The Republic of T.

Black. Gay. Father. Vegetarian. Buddhist. Liberal.

Coercion v. Care

I’ve been meaning to post some kind of follow-up after my last three posts on mental illness and mental health care (or the lack thereof). After going off about the lack of mental health services, or lack of access to treatment, can lead to problems for the mentally ill, their families, and the rest of society, it was encouraging to read about states increasing funding for mental health services. But it raises some interesting questions about how to achieve a balance that also protects the rights of the mentally ill.

I thought about it a couple of weeks ago, when I read about Kaine’s plan to boost mental health funding, in the wake of the VA Tech shootings. But that funding comes with a reform that—though apparently intended to address situations in which people, like VA Tech shooter Seung Hui Cho, don’t get court ordered treatment—raises questions about the effectiveness of basically coercing the mentally ill into getting treatment.

Gov. Timothy M. Kaine (D) announced a plan yesterday to pump $42 million into Virginia’s troubled mental heath system, a proposal that advocates and state officials said is the beginning of an intense discussion about how aggressively the state should adopt reform.

At a news conference in Richmond, Kaine stood alongside mental health advocates and the parents of two students injured in the Virginia Tech massacre, which prompted the reforms. He said he was seizing a “historic opportunity and responsibility” to boost funding for mental health programs, change the criteria required for someone to be involuntarily committed and impose new regulations on community-based clinics.

…Kaine stopped short of proposing broader, more aggressive reforms that some lawmakers have suggested they would like to see when the General Assembly convenes next month. For instance, several legislators said in interviews that they would like to see bills broadening the ability of the state to coerce people into outpatient treatment. Such proposals are expected to ignite debate on how far and how fast the state should change its system.

…In addition, Kaine proposed spending $10.3 million over two years to hire 80 additional clinicians to focus on youth or adult counseling at outpatient facilities. A recent report by the state auditing agency said Virginia is in dire need of more services for children.

…A major part of the package directs about $14.6 million to emergency mental health services. The money would provide greater access to psychiatrists who specialize in treating mental patients in crisis, increase staffing at intervention centers and create more local crisis stabilization units, which are designed to stabilize those having a mental health crisis in a small clinic instead of admitting them to a hospital.

The extra money may indeed prove helpful the state Supreme Court’s Commission on Mental Health’s report that part of the problem with Virginia’s mental health system is dearth of resources illustrated by the system’s failure to catch Cho, and directly impacted by funding: shortage of beds, low pay for caregivers, lack of hospital reimbursements, etc. The commission issued a report in August, recommending reforms to Virginia’s mental health care system. More recently the commission has recommended loosening standards for committing the mentally ill.

A Virginia Supreme Court commission on mental health laws yesterday proposed loosening the state’s standard for when mentally ill people should be committed to hospitals, an issue that has come to the fore since the Virginia Tech shootings last spring.

Virginia has one of the nation’s toughest standards for involuntary commitment. Under state law, a mentally ill person can be committed only if the person poses an “imminent danger to self or others.” The proposal would allow a magistrate or special justice to commit a person to treatment if there is “a substantial likelihood” that the person would cause “serious physical harm to himself or herself” in the near future or could “suffer serious harm due to substantial deterioration.”

…Among its recommendations, the commission called for more crisis stabilization beds and expanded availability of basic mental health services for a variety of people with disorders. Many mental health advocates, lawmakers and state officials have worried for years that Virginia has provided too little funding for community mental health services.

The commission also called for better monitoring of mentally ill people in the community. Often there is confusion over how a person who is ordered by a court to receive services should be monitored. In the case of Virginia Tech gunman Seung Hui Cho, there was confusion over who was to monitor him after he was ordered into treatment in December 2005. As a result, he never received it. The commission recommended that specific guidelines be adopted, such as listing consequences of not complying, when mentally ill people are ordered into treatment.

I don’t know if Cho, or at least his victims would have benefited from a system that included consequences for not complying with treatment (a subcommittee in Virginia’s House of Delegates is drafting legislation on the standard), but a similar system seems to have worked in New York.

Susan Wezel had been committed to the city’s hospital wards more than a dozen times in 10 years. Her psychosis was so deep and debilitating that she lost her career and her relationship with her son, as she refused to take her medication or follow treatment.

But because of a New York state law, Wezel hasn’t been hospitalized in more than a year. She doesn’t wander the streets alone at night anymore. She takes her medication willingly. She even has plans to follow her dream of singing at a neighborhood nightspot, something that was unthinkable 18 months ago.

Wezel and her caseworker agree that the transformation occurred because of the law, which allowed officials to force Wezel into an outpatient treatment program after she was discharged from a hospital.

…”All of this has saved my life,” Wezel, 50, said in an interview at her caseworker’s office in Queens. As part of the treatment order, she was given immediate access to a caseworker who closely monitors her through visits and phone calls. If Wezel fails to comply with her treatment, she can be picked up by police and taken to a hospital.

Wezel’s experience with forced treatment underscores one of the most controversial issues in the care of the mentally ill. Seung Hui Cho, the Virginia Tech gunman, had been ordered into outpatient treatment, but officials didn’t monitor whether he received it, and he never did.

Had something as detailed as Kendra’s Law been in place, with its high expectation of accountability, officials might have been forced to monitor whether Cho got treatment, supporters of such measures say.

On the other hand courts have ruled over and over again that the mentally ill have the right to refuse medication. At least, the cases I’ve read say that people involuntarily committed to psychiatric institutions have the right to refuse to take medication. How that impacts people who are court ordered to undergo outpatient treatment, I can only guess.

I don’t know, but I think opponents of measures like Kendra’s Law have a valid point: coercion alone doesn’t work. Funding, for medication, more caseworkers, etc., has to be part of the equation, because a huge part of the equation is the availability of services and the ability of individuals to access the services they need.

But what if they don’t want treatment, no matter how much they need it?

There are two things to be balanced here, though I don’t claim to know exactly how. One is the public cost of giving, in some cases very expensive, mental health treatment to people who are very likely to need them for a lifetime. As I pointed out before, that has to be balanced against the cost incurred when some of the untreated or under-treated end up in our criminal justice system. The other is the right to personal autonomy, which has to be balanced against the danger that some people with untreated mental illness pose both to themselves and the rest of us

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