Recently, half the patients on the dual-diagnosis unit at Sheppard Pratt were homeless. Even if staff could begin meaningful treatment in the three to four days their managed care companies allowed, it was clear that discharge would lead to readmission in the near future. It is becoming alarmingly apparent that as inpatient care wanes, vigorous outpatient treatment must take its place. But how will this work for those patients who do not take their medications or defy therapeutic efforts? They, too, stay a shorter time in the hospital. The revolving door of hospitalization for mental illness has already become a huge turnstile, disgorging mental patients onto the street or into jails. What is to be done?

One solution is that of involuntary outpatient treatment. Thus, a paranoid schizophrenic with a history of multiple rehospitalizations for dangerousness will be informed by authorities that he must comply with outpatient treatment and take his medication or he will be detained against his will. A welfare recipient with substance abuse will be told that he must submit to urine testing and therapy or face the cut-off of his welfare benefits. And an attorney is warned that she must have treatment for alcoholism or suffer the loss of her license to practice law. These, and other constraints on the freedoms of patients, already comprise the elements of mandatory therapy in such states as Massachusetts and Washington. Yet society remains troubled by coercive treatment. Legislatures are loath to impose such regulations on constituencies. Ironically, it is the patient advocacy groups such as NAMI who press for coercive treatments even more than victims of crimes such as pedophilia.

Historically, most of the seriously mentally ill in Western society have been confined to institutions against their will. Fear of violence — to self or others —especially from delusional individuals, or those behaving erratically, has traditionally justified the concept of involuntary hospitalization. But in recent decades, the civil rights of those very mentally ill have triumphed. These victories have led to grave deficiencies in treatment as patients are released from the hospital prematurely. Paralleling this phenomenon is the very essence of hospitalization, an event which has changed dramatically with managed care. Patients are now admitted not simply because they are ill, but because they are dangerous. The criteria for retention within the hospital is continued risk, but nothing more. Thus after a few days of what is called "crisis stabilization," the patient's insurance is halted and he is put out, or in severe cases, transferred to a state hospital. There, too, stays are shortened. Fashioning itself like the private counterpart, the public sector has eliminated any semblance of refuge. Once functioning as a community haven for the ill, state hospitals are barren real estate with boarded up units, empty recreation halls, and vending machines instead of kitchens.

The psychopharmacologic treatment of severe mental illness has had a paradoxically contributing effect to abrupt hospital stays. Rather than augmenting care, drug treatment has counter-intuitively undercut it by effecting acute symptomatic relief at the price of long-term treatment. Patients are rapidly medicated, then released as if the core illness was abolished. The truth is otherwise. Core illness takes great time to effect and requires the full range of individual and social therapies. But few hospitals have full-time art or occupational therapists on their staffs any more. Psychosocial therapies are seen as luxuries, not necessities. Leaves of absence to test improvement are no longer allowed.

Discharge without adequate treatment has created a vast new set of problems. In the last four decades, hundreds of thousands of patients have been deinstitutionalized. Some have managed well with supporting housing, rehabilitation, and community outpatient settings. But for others, the return to the community is a phantom concept. Many have gone from the hospital to the street, and from the street to jail. As long ago as 1939, Penrose demonstrated a negative correlation between the portion of people in a given nation placed in mental hospitals and the portion held in jail. In 1999 the Department of Justice reported that as much as 16 percent of the population of state jails and prisons suffer from several mental illnesses. This translates to more than 250,000 individuals. Housing 3,500 and 2,800 mentally ill inmates respectively, the Los Angeles County Jail and New York Riker's Island Jail are currently the two largest psychiatric inpatient treatment facilities in the country. This warehousing of the mentally ill in jails and prisons harkens back to the deplorable conditions in the nineteenth century, which prompted Dorothea Dix and the Quakers, who founded Sheppard Pratt in Baltimore, to develop asylum care.

We have, then, expanding populations of partially-treated, severely ill patients flowing into our communities. In 1995, Torrey and Kaplan estimated that 250,000 individuals were living in the community, who just a few decades before would have been patients in state psychiatric hospitals. Yet we know full well that an episode of mental illness may last many months, if not years. What, then, is the recourse for patients who need help to remain functional?

As of today, 40 states and the District of Columbia have outpatient commitment statutes, although most of these states implement this authority in a haphazard and inconsistent manner. Generally, some form of tragedy has spawned the creation of an outpatient law; for instance, the case of Andrew Goldstein who pushed Kendra Webdale onto the subway tracks in New York ultimately led to the passage of "Kendra's Law" establishing mandatory outpatient treatment in New York. But this is a drastic case. Are less extreme cases eligible for coercive treatment?

I believe we have little choice in the matter if we are to meaningfully treat the mental patients in our country. Doing something to someone else for "their own good" is fraught with ethical and moral dangers. To insure a democracy, there must be checks and balances, rights to hearings, advocates, and judges. I call for a "caring coercion." I believe rather than abandon our mentally ill, we can thoughtfully attempt to treat them outside the hospital.

Day and partial care facilities can be constructed. The hospital milieu — once a haven of healing — will need to be resurrected in spaces once bordered by locked doors and shatter-proof windows. And novelty and innovation will be requisite; simple legislation is not enough.

In November of last year, President Clinton signed a bill that authorized funding of up to 100 mental health courts for nonviolent offenders who are mentally ill. Building on models from Broward County, Florida, and King County, Washington, this initiative would have special judges hear cases involving persons with mental illness who committed nonviolent crimes. These judges would decide whether the offender should be placed in outpatient or inpatient treatment programs to be monitored closely.

Simultaneously, grants also will be awarded to local governments to set up the training of law enforcement officials and judiciary personnel to identify and address the unique needs of mentally ill offenders. These alternatives, though far superior to simple incarceration, still await meaningful implementation.

Most community mental health centers are not equipped to handle mentally ill offenders. There must exist all those techniques and modalities which would be available within a hospital. This is hardly a casual undertaking. The coercion must be a caring one insofar as there is present a panoply of services—a full hospital without walls. If we can erect such institutions, we can begin to erase the shame of our untreated mentally ill.

Steven S. Sharfstein, M.D. is President & Chief Executive Officer of Sheppard Pratt Health System. [Reprinted by permission from Sheppard Pratt Health System's New Psychiatric Review, March, 2001.]

Society has much misinformation and misunderstanding of those with mental illnesses, which has lead to prejudice and discrimination. Attorneys and judges rarely receive any training about mental illnesses in their legal studies. When a mental diagnosis is related to a legal matter, a person with a disorder, more often than not, cannot find an attorney who is familiar with his or her illness. Instead, the lawyer may have this same distrust and stereotypical attitudes as does much of the population. How can there be justice for the millions of Americans with mental illnesses, if their own lawyers doubt their credibility and may presume they are unfit for employment or parenting, and do not deserve to be treated normally, because of a mental diagnosis?

I understand this problem all too well. In 1988 I was diagnosed with a manic-depressive episode. I have been unjustly treated in employment, medical insurance, and in the family law courts. For the gory details, you will have to wait for the book, or until Lifetime — Television for Women discovers my incredible story.

Meanwhile, I have launched my personal campaign to see that all lawyers, all judges, and all school children in Kindergarten through Grade 12, learn basic facts about mental illnesses. When this happens, we will have a much safer and healthier world, and justice will be restored to millions of Americans.

I successfully persuaded the Florida Supreme Court to see that the mentally ill can find lawyers who have had some training in mental illness. On February 8, 2001, Mental Illness Awareness was added to the mandatory continuing legal education (CLE) program of the Florida Bar.

I have accomplished a major first step, but advocates like you will have to carry this work nationwide. Every bar association has some means of changing bar rules. This is often through the recommendation of a committee or group within the bar. Florida also allows a petition, signed by 50 members, to be presented to the Florida Bar and then be reviewed by the Florida Supreme Court for a final decision.

My petition stated that Florida's Rules labeled it "misconduct" for a lawyer to discriminate against someone because of a "disability," even if it were through "callous indifference." The argument was made that discrimination based upon a lack of education about the mentally ill amounted to misconduct. Before the June 1998 annual bar meeting, I wrote persuasive letters to each bar section, telling the leader how important this rule change was and giving them basic mental illness facts as to symptoms, frequency in the population, and examples of injustice. At the convention, I made brief presentations at several committee meetings and at the Council of Sections meetings, composed of all committee or section leaders. Many of the leaders I had written, and others, signed the petition, showing support from all areas of the bar.

Before the midyear bar meeting in January of 1999, an attorney, whose son has schizophrenia, and I addressed the Board of Legal Specialization and Education. While supporting the basic education, the BLSE proposed it as an elective course. They feared opening the floodgates and having many groups petition for inclusion. They also suggested removing "substance abuse" from the mandatory category and placing it back in the elective area.

By the May 1999 Florida Bar Board of Governors meeting, I had rallied the assistance of Florida's NAMI (National Alliance for the Mentally Ill), National Depressive & Manic-Depressive Association groups, and Mental Health Association leaders, asking them to contact specific Board of Governors members in their local areas and talk to them about the plight of the mentally ill. I had learned of key bar members who had family members with mental illnesses, and had enlisted their help in writing and calling the Board. I even wrote the Governor — whose attorney sent the Board a letter noting the Governor's support. I also wrote his mother, Barbara Bush — who had acknowledged personal encounters with the common illness of depression.

Hard work, personal contacts, political helpers, and prayers paid off. The Board of Governors voted unanimously (50 to 0) to support mandatory CLE in Mental Illness Awareness. Board member after board member spoke eloquently in support, telling stories of attorney suicides and career destruction that could have been prevented. I got goose bumps and fought back tears. They understood. They wanted to help. It was thrilling.

From May 1999 to February 2001 I waited. Patience is not the strong suit of a high energy bipolar. The wheels of justice turn ever so slowly — and then we had a presidential election and all those chads. But, finally, on a day that I happened to be in Tallahassee, our capitol, for a mental illness advocacy campaign, I dropped in again to the Florida Supreme Court and was directed to the clerk's office. "You mean these Rule changes," the assistant said holding up a phone book size summary of the 2000 Rule changes. I anxiously flipped through to the proper Rule number and then began saying, "Yes, Yes, Yes!" in my best When Harry Met Sally impression. Mental Illness Awareness is now an area of CLE and in the mandatory category.

On Sunday April 22, I shook the hand of the Chief Justice of the Florida Supreme Court as I was leaving the Methodist church where he was a lay speaker. I told him I was the lawyer who launched the effort for attorney education in mental illnesses. "Guess what," I said, "God wants the judges to learn this, too." I am counting on the faith community and Justice Wells to help in this civil rights movement.

I am a self-funded advocate, only because our society has not yet realized the great need for the work I do. My children's health is at stake. I cannot think of a better use for my law degree or my medical technology degree. I work for a boss who works miracles. Faith removes stress — and stress causes episodes of mental illness. It works for me.

Now, please, go start a civil rights movement for the mentally ill in your state. Ask your local and state bar associations and judges, state and federal, what they are learning about mental illnesses. Write letters to the editor. Ask your faith community to help. Let those one-in-five families and the many capable people with a mental illness in your community to help you restore "justice for all."

Having suffered from schizophrenia for the past 30 years — including a period of homelessness — I know the complexity of the illness.

When I was a young woman in my twenties, working for an airline and traveling throughout the world, my life was wonderful, exciting. I was part of the theater scene in New York, liked the fabulous restaurants there, and was thoroughly enjoying my life.

One day, however, my life changed drastically. I was diagnosed with schizophrenia, hospitalized, and given medicine. When I was healthy enough to leave the hospital, I was overwhelmed. I could not believe the medicine was good for me, because I had never felt so depressed and lethargic as I did while taking the medicine. After a few months., I decided to stop taking the medicine, believing, as my psychiatrist did, that I would be fine, that I had been struggling with the transition from teenager to young womanhood, and that my "breakdown" would probably never recur. This was the thinking in the 1960s. There was no talk then of body chemistry being involved with schizophrenia.

I did go off my medicine about six months after my first episode. I felt great: I had my alertness, my good sense of who I was; I was not depressed; and I looked forward to working again. Instead, within weeks I was again hospitalized. This time I was sent to a long-term care facility, a state hospital. During this time I decided to take charge of my life. I realized that when I was taking the medicine I was able to stay in the community; without the medicine, I was institutionalized. Psychiatrists at that time believed that the patient's environment was the cause of schizophrenic episodes. I decided not to believe that. In my na�ve way, it seemed to me that a pill kept me healthy; without that pill, I became mentally ill. I determined I would find a way to cope with taking the medicine, because I did not want my life to be a revolving door from society to the hospital and back again. I decided to try to work with my new psychiatrist, finding a way to take my medicine so it would not affect me during the day. I was able to take most of my medicine during the evening and work during the day.

While in remission I met a good man and discussed with my doctor the feasibility of my getting married and having children. In 1966, there was no evidence that body chemistry was responsible for schizophrenia; therefore, the possibility of passing the illness to children was not considered. I did marry and gave birth to two children.

During the course of the marriage, if we had an argument and I got angry, my husband would say, "Valerie, are you getting ill?" I wasn't getting ill, but my illness was a controlling factor for my husband to use over me. As this kept happening, I knew the marriage was over for me and that I would leave it as soon as my daughters were a little older. I did leave and retained custody of my two daughters. For 14 years, I remained healthy and was not rehospitalized. I took my medicine and went to psychotherapy. I had gained a relative peace, acceptance, and a good level of happiness.

Then came a dramatic schizophrenic episode. It started when someone began harassing me in the middle of the night. This harassment culminated with the person cutting my bedroom screen. I was terrified that because I slept so soundly as a result of the medicine, I would awaken one night with a stranger in my apartment. I decided to stop taking my medicine against the advice of my doctor. I had to do what I thought was responsible, and that was to be semi-awake in case an intruder entered my apartment. The police finally staked out my apartment and apprehended the person who was harassing me, but the damage was done. Because I was an adult and not acting out, I was free from forced hospitalization. I did not know I was ill. My ex-husband took our children, which I thought was kidnapping. No one would help me have the children returned. I must have been visibly ill, although I was not aware of it.

I went deeper and deeper into schizophrenia, ending in homelessness for a two-year period. During this period of homelessness and mental illness, I faced the dangers of street living, including being beaten and raped, almost freezing to death, and being malnourished, but I was free. In that state, freedom was what I wanted. My imaginary friends would explain all the tortures away, saying that I had to learn to be strong, or that the brutality occurred because I was mistaken for someone else. This odyssey ended one day when I decided to do whatever it took to have the good life I had known. I still did not know I was ill, but I did associate taking medicine and being hospitalized with living as I had previously, before homelessness.

One day, I summoned every bit of strength I had and did not back away from institutionalization. Fortunately, the psychiatrist I saw during the admittance process treated me with empathy, compassion, and respect. I trusted him, and, therefore, did not back away from my decision to seek treatment. I remained hospitalized for a six-month period, three months of which were spent waiting for abed in a housing program in the community.

After I was out in the community again, I sought out the psychiatrist who had treated me during most of the time I suffered from schizophrenia. Because I did not have the stresses of being a single parent with two small children, I did not need the amount of medicine I had needed previously. Taking my medicine became easy for me. I took one dose at night before going to bed. This way, during the day I was not tired and could function well, holding a good job. I reunited with my children and built another life for myself. I still see a therapist and can call between visits if I am very upset. I don't abuse this arrangement, and it has served me very well.

This brings me to outpatient commitment and being monitored in a program such as the Program of Assertive Community Treatment (PACT). Because I have been monitored for most of my adult life, and am grateful for it because it helps me not to slip into homelessness again, I am a proponent of outpatient monitoring with guidelines that allow a person to live in the least restrictive environment, as I have been able to do all of my adult life. I firmly believe that if a person is rational and wishes to live in a homeless state, that is his or her right.

However, if a person is living in a state of fantasy and imagination (voices and hallucinations) and is lacking free will, I believe he or she should have to receive treatment through outpatient commitment until he or she is again living in reality. If ongoing linkage is indicated because the person has proven to be at risk for entering a schizophrenic state (usually from lack of medication compliance), I believe the person should be committed on an outpatient basis to be able to live in society. I don't think a person without free will should have the right to say, "I want to stay in this state and live in society." A state of schizophrenia is one without reason. I don't think it is fair to the person who may never again know reality if left in this state of schizophrenia, nor do I think it is humane or responsible to society. [Reprinted from Schizophrenia Bulletin Vol. 27 No. 1 2001, by permission of the author.]

Minnesota's victory

Governor Jesse Ventura signed SF179 [the combined bill for HF281 and SF179] into law on June 30 [2001]. The Senate and House passed different versions of the bill and it was in Conference Committee for a few weeks at the end of the session. One of the last issues to be resolved was a concern that judges, out of habit, would commit people under the new standard to the hospital, rather than to assisted outpatient treatment, even if they did not need hospitalization. The Conferees finally agreed to insert a provision directing judges to commit people to community programs under the new standard rather than hospitalization. They passed the revised bill on June 28 [2001] and sent it to the Governor for signature.

The law will help provide access to treatment when it goes into effect in July 2002. It allows for earlier intervention, by removing the requirement that danger be "imminent" for emergency response, and by improving the standard for treatment so that a person's deteriorating psychiatric condition may be considered in the standard for care. The law also allows for lengthened hospital stays to stabilize a person's condition as well as timely intervention with medication.

Our profound admiration and grateful congratulations go to Minnesota Representative Mindy Greiling, the original sponsor of this legislation and the leader of the effort for treatment reform in her state.

The Florida Mental Health Act (The Baker Act) 2000 Annual Report (hereinafter "Report" www.fmhi.usf.edu/institute/pubs/ pdf/mhlp/bakeract) summarizes and analyzes data for cases initiated under the Baker Act, Florida's mental illness treatment law. The Report illustrates clearly how the Baker Act has shifted the burden of caring for individuals with the most severe mental illnesses to the law enforcement community. The data in the Report also demonstrates that the Baker Act's dangerousness standard creates a risk of harm for people with severe mental illnesses and officers. The Baker Act's lack of an assisted outpatient treatment provision adversely impacts the quality of life for the most severely ill and fosters the high recidivism rates reflected in the Report.

Consider the following:

• More than 80,000 Baker act cases were initiated in Florida in 2000.
• Law enforcement initiated 36,000 — nearly as many as the 41,000 that were initiated by mental health professionals.
• In nearly half of Florida counties, mental health professionals did not initiate any Baker Act cases in 2000. (A Florida sheriff explained that the mental health professionals in his county refer all Baker act cases to the Sheriffs office because the Baker Act requires that people be dangerous).
• 82% of the Baker Act cases initiated by law enforcement agents (30,000 cases) specified that there was a "substantial likelihood that the subject would cause serious bodily harm to self or others in the future as evidenced by recent behavior" placing individuals with severe mental illness and officers at in significant risk of harm.
• 15,879 individuals had two or more Baker Act cases in a 21-month period.
• 32 individuals had more than fifteen Baker Act certificates in a 21-month period.
• 1,040 individuals were subject to the Baker Act six or more times in a 21-month period representing more than 8,000 Baker Act hospitalizations. That means, one-third of Baker Act cases were for 15% of the people subject to the Baker Act.

The Treatment Advocacy Center was organized as a nonprofit organization dedicated to eliminating the legal and clinical barriers preventing timely and humane treatment of those who suffer from severe mental illness and are not receiving appropriate medical care. Unfortunately, for those who are currently embroiled in the battle to get help for a loved-one, changing the laws may seem like a "too little, too late" proposition. But you should not have to be alone when you fight the battle to get treatment for someone with a mental illness. A qualified attorney can be instrumental in guiding you through the legal maze surrounding mental illness laws.

In an effort to bridge the gap between those who are suffering from mental illness and those who can provide assistance, TAC is compiling an Attorney Directory. Our efforts to compile the directory come in response to the urgings of countless friends and family members who have called our office for help understanding state assisted treatment laws. Our hope is that the directory will be an invaluable resource in the battle to get help and understanding for those who suffer from mental illness.

Because of the great need for qualified and experienced civil commitment attorneys, we will provide attorneys a free listing in the directory. In addition, access to the directory, once completed, will be free of charge. We anticipate a publishing date in February 2002.

We would like to extend an invitation to qualified civil-commitment attorneys to be a part of our Attorney Directory. Further, if you know of any attorneys who could be an asset to our directory, we encourage you to inform them of this opportunity to be a part of the catalyst for change. Attorneys may sign up for listing in the Attorney Directory by calling our office at (703) 294-6001, or by filling out the online registration form.