Testimony Regarding the Results of the Research Study of the New York City Involuntary Outpatient Commitment Pilot Program

Harvey Rosenthal, Executive Director New York Association of Psychiatric Rehabilitation Services

This testimony represents the collective position of an organization that has joined thousands of consumers and hundreds of progressive community-based mental health service providers in a powerful coalition dedicated to improving services and social conditions for people with psychiatric disabilities. NYAPRS works to promote an environment in which:

the goal and expectation of recovery is afforded to every individual

individuals have widespread access to a broad range of quality recovery-centered psychiatric rehabilitation and self-help services

the rights and stated needs of people with psychiatric disabilities are considered central to public policy and service development

This testimony is based on direct feedback from consumers and providers, collected over the past few years in NYAPRS-led forums, focus groups, meetings and conferences held regularly across the state. It features considerable input from people diagnosed with major mental illnesses who are overcoming numerous personal, systemic and social challenges to achieve a life in recovery.

First, we believe that the results of the Research Study on the Bellevue Involuntary Outpatient Commitment Pilot need to be examined in the context of other recent notable findings in this area:

People with these diagnoses can and do recover, especially when given access to rehabilitation-based services. Thirty-plus year follow-up studies of individuals residing on back wards of a Vermont State psychiatric hospital showed very successful community adaptation (more productive, fewer symptoms and better overall functioning) when offered accompanying social, residential and work-based rehabilitation services. Harding et al, British Journal of Psychiatry, 1995

A growing array of community-based rehabilitation and peer-operated services are very effective in helping even "hard-to-serve" groups manage their disability and engage in productive and independent lives, according to studies conducted by Fountain House, the Center for Psychiatric Rehabilitation, Matrix Research Institute, the Mental Health Empowerment Project and may others including:

a NYS Office of Mental Health 1993 study that demonstrated that over 70% of self-help groups report their members stay out of the hospital, hold a job and are living more independently and assuming more responsibility.

a recent study demonstrating that Pathways to Housing, an innovative New York City-based program that provides immediate access to permanent independent housing and assertive community support to individuals with psychiatric disabilities who were homeless, was successful in helping over 80% of its clients maintain stable housing for a 30-month period (Tsemberis et al).

Yet, fewer than half of those diagnosed with major mental illnesses are currently gaining access to a proper array of community care that includes these approaches, according to a national study funded by the Agency for Health Care Policy and Research and the National Institute of Mental Health in March of 1998.

Instead, consumers have been relegated to relying on more traditional mental health services they have frequently experienced as negative if not harmful, as described in:

A 1994 study by the NYS Commission on Quality of Care for the Mentally Disabled showed that the use of restraint and seclusion in the state's psychiatric hospitals had doubled over the past decade and been associated with over 100 patient deaths. An accompanying survey of over 1,000 former inpatients demonstrated that almost one third reported that they had experienced serious concerns for their safety and well being and that their basic dignity and privacy were routinely violated.

A recent series in the Boston Globe revealed that over 2,000 patients had been the often unknowing victims of a disturbing series of experiments by psychiatric researchers exploring the biology of psychosis that deliberately either injected clients with drugs designed to exacerbate delusions and hallucinations or withheld medication from those seeking urging care from hospital emergency rooms.

Another recent series in the Hartford Courant found that hundreds of people, a disproportionate number of them children, have died in restraint-related incidents over the past decade.

A City Limits Magazine account of very demeaning and disheartening conditions experienced earlier this year by a reporter who managed to gain entry to the psychiatric unit of a local New York City hospital.

A California Department of Mental Health survey showing that 55% of former patients reported an avoidance of traditional mental health services because of their experiences of being involuntarily committed (Campbell and Schraiber).

\ In turning to the findings of the research conducted by Policy Research Associates on the Bellevue IOC Pilot program, we were struck by the are struck by the following observations:

Force had no effect on improving outcomes.

There was no justification for the introduction of a coercive program of involuntary outpatient commitment.

If the program does indeed support improved client outcomes, it appears due to the efforts of the program's Coordinating Team in the "mobilization, coordination and follow up" of an "enhanced"package of services that were delivered in a climate of "ongoing and flexible negotiations."

Due perhaps to the "tenacious follow up" and the "heightened sense of accountability extended by the Coordinating Team", the program largely served to make available to its participants a more adequate array of community-based services delivered by more responsive and accountable service providers.

In keeping with the findings of the MacArthur Foundation study, none of the participants was involved in any acts of violence.

Discussion of the Issue of Forced Community Treatment

OPC is a false substitute for good services, and potentially covers up the need for and diverts badly needed funding away from the proliferation of responsive, effective and respectful community-based services. Involuntary outpatient commitment, and other forms of force, do not yield better results in assuring treatment outcomes.

Programs that work well with "treatment resistant" people are based on choice, not force.

Force breeds resistance: Even the threat of forced treatment causes people to avoid services altogether. Coercion results in feelings of fear, anger and repugnance towards mental health services and paradoxically promotes the very resistance it is designed to address.

"The key problem in community mental health care has always been funding. The relative success of coerced community treatment as compared with voluntary community treatment cannot be adequately assessed until an appropriate range of services is available. (Stefan)

Burden to taxpayers: OPC involves high costs in policing people to make sure that they are in participating in mandated services.

"What outpatient commitment is far more likely to achieve is the disruption or destruction of trust, the precluding of adult responsibility, and the creation of an adversarial relationship which is in and of itself dangerous - one that actually encourages defiance. Do not underestimate the degree of alienation, desperation and rage created by the use of force." Laura Ziegler

"Even now many people won't seek treatment for their mental illness because of the stigma attached to it. This bill would have a chilling effect on those who are struggling with the decision to seek help. People would no longer feel safe to tell their treaters anything because of the fear - fear that their choices would be taken away from them" Yvettte Sangster.

"How can you enforce order and save the professional relationship? (provider response to Research Study)

OPC will serve to obviate and/or destroy the creation of trusting, therapeutic alliance with treatment providers that is essential to positive client outcomes (per Dr Daniel Fisher)

Arbitrary nature of inflicting forced treatment on this population: "Why can someone check out of the hospital with arrhythmia (and therefore be presumably ‘dangerous to self'), but not with schizophrenia?" Dr. Thomas Szasz

"Involuntary treatment for treatment of mental disability is unquestionably the most severe action a government can impose upon an individual, short of a criminal charge and conviction. Indeed, in many respects, civil commitment has been compared to a criminal sentence in that both deprive the individual of his or her liberty, usually involve forced residence in an impersonal institution, subject the persons to indignities of many sorts as well as to the general control of the variety of persons who run the institution. And, in the case of forced treatment, a person can well be subjected to extremely distasteful side effects, dangers of short term and long term related disabilities and conditions, and the possibility of drug errors which may result in serious harm, including death in some instances."

Paul Stavis, Counsel, NYS Commission on Quality of Care

OPC makes an entire class of people subject to involuntary detention and forced treatment based on a presumed eligibility status, resulting in a blanket violation of individuals' civil rights.

The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.: "Indeed, this Commission believes that serious efforts by health care institutions to ensure that patients have one identifiable and reliable source of information concerning their care would do far more to remedy the current ills of the health care system than would legal prescriptions with which compliance can neither be assured nor enforced."

Forced treatment initiatives like OPC have been disproportionately aimed at people of color.

OPC criminalizes the unwillingness to enroll in services they (and many others) perceive as inadequate, unresponsive and in some cases harmful.

IOC draws badly needed resources away from a community-based system of services that is woefully underdeveloped in many critical areas.

Coercive treatment damages self-esteem, sense of self-determination and integrity.

Coercion serves to re-trigger psychological wounds associated with past experience of violence and abuse.

Some providers in the study agreed that "In reality, sometimes people are non-compliant for good reasons" (citing "what do you do about people who take their medication but they get terrible side-effects, or when medications don't work?).

IOC amounts to a misguided tinkering with a deficient system that imposes coercion as a substitute for an adequate, accessible and appropriate array of effective community-based services and supports.

Resisting services which have proved to be disempowering, demeaning if not harmful to many can hardly be seen as an irrational act denoting incompetence but a choice individuals have a right and a need to make. Fix the services rather than force them on people.\

Recommendations

City and State government should renew their commitment to dramatically expand the availability of effective, person-centered rehabilitation and recovery-based services via:

• enhanced funding streams
• continued full funding of Community Reinvestment program
• full enforcement of initiatives within the soon-to-be-implemented Special Needs Plan program that guarantee broad consumer choice from a full array of services (including rehabilitation and self-help) that must demonstrate proficiency in helping consumers achieve recovery-centered outcomes.
• adequate rate structures within the SNP program to assure enhancement of existing services
• full funding of New York/New York II program
• passage of full mental health parity legislation
• Offer an adequate range of service options, which people want and identify as responsive to their needs and that promotes wellness, healing, independence and personal responsibility.
• Provide adequate discharge planning from inpatient stays.
• Provide adequate crisis prevention and management services, especially the highly promising and innovative peer-operated crisis support, diversion and respite services.
• Help people develop and file advanced directives to go into effect in the event of a crisis.

Testimony Regarding the Results of the Research Study of the New York City Involuntary Outpatient Commitment Pilot Program

December 16, 1998

Offered by Harvey Rosenthal, Executive Director, New York Association of Psychiatric Rehabilitation Services, with support from:

Association for Community Living\ Brooklyn Peer Advocacy Project\ Clubhouse of Suffolk\ Community Access\ Community Living Associates\ Hands Across Long Island\ Howie the Harp Advocacy Center\ INCUBE, Inc.\ Institute for Community Living\ Mental Health Empowerment Project\ Mental Patients Liberation Alliance\ NAMI-FACT\ National Empowerment Center\ Restoration Society\ Skylight Center\ Urban Justice Center\ Venture House

The contact point for the Coalition to Stop Outpatient Commitment is:

The Resource Center, 291 Hudson Avenue Albany, NY 12210 (518) 463-9242, FAX (518) 463-9264

In addition, NARPA has materials available from the workshop, "the Politics of Outpatient Commitment: Recent Initiatives in Three States,"which was presented at NARPA's November 1998 conference in Albany, New York.

Last updated June 14, 1999