I was thinking about a woman I never knew today. Her name was Gloria Leonidas, and she was one of five people killed just over a year ago in what has become known as the Seattle café shooting spree. Gloria was a wife, mother of two daughters and well-known community volunteer. The day she was shot started out just like any other day for her. And then she was gone.
The man responsible for her death, Ian Stawicki, had shown a variety of mental illness symptoms over the years, becoming increasingly violent in the last handful. He’d never been a patient at a psychiatric hospital, but was charged twice with misdemeanor assaults (charges that were later dropped). He owned guns. His family knew something was wrong with Ian, but didn’t know how to get help for him, and Ian wouldn’t seek help on his own.
This isn’t a unique case. Margaret Ryan was killed in Seattle last year, too, by her mentally-ill son, Brodie Lamb. He was also known to have violent outbursts, but unlike Stawicki, he’d previously been both convicted and treated with medication for his illness. He refused to comply with court orders for continued treatment of his mental illness, however. And then he killed his mother.
There are good arguments against involuntary treatment for mental illness, and I agree that no one should be forced to take medication except when they’re a threat to themselves or others. But why aren’t more states willing to put adequate money into funding follow-up outpatient care for a person with a serious mental illness?
According to a recent study on involuntary outpatient treatment, a state’s investment in such programs, where caseworkers visit patients to ensure they stay with their therapy and medication, can lead to lower overall health care costs. Researchers at Duke University found that patients in the program require fewer revolving-door hospital visits and become more productive in society. Here are the stats.
Forty-five of the 50 U.S. states have some form of involuntary outpatient treatment, however the level of states’ investment is so varied that for all intents and purposes, in some places, the program doesn’t exist. Other states, such as New York, have invested heavily. The program took shape there after 32-year-old Kendra Webdale was pushed to her death on the tracks of a New York subway by a man suffering from schizophrenia. But even with New York’s significant investment, it happened there again just last year, when Ki Suk Han was killed.
So where do we go from here? Do we keep trying to build involuntary outpatient programs (and plug the holes in the existing outpatient programs)? And can we do that without stomping all over basic civil rights? Or does the safety of the whole outweigh the rights of the individual in these cases?
What are your views on this issue? All opinions are appreciated.
Note: this post was updated on 08/31/13 to correct references to “involuntary outpatient commitment” where it should have read “involuntary outpatient treatment,” including in the title of the post. D’oh!
Everyone I know who has a family member with mental illness is frustrated beyond words because legally there is nothing they can do to help them get better. And typically, the person who is mentally ill thinks there is nothing wrong with them. If mentally ill people had the logic to make good decisions, they wouldn’t be mentally ill. The whole system is ridiculous. Thanks for the thoughtful post, Laura!
The frustration watching a family member in a mental health crisis and feeling powerless to help is huge, I agree. But I also worry that if someone is forced to receive treatment, how good will that treatment be? Will they be well taken care of, or heavily medicated and released again without any follow-up support? Unless a government is heavily investing in mental health care, I can’t even imagine the wide range of care that exists across states, provinces and countries, some great and some possibly more harmful than good. So beyond just getting a person to agree to treatment or administering it involuntarily, there’s still such a big hill to climb. Thanks for your comment, Mary.
I just think that we can’t prevent everything. There will still be people who slip through the cracks. No matter what we do, bad things will continue to happen to innocent people and these will always be a tragedy. I think we have to keep doing the best we can do. (I am in New York State and there are so many services, yet, still Christmas Eve Firefighters were killed coming to a fire to help people by a mentall ill person. The whole community was shaken. One victim was 19 years old.
One day a few years ago a mother of a client called me to ask how the session went with her ex husband the night before. I was weary about the apppointment, because I knew of his mental illness. But aside from some negative gossip about his ex nothing untoward happened. She then told me why she asked. He had just held up a bank at gunpoint and was being detained (he is now serving a 12 year sentence.) 12 hours after I saw him and I would have never guessed. Never. Thank God, he didn’t shoot anyone. But I will always wonder what I missed that night because obviously he had it planned already when he saw me.
Wow, that’s a mind-blowing anecdote, Jodi. Twelve hours later. People can be really good at hiding stuff, hey? You’re right, people will always slip through the cracks. I do wish that there were better resources available across the board. New York State appears to be a leader in that, which is great.
Follow-up care is so important for the path to recovery. Even though my mom was always voluntarily committed, she would get out and then mess-up her medication, and then have to go back again. It was a brutal process. Once she finally found the right doctor, the situation improved, but I can only imagine if a caseworker had been on her to stay on track, her situation would have improved much sooner. Why does it take moving mountains for this to become clear when it comes to treating the mentally ill?
I wonder what the standards and availability are for follow-up home care for physical ailments, e.g., physical therapy, occupational therapy, etc.? I know the concept is much more established than follow-up home care for mental illness. I think it would be a huge step forward to have this be a standard resource for people who have received inpatient treatment. I think I’m going to have to do more research on this! Thanks for sharing, Jeri.
I too support follow-on care to help both the individual as well as potentially protect others from harm. I have a mentally ill cousin. My family tried all sorts of ways to persuade him to seek help which he continues to refuse. It’s heartbreaking to know there is nothing any of us can do to help him. While he hasn’t been physically violent to my knowledge so far, he does fly into rages over seemingly (to others) minor things. I don’t know what the answers are, but I believe we as a society haven’t come even close to figuring out compassionate and effective mental health care systems. I’m glad you write about these issues periodically. It’s important to shine a light on this problem.
Thank you, Jagoda. What’s interesting to me is that both of the cases I referenced in my post had situations of violence (and related charges), but at that point, it’s all still so much in the criminal/judicial track that the mental health assessment piece may not even be there. How to get these two fields to overlap more, hey? I agree, though, as a society, we have a long way to go in figuring this stuff out so that families like yours don’t have their hearts broken over and over and your cousin can have better opportunities.
This is a tough one, Laura. On the one hand, it’s hard not to support a person’s choice to live at risk. On the other, if that person was receiving appropriate treatment, would they be making those same choices? Whose rights come first? I’d like to think that if future me were to be diagnosed with a mental illness that profoundly altered my behaviour and perceptions, my family would be able to intervene on my behalf. It’s disheartening to know that’s not the case, and depressing as all get out to think of all the people out there who aren’t getting the support they need (and may on some level want).
I appreciate this makes-me-think post, Laura.
It is a tough one, Kern. Because you (I’m using the collective you) know that someone in the throes of a mental illness crisis isn’t going to make good choices. And you also know that not everyone in families have the best interests of the family member with the illness at heart. But I don’t know, it may be a sweeping generalization, but I get the feeling that there are so many people with a serious mental illness who don’t get enough support to help them live stable lives. After the wave of deinstitutionalization in the 1960s, it swung so far the other way that outpatient care has never caught up. And I think that each person, and each case, is so different that there isn’t one solution that fits all, but that we just need *more* outpatient resources and more individualized care for those with serious mental illnesses, period. Thank you for your input on this one.
Hi Laura,
Like the other folks who’ve posted, I think this a painful dilemma. Sorry I’m a bit tardy in bringing my comments from Twitter over here to your blog but thank you for inviting me to. 🙂
My experiences as a service provider and also as a family member have taught me that proving “grave disability” or “eminent threat to self or others” to a clinician, much less a judge, is tough. Oftentimes family members, service providers and other paid and natural supports know which individuals experiencing mental health problems are the rare few who are likely to behave in a violent way. These supports often recognize triggers and warning signs and many can tell you days, or even weeks in advance, when the their client/friend/family member is decompensating and likely to become violent but aren’t able to procure court-ordered intervention until someone actually gets hurt. Part of the challenge in this situation is that even folks who are very sick can pull it together enough to conceal symptoms during an evaluation or hearing.
On the other side of the discussion, we must recognize that folks experiencing chronic mental illness are far more likely to be abused and/or exploited (I can’t quote the statistics but they are horrifying) than someone not mentally ill and there’s a long and well-documented history of these folks being signed into involuntary treatment when it did not suit their best interests.
Additionally, people with mental illnesses who do behave violently are a small minority of the larger population of folks experiencing chronic mental illness.
I want to see a more efficient legal and treatment response to those who are decompensating and at risk for becoming violent, while also protecting those same folks (and others) from abuse and exploitation.
Marcy, I so appreciate that you took the time to put your thoughts down here because it’s invaluable to hear from people who have experienced different sides of the issue, e.g., as family members, clinicians, caregivers and clients. Thank you!
The point you make about those who behave violently being a small percentage of the overall population of people with a mental illness made me step back and remember that as tragic as the stories are that hit the news headlines, they’re getting media coverage because they’re newsy, not because they’re common.
Another thought I had was to wonder if the people who have been abused/exploited through involuntary treatment still really did need the treatment, and it was the method of delivery (person, place or thing) that was exploitative. In other words, if those people had been involuntarily treated by someone different or with a different treatment protocol, would the outcome have been so much more favorable that it would support involuntary treatment. In that scenario, the level of care (and appropriate oversight of that care) is as central to the issue as the part about it being involuntary. And if more focus was put on the quality and oversight of that care, it would go toward addressing your sentiment at the end of your comment.
My post’s use of the violent tragedies as examples didn’t serve to highlight the plight of the non-violent person with a mental illness, and what is fair and good outpatient treatment for them. I’ve heard so many stories of people with bi-polar who spend a week or two in the hospital to get back on their meds, then go off them again a few months after they’ve been released. It turns into two or three hospital stays per year, and a huge disruption to their personal and professional lives. Is enforced compliance for a person in that situation even something that we should consider as a society, or accept the fact that those kinds of people will cycle through the hospital doors over and over again (and lose jobs and partners over and over again)? It makes me so uncomfortable to stand behind anything that’s forced, but I see so much potential for long-term improvement in people’s quality of life.
This is indeed a complex issue you have raised. Psychiatry is the only medical specialty that contemplates ways in which to force treatment. Outpatient commitment criteria is slightly different than inpatient involuntary commitment, which is generally where I get the most requests for assistance in the process. How do I MAKE my loved one get help? Why can’t the system do something to force them to “do the right thing?”.
I think it’s important to point out the ways in which the help isn’t always helpful. The medications don’t work for everyone, and at best, they mask symptoms rather than treating illnesses. We are generally very hard on people who refuse to take medications that don’t work that well and have life-long serious side effects causing health risks that rival the original condition. Forced check-ins that mirror probation appointments have often criminalized mental illness as has the manner in which some states deliver outpatient commitment services. In fact, a few really good models of psychiatric rehabilitation and recovery (such as ACT teams) have been used to enforce outpatient commitment law, which changes the dynamics of the model altogether, and renders it useless in terms of outcomes. Many states have refused good models because of their misuse and subsequent reputation.
Many studies exist on what works for severe mental illness and surprisingly, it isn’t force. It’s housing, meaningful work, respect and dignity, appropriate and self-directed treatment that is holistic and compassionately co-managed in partnership with the patient with simultaneous education and support for involved families. Despite this data, our system in the US is designed for maintenance at best, not recovery. The more attention to violence, the more discussion of force, which is the entirely wrong discussion to have. The discussion should be more about how we are failing to deliver meaningful care to people with mental illness. What if psychologists and psychiatrists were reimbursed based on patient outcomes? I wonder what would be different in that 15-minute-every-six-weeks medication appointment or if we would ensure people were taken care of in a way that truly gave them opportunities to recover. Maybe the “force” that should govern the treatment of these conditions has been displaced on to patients when it really belongs with the providers. Hmmm.
Jill, you’ve added so many important points here. I hadn’t even equated forced treatment with criminalization of mental illness. And the model of medication management that has become the reality with a lot of psychiatric care is infuriating. I’ve been there myself, and was disappointed that going to a specialist offered nothing deeper or different than going to my family doctor.
I think the need for outpatient follow up is there. What you’ve reminded us of is that we should be looking at how it’s delivered. Involuntary treatment could very well turn into voluntary treatment if the delivery mechanism was different. It’s just like models of learning. Are we more receptive learners when information is shoveled at us, or when we’re given the chance to engage?
Even with shifts toward meaningful care, the crisis element of mental health doesn’t go away but is hopefully greatly reduced. And when I wrote the original post above, I was incredulous that in both of the stories I referenced, the person’s initial acts of violence were only treated criminally, and not from a health perspective, which to me is a good indication that there isn’t the right law enforcement training and departmental linkages in place to work with a person in that situation.
Thank you so much for your insights. I’ve written a new post for this week dedicated to consumer empowerment based on what you and Marcy brought to this discussion.
Laura,
You’ve posed an interesting question about whether folks may have needed treatment but been abused because the treatment itself was less than effective or safe. That is certainly the case for many folks who received hysterectomies, lobotomies & quite likely some forms if ECT. Unfortunately, many folks in this vulnerable population have historically been involuntarily signed into treatment (usually in-patient, though) for motivations that have also included finances, convenience & social stigma.
Involuntary out-patient care is often ineffective because individuals really have to be invested in cognitive/behavioral changes around medications, self-care & symptom management for treatment to be effective. When folks are not invested, they’ll find ways to cheek oral non-dissolving meds & can sabotage other elements of treatment in a variety of ways. Meds are so rarely effective to the degree that med compliance alone would engender a change in long-term patterns that true & lasting change only results from combination of approaches.
You’ve given an excellent example of why making changes to the system is difficult by citing the classic manic or hypomanic cycling of someone with unmanaged bipolar disorder. Where do we, as a culture, draw the line in the sand about involuntary treatment? Most of us agree that violence is unacceptable but what about risk-taking behavior? Speeding in an automobile? Challenging someone to a fight? That grey area is so broad that it’s difficult to sort out what should be allowable & what should not. Western culture has a terrible track record with this issue, labeling and forcing various treatments on homosexuals, women, activists, etc. I’m not saying we shouldn’t discuss it & try to sort these things out, but rather pointing out the challenges in defining or redefining those lines.
I find I agree with Jill about the desperate need for more discussion of, and movement towards, meaningful care, though I don’t agree that discussing violence & force is a “wrong” discussion. Really, from my perspective *all* discussion conducted in a compassionate, caring and searching for info/ideas mode is right discussion. The taboo of mental illness still runs deep & folks are too often frightened to even think or converse deeply about the topic.
I want to add that, as a family member, I (and other family members) have experienced significant violence at the hands of my sibling who has a mental illness. I want what is best for my sibling AND I recognize that victims of violence should not be quieted. Although not statistically common, it is a very real issue & all citizens have a part in this conversation.
Hi Marcy, I’ve now had more than a week to digest your great input (and wrote a new blog post for this week where I’ve attempted to highlight the flip in focus that you and Jill talk about).
There’s a lot of stigma tangled up in involuntary treatment, I’ve realized. Or, rather, perpetuation of stigma. It definitely does not respect the dignity of the person on the receiving end, and like you’ve pointed out, if it’s purely medication-focused, it likely falls short in its effectiveness anyway. Better treatment plans will ultimately cost more money in the beginning (and likely less in the end) but governments can be rather short-sighted in their willingness to pay more up front when it’s not politically viable (and it usually isn’t).
You also raised a good point with regard to risk-taking behavior. If speeding in an automobile was cause for involuntary treatment, I’m a goner! The boundaries are definitely grey, though. Violence, on the other hand, will always present a problem, and if family members or government don’t have the ability to intervene in some manner, we’ll create more victims, not to mention those who end up living in fear (I have a family member whose bi-polar grandfather tried to use his car to run her car off the road; a restraining order was the best they could do after that). But now I am going to keep my questions focused on how we can deliver better care so that the interventions don’t have to be forced and behaviors don’t escalate to the point that require intervention?
We really have to think about ways in which we have failed to design and deliver successful mental health care We are working within the effects of pervasive stigma and marginalization…so much so that we are not aware of it. We have normalized poor treatment of these conditions and can hardly imagine anything different. But try to. Think about prevention. Why, with mental health care, do we have a system that will respond to needs only after the illness is so bad there is risk of actual HARM? We wait that long why? We wait that long for people to spontaneously heal themselves? Resolve their character flaws? Pull hard enough on the boots straps that all issues resolve? Snap out of it? I think in some ways we impose judgements like this until we simply can’t any longer. When someone is ill enough to pose a threat, then, and mostly just then, do we stop judging them for the seemingly volitional actions of a complacent citizen failing to deal with their own issues, and see the illness for what they are and have been all along, biologically based brain disorders.
Yet we know full well at this point, that attending to someone who has experienced trauma makes the difference between a functional person and someone with lifelong PTSD. We know that intervention with grief and loss early on can prevent a full blown major depressive episode or series of episodes. We now know that early identification and treatment of schizophrenia can completely change the trajectory for that illness. But do you know of any prevention programs? Are any prevention efforts apparent and visible to you?
My insurance plan covers dental prevention 100%. I also can get a number of medical exams for early detection, for free. If I were to sign up for preventative mental health care, I would likely be diagnosed with some sort of personality disorder or be noted as a hypochondriac or seen as “psychosomatic”.
I just wonder why we can’t do better with all that we know. Treat the brain like it’s part of our bodies (thanks DeCarte for screwing THAT up), design our programs for recovery, not maintenance, and be held accountable for the outcomes. None of tend to even have these discussions until something horrible happens (which is really my point) or unless we are faced with trying to find help. Anyone who has sought help in a crisis knows that this system isn’t working.
I am eager to hear what we can do with the medical homes models that takes mental healthcare out of it’s own underfunded stigmatized area and puts it back into public health and primary care. It’s about time.
I don’t have a lot of insight into medical insurance benefits as I’ve had the same (limited and quite inadequate) individual insurance plan for most of the nine years I’ve lived in the U.S., but I do know that my mental health benefit for standard outpatient care is only half (six visits vs. 12) of some of the other treatment areas, such as chiropractic. Preventative care for mental health isn’t out of reach if we can first get on the level in terms of base care.
You’re right in that we do have a lot of knowledge and information that we’re not putting to good policy use. Kind of reminds me of the case where cars weren’t being built using the full fuel efficiency designs that were known because of the oil lobby. That’s my ‘hmmm’ on that one!
Thanks for your continued sharing, Jill, and the medical homes model is something new to me, so I appreciate the head’s up on that.
I’ve both worked in mental health and been an outpatient, the latter for most of my life. I’m also an advocate, and in the process of developing a nonprofit for advocacy and support. I absolutely understand how even someone with a diagnosis of depression (versus, say, someone with a diagnosis of psychosis) could get to the point of hurting another (not condoning it, just understanding some of it, to a degree). My experiences with both medical and mental health professionals (esp. in the last 5 years) has shown me that there is woefully inadequate understanding when it comes to the depth of suffering that many folks these days are feeling. There is no connection between professionals and patients/clients. the availability of adequate care is completely out of financial reach of most people, many medications (which, most recently, are in question as effective anyway) are not affordable (I, for example, have been denied access to the one and ONLY medication that helps me because I can’t afford it, even on insurance), and the stigma among medical professionals, employers, and the general public remains huge. I have horror stories I could tell you about my family doctors and the care I don’t get.
I think the critical issue here is reaching people before they need involuntary treatment. Anytime anyone is forced to do something against their will, you will likely not get very good compliance. And preventing that need is going to take a lot more education and advocacy and support – of doctors, families, the public, and patients. A lot more than we’re doing now.
Diane, you’ve painted a bleak picture here, but it’s important that we hear and know this, and thank you for sharing your personal experience.
Reaching people before they need involuntary treatment — that is a sound principle, and then, of course, I’m trying to imagine what that would look like. It makes me think of some programs which are created and led by the outpatient consumers, where they have fundamental control over the program and support groups’ objectives and agenda. And I think those programs are pretty rare. I’ve read about one in Massachusetts, and one on the West coast (either California or Oregon), and that’s all I could find back a few years ago.
Laura, I think the picture *is* bleak. That professionals in any discipline would allow their clients to, essentially, die because they don’t have the education (or, in some cases, care) to properly help them speaks volumes of our society at large. For the rest, the power is lacking to combat those whose greed outweighs all else.
Admittedly, I am speaking as one who has repeatedly gotten no help or who has had to fight tooth and nail to get what I have gotten. That is exhausting and, at least for me, hardly seems worth the effort most of the time.
A couple of years ago I learned from a very well-respected mental health advocate that the community-care model in WA state was largely staffed by young graduates with arts degrees–often English majors–who were making minimum wage and lasting about three to six months on the job. I was beyond flabbergasted.
And to hear the challenges you’ve faced, especially given that you’re articulate and knowledgeable–I can’t even imagine what happens to someone who is less equipped or able to state their case or advocate for themselves.
It’s really a mess.