28Xavier F. Amador, Awareness of Illness in Schizophrenia, 17 Schizophrenia Bulletin 113 (1991); S.N. Ghaemi, Insight and Psychiatric Disorders: A Review of the Literature, with a Focus on its Clinical Relevance for Bipolar Disorder, 27 Psychiatric Annals 782 (1997).

People were interested in Workshop 3B at the annual convention. People filled every seat; people were sitting four across in the aisle; people were standing three deep at the back; and, we regret, many others were turned away. Audiocassettes of workshops were on sale at the convention, and, although it was held on the last day of presentations, the tape of 3B was the first to sell out. Yes, there was interest. But why all this attention?

Strangely, the focus of 3B, presented by the Treatment Advocacy Center, was an effect of mental illness that seems obvious. Entitled, What Is It Like To Be Sick and Not Know It?, the workshop detailed from both a clinical and personal perspective how a person can be overcome by mental illness, yet be completely unaware that what they are experiencing is caused by the illness. One of the most disturbing ramifications of this effect is that people in need of help because of their illness, will at times not seek treatment because they do not believe that they are sick.

Moderator Mary Zdanowicz introduced the workshop's featured speaker, Dr. Xavier Amador, Professor of Psychology in the Psychiatry Department of Columbia's College of Physicians and Surgeons. Dr. Amador is among the foremost experts on why people with mental illness often refuse treatment despite their obvious need for it.

He and others in his field have found and documented in numerous studies, as Dr. Amador lucidly described, that a prevalent effect of mental illness is that a person can lose, or have impaired, the ability for self-assessment. This is a physiological symptom of mental illness known as anosognosia. It is akin to the results of physical trauma to certain parts of the brain. Dr. Amador convincingly showed that what are commonly termed "treatment denials" instead result from illness making a person unable to assess his or her own condition.

Following Dr. Amador were five people who have experienced anosognosia. Each spoke of how this confounding condition left him or her completely unaware of being very, very obviously sick.

Ken Kress enthralled the crowd with a wit and a speaking style worthy of a spot on the Letterman show. He told of his experiences with a long-time friend who was also bipolar. When his friend would become symptomatic, Ken would attempt to coax him into getting help, and the friend would try to do the same when Ken started to drift towards mania. But neither could ever convince the other that he was sick. Neither could break through the effects of anosognosia on the other.

Donna Orrin movingly told of her illness causing her to believe self-mutilation was her best course of action. She said, "I didn't think I was hurting myself, I just had to do it to keep them from coming in."

"I thought that my first suicide attempt [30 years before] had succeeded and that everything else in between was an illusion. I thought I was already dead," was the reason for Bernie Zuber's perilous and irrational actions at one time. Both Bernie and Donna had no idea that it was the symptoms of mental illness that were causing their worlds to convulse. Both were victims of anosognosia.

Jonathan Stanley described the worst physical pain he had ever experienced. Searing radiation, nonexistent radiation that was a product of his psychosis, caused it. He was that sick. He was also so sick that he had no idea he was ill.

Last to speak was Fred Frese, and he was as only Fred Frese can be. The room shook with laughter. He intertwined multiple, seemingly tangential points. And, when he was done, Fred had not only entertained the packed room, but had perfectly summed up and punched home the essence of the workshop's message.

Dr. Amador has just released a readable but comprehensive and helpful book on anosognosia and strategies to get treatment for those affected by it. Part of the proceeds from the book will go to NAMI. For information or to order I Am Not Sick, I Don't Need Help, visit www.vidapress.com or call 800-431-1579.

[Mr. Stanley is Assistant Director of the Center.]

The Treatment Advocacy Center set up a booth at the annual NAMI Convention in San Diego, California, June 14-17. The booth saw a steady and thick stream of interested attendees throughout the convention, including Center supporters stopping by to see what was new, people who had been recommended to the Center by a friend or a forwarded copy of Catalyst,, and newcomers interested in finding out what the organization does.

The booth provided a large selection of printed materials including copies of Catalyst, a sign-up sheet for the mailing list, copies of the Model Law and related press release, as well as articles by Dr. Torrey and Mary Zdanowicz. There were also copies of recent news media videos and the videotape of the conference at George Washington Law School. It was noted that more people seemed to pause at the booth when Dr. Torrey appeared on the screen. The video presentation led to an unexpected number of people requesting copies of other videos in the Center’s collection to use in trainings and for their own information. Since the convention, additional orders for videos have continued at a constant pace.

Several NAMI members, including Consumer Counsel members, had heard of the Center and came to learn about the organization firsthand. The vast majority of consumers who came to the booth agreed with the mission of the Center and expressed interest in learning more about the Model Law. Additionally, some asked for multiple copies of the new Model Law to send to other interested people in their state. Many newcomers took sign-up sheets for Catalyst away with them, and approximately 60 people completed the forms and left them at the table.

A number of NAMI librarians or leaders of local NAMI chapters came to order additional materials for their libraries and members. A surprising number of the NAMI members who came to the table had either seen Catalyst or were already receiving a copy through someone in their organization. Jonathon Stanley noted that, "Knowledge of us and our issues has increased greatly over the first two years we were at the convention."

Mary Zdanowicz noted that this provided one of the more comforting aspects of the convention, "I finally had an opportunity to meet so many wonderful people who I have developed a relationship with over the last two years." Jonathon Stanley and Rosanna Esposito had the same experience as supporters that they had worked with over the telephone or via e-mail came to the booth to introduce themselves.

The Center’s team also educated many Californians about AB1800, the proposed LPS Reform law and its status in the state legislature. Jonathon Stanley had prepared packets with the latest update for people who had been following the progress of the bill.

During the time prior to the Center- sponsored panels, cards were passed out with the time and location of the sessions. Many people walked away with the cards and while there is no way to tell, the advance attention may have contributed to the overwhelming turnout.

The most interesting aspect of the booth was the opportunity to hear individual stories firsthand. While the personal struggles can not all be conveyed, the idea that there are many people who appreciate the work the Center is doing and need the movement to continue came across very clearly.

[Ms. Johanson is a legal intern with the Center.]

The Treatment Advocacy Center conducted a workshop, "Introducing the Treatment Advocacy Center's Model Law for Assisted Treatment" at the NAMI Convention on Saturday, June 17th. The Center's Mary Zdanowicz, Jonathan Stanley and Rosanna Esposito presented the Model Law to the many conferees who attended this special session.

Mary Zdanowicz, Executive Director, opened the session with a look at why and how the Model Law was created. She explained that outdated state laws of the 1960s and 1970s have resulted in many of the most severely ill going without needed treatment and, in too many cases, becoming homeless, incarcerated, suicidal, victimized or prone to violent episodes. Ms. Zdanowicz stated that progressive assisted treatment laws must be crafted to reflect the significant advances that have been made in the last decade in our understanding and ability to treat severe mental illness. We now know that these conditions are treatable biological brain diseases and not lifestyle choices, as was the prevailing thought three decades ago. In drafting the Model Law, the Center solicited advice and assistance from individuals who are diagnosed with severe mental illnesses, their families, and medical and legal professionals.

Jonathan Stanley, Assistant Director, highlighted some important aspects of the Model Law and noted that it is a compilation of the most effective provisions of existing state laws. The Model Law enables treatment for those overcome by severe mental illness, who are adjudicated to be dangerous, gravely disabled or chronically disabled. The last two criteria also require that a person is either unaware that he or she is ill or is otherwise incapable of making rational decisions concerning proposed treatment. The Model Law also adopts procedures from various states that promote clinical and judicial efficiency, such as having a combined commitment and treatment proceeding. The only "new" provisions, not in state laws currently, are for the additional protection of the rights and well-being of those placed in assisted treatment.

Rosanna Esposito, Attorney, detailed the Model Law provisions for assisted outpatient treatment. If an individual meets the criteria for assisted treatment, that individual may be placed in either inpatient or outpatient care. The Model Law requires that an assisted outpatient treatment order include provisions for case management and services. Ms. Esposito also reported findings from the most recent studies that demonstrate that assisted outpatient treatment is effective in reducing hospitalization and violence.

The Model Law is now available on the Center's Web site: . To receive a hard copy of the Model Law by mail, please contact us at 703-294-6001.

[Ms. Esposito is an attorney with the Center.]

The Treatment Advocacy Center's Model Law for Assisted Treatment is a cautiously considered proposal to promote the provision of care for those who need it because of the effects of severe mental illness. At the same time, the Model Law includes numerous overlapping protections to safeguard those under court-ordered treatment and to ensure that only those for whom it is appropriate are placed or remain in assisted treatment.

The Model Law is more remarkable for what it is not than for what it is. It is not entirely revolutionary nor does it eradicate the basic constitutional protections provided by current treatment laws. There are familiar provisions for emergency treatment; a subsequent certification for a treatment hearing by an examining doctor; a more lengthy process to petition for the treatment of someone less sick; under different names, outpatient commitment and conditional discharge; periodic reviews and possible renewals of treatment orders; and a host of other mechanisms common to current laws for securing treatment for those overcome by mental illness.

A cursory examination may give the impression that the Model Law maintains the status quo, when it is actually a compilation of the most effective provisions of existing state laws. Variations of virtually all of this proposal's sections are the current law somewhere in the United States. In essence, we have combined each of the best available components into a statutory model better than any currently in effect.

Only in one area have we dared to be creative: the protection of the rights and well-being of those placed in assisted treatment. There we put forth procedures more extensive and vigilant than those now in place anywhere in the nation.

Following is a description of some of the key aspects of the Model Law.

In developing a system to place individuals in psychiatric care, the most crucial question is, "When is such an intervention appropriate?" The answer is found in the legal standard that a person must meet in order for his or her placement in treatment to be allowed under the law. The Model Law sets out four alternative criteria that, if met, justify assisted treatment.

1. Chronically disabled: Only a few states have criteria designed to help people stuck in the "revolving door" of repeated hospitalizations, symptomatic behavior, and, for many, incarcerations. "Chronically disabled" allows consideration of possible harm to a person with symptomatic mental illness in light of past psychiatric history (which would include previous non-compliance with treatment), current likelihood of treatment compliance, and the risk of deterioration without treatment. This standard is thus tailored to assist those who are stuck in the revolving door.

2. Gravely disabled: A number of states have included "gravely disabled" as grounds for treatment placement. Most of these laws define this condition as when a person becomes so incapacitated by mental illness as to lose the ability to provide for his or her basic needs, with these normally delineated as food, clothing, shelter and, sometimes, medical care. The Model Law mimics the more progressive of the jurisdictions with gravely disabled criteria by explicitly including someone who is likely to suffer significant harm without treatment.

Incapable of making an informed medical decision: While not an independent ground for treatment placement, the "gravely disabled" and "chronically disabled" criteria each also require that the person is either unaware that he or she is ill or is otherwise incapable of making rational decisions concerning proposed treatment. Non-dangerous individuals who are capable of making informed medical decisions should not be placed in assisted treatment.

3. Danger to others: Every state allows for the court-ordered treatment of individuals who because of mental illness are a significant threat to the safety of other people. The Model Law incorporates a definition of "dangerous to others" similar to that of most states, but makes clear that presenting a threat to a person in one's care, such as a child, or having caused intentional damage to the substantial property of another shall be evidence of dangerousness.

4. Danger to himself or herself: Similarly, every state allows for the assisted treatment of those who are demonstrated to be a danger to themselves, but the Model Law makes clear that a person's past related behavior shall be considered when making the determination as to whether someone meets this treatment standard.

Many provisions of existing assisted treatment laws make little sense. They delay needed treatment, are inefficient from either a judicial or clinical perspective, or are concepts from other areas of law ill tailored to assisted treatment proceedings. The Model Law adopts procedures from various states that promote both clinical and judicial efficiency.

Combined Commitment and Treatment Proceedings: Although a common practice, the disadvantages of having separate hearings on whether a person should be committed and on his or her capacity to refuse treatment are patent. Having an interval between rulings on commitment and treatment produces the inherently cruel circumstance of medical professionals having to confine a psychotic or delusional patient without being able to provide treatment. Under the Model Law, the judicial determinations about treatment placement and the ability to refuse treatment are made in the same hearing. There is no reason, either logically or constitutionally, that both decisions should not be made concurrently. To be eligible for treatment placement under the Model Law, a person must be found either incapable of making an informed medical decision or to be a danger to himself, herself, or others. Each of those conditions is a constitutionally sufficient ground to suspend an individual's right to refuse treatment. Furthermore, the adverse ramifications of any such finding are mitigated by the Model Law's specific prohibition against an assisted treatment determination impacting a person's legal rights and privileges unrelated to the provision of treatment.

Single standard: The Model Law has the same standard for the placement of individuals in both inpatient or outpatient care. Some states have established distinct outpatient and inpatient treatment placement standards. Because of the different criteria, it is difficult in these states to transfer outpatients to inpatient status, and vice versa. A person who meets a more permissive outpatient standard may not meet the more stringent inpatient criteria. As a consequence, the Constitution's Due Process Clause requires there to be a hearing to determine whether an outpatient meets the more strict standard before being transferred to inpatient status. Because the Model Law has a single standard, judicial approval is not required to change a committee's treatment program. Nonetheless, the Model Law does provide safeguards that ensure that such transfers are appropriate and the least restrictive alternative that will meet the patient's clinical needs.

Psychiatric Treatment Board: Most times, the decisions of whether or not to place a person in treatment and, if so, what type of care is most appropriate are left to a judge who has little experience with or understanding of mental illness. The Model Law's decision-maker is a judicially-empowered panel made up of a lawyer, a physician and a person who has demonstrated experience, either personally or through a close relative, with mental illness. The advantage of having a tribunal with such a depth of knowledge and variety of experience is obvious.

Treatment plans: Extensive services may be included in an assisted treatment order providing for treatment on an outpatient basis. A treatment plan is mandatory for a person being discharged from assisted treatment.

Where the Model Law does substantially depart from existing state laws is in enhancing the rights guaranteed to people with mental illness placed in assisted treatment and the rights of their families.

Family rights: Under the Model Law, relatives may, under certain circumstances, become actual parties to the assisted treatment proceeding, with the right to have counsel, present evidence, cross-examine witnesses, and appeal. When bringing a petition, family members are also eligible for the assistance of designated counsel.

Consumer rights: The Model Law has an extensive number of protections for those placed in assisted treatment. Subjects of assisted treatment petitions have the rights delineated in most state laws; i.e., to have designated counsel, to present witnesses, to appeal, to not have placement in treatment otherwise affect one's legal status, etc. Additionally, the Model Law introduces two novel procedures. Included is a formal grievance procedure whereby patients can bring complaints to the facility's medical director and, if necessary, to the Psychiatric Treatment Board. Perhaps even more significantly, the Model Law calls for the examination of a person placed on inpatient assisted treatment for medication side effects every thirty days by a psychiatrist or physician other than the one treating him or her.

[Mr. Stanley is Assistant Director of the Center].

On June 21st the Supreme Court of South Dakota upheld an appeals court decision ordering forced medication in the case of Steinkruger v. Miller, 2000 WL 815956 (S.D.), 2000 SD 83. The Supreme Court found that the South Dakota statute allowing involuntary treatment of incompetent, involuntarily committed patients (S.D. Codified Laws �27A-12-3) is constitutional, regardless of the fact that it contains no explicit least restrictive alternative requirement. Statutory language suggesting a least restrictive alternative requirement was deemed by the Court sufficient to maintain the statute's constitutionality.

DeWayne Miller is an involuntary patient at the South Dakota Human Services Center in Yankton, South Dakota. His diagnoses have ranged from schizophrenia to bipolar disorder. He holds delusions that "he can read minds, that he is pregnant, that all medications are poison" and he believes that smoking will cure his chronic obstructive pulmonary disease. The court recognized that Mr. Miller's disorder has impaired his judgment, that he lacks awareness of his illness and therefore refuses medication. His treating physician determined that psychotropic medication is the least restrictive treatment available for his condition, and that the benefits of such medication would "substantially out-weigh" any side effects.

In South Dakota a court may order forced treatment if it finds by "clear and convincing evidence" that the patient is incapable of consenting because his or her "judgment is so affected by mental illness that the [patient] lacks the capacity to make a competent, voluntary, and knowing decision" regarding medication. S.D. Codified Laws �27A-12-3.15. Psychotropic medication must be "essential," "medically beneficial" and "necessary" because the patient:

(1) "presents a danger to himself or others;"

(2) "cannot improve or his condition may deteriorate without the medication;" or

(3) "may improve without the medication but only at significantly slower rate." S.D. Codified Laws �27A-12-3.13, 12-3.15.

Mr. Miller's attorneys argued that treatment refusal statute violates substantive due process because it does not specifically require that the treatment be the least restrictive alternative. However, because the statute requires that forced medication be "essential," the Court held that this language amounts to a least restrictive alternative requirement. The Court also found that there was no treatment available for Miller that would be any less intrusive. Miller had refused to participate in the local outpatient community program IMPACT (Individualized and Mobile Program of Assertive Community Treatment).

The Court also recognized that, "South Dakota has a strong parens patriae interest in caring for mentally ill persons and psychotropics retain a vital place in mental health treatment. It would be cruel forbearance to allow incompetents to reject senselessly the medicine necessary to restore their mental health."

The case is significant beyond the obvious implications of validating the constitutionality of South Dakota's law. It is evidence that courts are becoming much more sophisticated in applying the scientific advances in our understanding of severe mental illnesses to concepts in the law. The correlation between "lack of insight caused by illness" and the legal concept of "incapacity to make an informed medical decision" is drawn in this case. The court's recognition of the State's parens patriae interest and the "cruel forbearance" not to care for those in need are particularly significant and a source of hope that the law is beginning to acknowledge the need for treatment.

[Ms. Barry is a legal intern at the Center.]

AB1800, Assemblywoman Helen Thomson's progressive legislation to reform the treatment restrictive Lanterman-Petris-Short Act, has been on a roller coaster. Riding with it have been the hopes for rational treatment laws, as well as the enormous efforts, of the members of the California Treatment Advocacy Coalition ("CTAC").

On May 24 there was victory. The Assembly Appropriations Committee unanimously voted AB1800 to that house's floor. But at the same time there was defeat, the committee cut the $350 million funding request that Assemblywoman Thomson had made part of her bill.

However, this year's California budget negotiations made the loss of the allocation far less significant than it could have been. Those involved in the budget negotiations planned on coming to a total figure for increased mental health spending. Thus, unlike last year with Kendra's Law in New York, funding designated for AB1800 would not increase the total amount spent on mental health by the state.

On May 31, AB1800 blazed through the full Assembly. Despite the late hour and being inundated with bills stacked up in the face of a legislative deadline, the entire Assembly devoted over half an hour to the bill-as much time as any legislation received all day. AB1800 passed 53-16, 77 percent of those voting favored rational treatment laws and two-thirds of the total Assembly supported the bill. This life-saving legislation seemed on the path to the Governor's desk.

But then came Senator John Burton, the Senate's President Pro Tem, majority leader, and most powerful legislator.

Perhaps it is the jerk of a civil libertarian knee in an inappropriate direction, but Senator Burton has imprisoned AB1800. The normal process is for a bill approved by the Assembly to go to a policy committee for a public hearing and the possibility of a vote on the Senate floor. Senator Burton has had his Rules Committee assign AB1800 directly to a study committee from which it cannot emerge without the Senator's permission. He is trying to stop the representatives of the people from considering this progressive measure—no consideration, no debate, no chance of a vote.

More mystifying than Senator Burton's opposition to AB1800, is why he would try to keep from the Senate a bill that has such wide and deep support. Numerous Californian newspapers and public officials as well as major civic and professional organizations throughout the state have endorsed the bill. Even San Francisco Mayor Willie Brown has enthusiastically backed this life-giving legislation. But this vital proposal is now threatened with a most undemocratic end.

But even if this year's campaign ends where it now stands, it will have been a success. The Assembly is now familiar with the need to reform LPS, almost all the newspapers have endorsed it, and CTAC has gone from nothing to hundreds united in the fight for treatment. The members of CTAC and NAMI California are attempting to educate Senator Burton, to convince him to loosen his grip on AB1800. Believing him sincere but misinformed, we hope he can be made to understand that to wait will harm thousands. But even should he remain unmoved, John Burton's procedural ploy will only prolong what we now know is inevitable. The flood of compassionate reform in California can be held back only so long.

Tuck away this year's experience in Connecticut for future reference. Just over a year ago, a person overcome by, and who had a history of non-treatment for, mental illness killed Reverend Robert Lysz near Hartford. In response, Representative Roger B. Michele introduced legislation that would allow for assisted outpatient treatment (AOT) in Connecticut, one of only nine states without it. Rep. Michele fought valiantly for his bill, and ultimately a "Father Lysz's Law" became law. It was not, however, AOT that Rep. Michele gained for Connecticut.

The new law will establish a pilot program offering intensive community support and peer-engagement specialists to individuals who have threatened to be or been violent in the last five years. This sounds similar to a Kendra's Law type program. And it is, except participation in the Connecticut version will be completely voluntary-a compromise made during the legislative process.

Yet, it is those incapable of making rational treatment decisions, unaware that they are ill, or incapable of maintaining participation in outpatient treatment that AOT is designed to help. For people willing to voluntarily select an intensive outpatient program, AOT is, most likely, unnecessary.

We are heartened that the new program will enhance Connecticut's voluntary services in a portion of the state. Hopefully, it will become a model for the infrastructure of a future AOT program. We also hope that it is, if proven effective, expanded statewide. At the same time we see that Connecticut's provisions for the assisted treatment of those most in need of help are unchanged. And we note that the law named in honor of Robert Lysz, would not have, if in effect at the time, saved his life.

Rep. Michele is undeterred by having to weaken the content of his legislation to pass through potentially fatal procedural roadblocks thrown in its path. He has sworn to come back again next year, the next, and the next,-as long as it takes to secure rational treatment laws for Connecticut. And when he returns, the Treatment Advocacy Center will stand with him.

Great news from the North! Ontario has enacted Brian's Law, a progressive law for assisted treatment.

On June 21, the province adopted a package of reforms to its Mental Health Act. Among these, it has added need-for-treatment criteria and community treatment orders, the Canadian version of assisted outpatient treatment.

We are impressed by and even somewhat envious of our Canadian counterparts behind this victory for all those denied treatment by unthinking laws. The measure steamed through the Ontario Parliament by an astounding margin of 82-10.

The Treatment Advocacy Center supplied informational and advisory help to the proponents of Brian's Law, but can take little credit for its passage. That goes entirely to the determined Ontario advocates behind the measure. We thank and congratulate them. They have saved lives.

The news of this grand success evokes thought that while the laws of countries differ greatly, the problems caused by untreated mental illness are international. One of Brian's Law's architects stated, "What it does is it allows us to provide early intervention for people who are a danger to themselves or a danger to others."

Sound familiar?