequently, I found 12-Step recovery to treat my drug and alcohol addiction, and as of this writing have over 11 years of continuous sobriety.

I was released briefly in 1989, but I had a setback and was re-hospitalized. However, I have been out of the hospital on a conditional release since 1991, without any altercations with the law.

My act of violence in 1987 could not go unanswered but the state of Ohio saw fit to place me in its mental health system as opposed to its criminal justice system. As a result of this decision, and although I am still under court supervision, I receive comprehensive treatment and live in the community. (In fact, I live in the home of one of the Chaplains by whom I was befriended).

Today, I drive, do volunteer work, go to 12-Step meetings, and plan to return to college. In addition, I am an amateur writer and I am going to take music lessons—all by the grace of God, good meds, some caring people and persistent footwork. Thank you for reading my story.

Once again passionately championed by sponsor Assemblywoman Helen Thomson, California's proposed reform of its treatment prohibitive Lanterman-Petris-Short Act was approved by the Assembly Judiciary Committee by a 10-5 margin. California is one step closer to having laws that reflect that those too sick to make rational treatment decisions must be helped—not ignored.

AB1800's next stop (and hopefully the last before the Assembly floor) is the Appropriations Committee. There the fight will be not only to keep the bill alive, but also to secure as much funding for it as possible.

Although the bill faces several more tough hurdles, including general votes on the Assembly and Senate floors, we believe it can succeed. This faith comes foremost from the dedication of the members of the California Treatment Advocacy Coalition (CTAC). The Treatment Advocacy Center is providing informational, advisory, and logistical support to CTAC, but any contribution we have made barely compares to the momentous efforts of CTAC's members and especially its two coordinators: Carla Jacobs and Randall Hagar.

We also have hope because it seems that more than just those Californians typically interested in mental health issues are rising to the call for rational treatment laws. Among the dozens of individuals, organizations, and public officials already officially declaring support for AB1800 are: ACLU Members for LPS Reform; American Association of Retired Persons; American Nurses Association California; California Clients for LPS Reform; California Judges Association; California Medical Association; California Psychiatric Association; California State Sheriff's Association; Los Angeles County Board of Supervisors; Mayor of San Francisco, Willie L. Brown, Jr.; National Alliance for the Mentally Ill; National Alliance for the Mentally Ill - California; National Sheriff's Association; San Francisco County Board of Supervisors; State Parole Board; Union of American Physicians and Dentists.

In a tight vote, the Iowa House of Representatives voted down a measure that would have expanded that state's use of assisted outpatient treatment as well as established a need for treatment-based standard for its use. This is a particular disappointment because the proposed legislation was among the most comprehensive, thoughtful, and innovative we have encountered.

The bill, HF 2366, was virtually single-handedly created and promoted by Ken Kress, M.A., J.D., Ph.D., who is professor of law and director of the Civil Commitment Project at the University of Iowa College of Law. Lessons learned, Professor Kress vows to return to the Capitol next year. He comments, "Let us hope our legislators realize that people with mental illness who need help should be helped, just like everyone else."

On June 24, 1999 near Hartford, Reverend Robert Lysz was bludgeoned to death in his church by Michael Oullette. Mr. Oullette, who has bipolar disorder, had a history of erratic behavior when not on medication for his condition. However, he had not taken any medications in the months before Father Lysz's death.

In the wake of this tragedy, Rev. Lysz's family, parishioners, and friends determined to take action. Representative Roger B. Michele of Bristol, whose district includes Rev. Lysz's parish, subsequently introduced a bill (SB 5699) that would establish, for the first time, assisted outpatient treatment in his state.

The bill is still being revised with the assistance of the Treatment Advocacy Center. The most recent version would allow for assisted outpatient treatment for people suffering from mental illness who have a history of medication noncompliance and associated violence and who are, without treatment, in light of their present condition, likely to again become violent.

We at the Center prefer laws that include not just a deterioration to violence criteria but also an eligibility standard based on a need for treatment combined with a lack of capacity to make informed medical decisions. Nonetheless, Representative Michele's measure would be an important victory if it establishes any type of assisted outpatient treatment program in Connecticut—one of only nine states that does not provide for some form of this proven treatment mechanism.

And still, the bill's focus on potential violence is easily understood. As Rev. Lysz's brother, Tom, explains, "My brother's death was the result of someone's violence. If someone were looking after the person who killed him, making sure he was still taking his medication, my brother might still be alive."

Relaxes the standard in existing law for assisted outpatient treatment. Allows treatment for someone who meets all the following criteria: probability of deteriorating symptoms in such person that will result in dangerousness; incapacity of such person to make an informed treatment decision; such person is likely to benefit from treatment; such person has a history of a need for treatment; such person exhibits symptoms that previously resulted in the need for treatment; and such person needs treatment to prevent deterioration of symptoms.

State Representative Mindy Greiling introduced a bold, compassionate bill (HB 3107) to reform Minnesota's outdated treatment law after a long battle trying to get much needed treatment for her son. On March 22, 2000 SB 2634 was substituted for HB 3107. The substitute bill retained provisions requiring notice to certain relatives and modifying consent provisions for minors, however, it failed to incorporate provisions for early intervention mental health treatment and the related need for treatment standard. According to the Minneapolis Start Tribune, Representative Greiling acknowledged that the reform bill was not likely to pass this session, but "that she fully intends to bring it back during next year's legislative session, and thereafter if need be."

AB 746 was sponsored by Representative Rhoades and an additional 28 representatives and senators. Even with this strong show of support and passage by the Assembly, the Wisconsin Senate let time run out on the bill. The Senate failed to pass the reform measure pursuant to Senate Joint Resolution 1, which dictated the session calendar. The bill changed current law by disallowing emergency detention under the state's relaxed need for treatment standard, the so-called "fifth standard." However, AB 746 also ensured that the standard would be effective beyond 2002 for court-ordered treatment.

House Bill 1063 was passed and signed by the Governor. It included several substantive changes to the statutes governing involuntary commitment, which family members and consumers need to understand.

Beginning on July 1, 2000, the definition of "danger to others" has been changed to say "a reasonable expectation that the person will inflict serious physical injury upon another person in the near future, due to a severe mental illness, as evidenced by the person's treatment history and the person's recent acts or omissions which constitute a danger of serious physical injury for another individual. Such acts may include a recently expressed threat if the threat is such that, if considered in the light of its context or in light of the person's recent previous acts or omissions, it is substantially supportive of an expectation that the threat will be carried out."

The definition of "danger to self" will be: "A reasonable expectation as evidenced by the person's treatment history and the person's recent acts or omissions which ... (continues much the same as in the "danger to others" definition; and continues in part (b) "...as evidenced by the person's treatment history and the person's recent acts or omissions which demonstrate an inability to provide for some basic human needs such as food, clothing, shelter, essential medical care, or personal safety, or by arrests for criminal behavior which occur as a result of the worsening of the person's severe mental illness."

"Essential medical care" is defined as "care, that in its absence, a person cannot improve or a person's condition may deteriorate, or the person may improve but only at a significantly slower rate."

The statute concerning the process for completing a petition for involuntary commitment, and the procedure which is described, include a change, which states that, "The state's attorney, or other person designated by the board of county commissioners, shall assist the petitioner in completing the petition." Since in the law, the word "shall" is determined to mean "must" there are two opinions (at least) about what that means. One interpretation is that it means they must if the help is needed. Another interpretation is that the designated person must be involved in the completion of the petition. We will have to wait and see what happens with that.

Another change was made in the "notification of next of kin upon discharge from the hospital" portion of the law where it now will read, "Upon obtaining consent to release information, reasonable attempts shall also be made to notify the person's next of kin. If the treating psychiatrist determines the person lacks the capacity to provide consent, the Human Services Center shall make reasonable attempts to notify the person's next of kin as to admission, or commitment to, or discharge from the Human Services Center, unless such notification is determined by the treating psychiatrist, with the input of the person's treatment team, to be detrimental to the person."

The APA Subcommittee on Mandatory Outpatient Treatment has become the latest group to recognize the ability of assisted outpatient treatment to benefit individuals with serious mental illness and prevent some of them from needlessly deteriorating. A report approved by the APA Board of Trustees in December 1999 starts with the following words:

"Mandatory outpatient treatment refers to court-ordered outpatient treatment for patients who suffer from severe mental illness and who are unlikely to be compliant with such treatment without a court order. Mandatory outpatient treatment is a preventative treatment for those who do not presently meet the criteria for inpatient commitment. It should be used for patients who need treatment in order to prevent relapse or deterioration that would predictably lead to their meeting the inpatient commitment criteria in the foreseeable future." (American Psychiatric Association Resource Document on Mandatory Outpatient Treatment.)

The entire report was issued in January/February 2000 as an APA State Update and contains an excellent review of the important research to date. The report makes 11 specific recommendations, which are intended to guide state psychiatric associations in developing their own legislation.

The APA Subcommittee had previously endorsed limited use of assisted outpatient treatment in 1987, but this report relies on new research and is much more conclusive. In addition, it overturns the 1987 recommendation that assisted outpatient treatment only be reserved for those who lack the capacity to make medical decisions. The new recommendations suggest that assisted outpatient treatment could be beneficial to individuals who meet the following criteria:

1. The person is suffering from a severe mental disorder (an illness, disease, organic brain disorder, other condition that (a) substantially impairs the person's thoughts, perception of reality, emotional process, or judgment, or (b) substantially impairs behavior as manifested by recent disturbed behavior); and

2. In view of the person's treatment history, the person now needs treatment in order to prevent a relapse or severe deterioration that would predictably result in the person (becoming a danger to himself or others or becoming substantially unable to care for him or herself in the foreseeable future) (Meeting the state's inpatient commitment criteria in the foreseeable future); and

3. As a result of the person's mental disorder, he or she is unlikely to seek or comply with needed treatment unless the court enters an order for mandatory outpatient treatment; and

4. The person has been hospitalized for treatment of a severe mental disorder within the previous two years and has failed to comply on more than one occasion with the prescribed course of treatment outside the hospital; and

5. An acceptable treatment plan has been prepared which includes specific conditions with which the patient is expected to comply; together with a detailed plan for reviewing the patient's medical status and for monitoring his or her compliance with the required conditions of treatment; and

6. There is a reasonable prospect that the patient's disorder will respond to the treatment proposed in the treatment plan if the patient complies with the treatment requirements specified in the court's order; and

7. The physician or treatment facility, which is to be responsible for the patient's treatment under the commitment order, has agreed to accept the patient and has endorsed the treatment plan.

In developing these criteria, the APA Subcommittee incorporates approaches adopted in New York's Kendra's Law, which the Treatment Advocacy Center (TAC) was very involved in developing. We are delighted that the APA Task Force developed a scheme consistent with TAC’s approach in such a substantive way. Our own approach was modeled on that endorsed by NAMI in 1995, and is incorporated in TAC’s model law, which will be introduced at the NAMI Convention.

With this report, the APA joins NAMI, TAC, and many other groups concerned about the seriously mentally ill, in recognizing that assisted outpatient treatment can be a useful tool to help some individuals with severe mental illness live safely and productively in the community.

For a copy of the entire report, which is highly recommended, contact your state APA or Katherine Becker, APA Office of Government Relations, at (202) 682-6321.

Often frustrated by a confusing legal system that seems more intent on releasing the mentally ill to fend for themselves than on treating people who are sick and desperately in need of medical care, family members in Fairfax County, Virginia find relief when their request for psychiatric treatment for their loved ones is championed by a George Mason University law student. Student attorneys bring balance to civil commitment hearings and ensure that petitioners' concerns for, realistic fears of, and evidence about the mentally ill person are properly before the Court.

In Virginia, a mentally ill person who is resisting treatment receives a court-appointed defense attorney to assist him. However, the petitioner, who is almost always a private citizen with no legal training, usually must represent himself, attempting to introduce evidence, produce testimony, respond to objections, and argue points of law. As a result, family members, neighbors, and friends of the mentally ill patient struggle to obtain assistance for the patient. By having students with third-year practice certificates represent these petitioners under the supervision of an experienced trial attorney, the Clinic provides effective advocacy for the family members, and ensures that all the important information about the patient is presented to the Special Justice, who determines whether or not the patient is in need of psychiatric treatment.

The Law and Mental Illness Clinic at George Mason University School of Law provides free representation to petitioners in civil commitment hearings in Fairfax County. Having Clinic students present the cases benefits both the law students and family members of the mentally ill. While learning how to be effective trial attorneys, George Mason Clinic students are also exposed to a great variety of issues surrounding mental illness. Students enrolled in the Clinic are required to attend the classroom portion, in order to receive appropriate training. In the classroom, Clinic students learn about the areas of mental illness law pertaining to civil commitment hearings, as well as practice trial skills for participation in the hearings.

The students appear weekly at hearings held in a Fairfax County courtroom located in Mt. Vernon Hospital. Under supervision, students participate in each civil commitment hearing that occurs that morning. At least two Clinic students appear at each hearing session we attend. The Clinic has had a positive influence on civil commitment hearings in Fairfax. Previously under-utilized commitment criteria, such as inability of the patient to care for himself, are now effectively presented and argued. The judges are also more willing to listen to the patient's medical history, as Clinic students have successfully argued that when the person's mental illness follows a pattern, then that pattern is admissible to prove the seriousness of the patient's current behavior. This enables Clinic students to argue that the mentally ill person isn't just making a "lifestyle choice." Rather, he is unable to control himself or ask for help because he is sick and needs care.

Julia Gorey, a University of Maryland School of Law student who is attending George Mason this semester only because she wanted to participate in this unique program, finds the Clinic "an opportunity to get an insider's view of the problems inherent in the local commitment systems, as well as an appreciation for the families' struggles."

Indeed, while most people voice strong opinions about the commitment system, it seems that few people actually observe the proceedings or have a true sense of the experience. Graduating student Kourosh Sabet-Payman remarks that, "the Law and Mental Illness Clinic has afforded me the opportunity to gain first-hand experience with the consumers and courts of Virginia. The Clinic has provided me with great insight into the lives of the mentally ill patients and has dispelled any stereotypes that I may have had about mentally ill patients."

Clients represented by Clinic students encompass various races, ethnic groups, and socio-economic backgrounds. Regardless of the petitioners' backgrounds, most aren't prepared for the judicial proceeding awaiting them at 7:00 a.m. when they arrive at the hospital. Most only expect to relate background information, and are startled and confused by the formal hearing proceedings. This challenges Clinic students to communicate complex information across cultural and language barriers. Interpreters utilized by the Clinic include Arabic, Farsi, Japanese, Spanish, Vietnamese, and sign language.

In addition to helping family members of mentally ill individuals and learning about civil commitment laws, the chance to be "real lawyers," by calling witnesses and making legal argument, greatly enhances the students' education. Current student Anne Corbin feels that, "this Clinic has provided me a great and rare opportunity to participate in actual cases. Practicing advocacy skills is a rare event in law school, and I am grateful this law school has the Law and Mental Illness Clinic."

Petitioners express great satisfaction with Clinic representation. One mother, who had been unsuccessful on previous attempts to have her son with schizophrenia committed, wrote a letter in which she said that the student, Jillian Cass, "did an outstanding job of asking the right questions, bringing up the salient points of the case, and countering the questions and points the court's appointed lawyer was trying to make on my son's behalf. Ms. Davoli ensured the focus of Ms. Cass' questions and inquiry. She seemed very experienced in handing this type of case. Their support made ALL the difference in my fight to get my son help for his illness." [Reprinted with permission from the author.]

Clinic students daily witness the relief and gratitude felt by the family members when their cases are effectively presented to the court. Another Clinic student, Liz Homoki, adds that student representation "helps balance the scales of justice for the families and patients."

For more information about the Clinic, please contact the Director of the Law and Mental Illness Clinic, Joanmarie I. Davoli, at George Mason University School of Law, 3401 North Fairfax Drive, Arlington, Virginia, 22201. Office: (703) 993-8214. Fax: (703) 993-8202. E-mail: [email protected].