Fixing Not Forcing Services

harvey2Harvey Rosenthal
Executive Director, New York Association of Psychiatric Rehabilitation Services (NYAPRS)

In the wake of several recent mass shootings, many are calling for an overhaul of the nation’s systems of mental health care. A national debate has been renewed over whether legislation is needed to force local officials and mental health providers to be more responsive to those with more profound mental health needs, and whether those groups should, in turn, force such individuals to accept some form of treatment. In this post, Harvey Rosenthal argues we should reframe the debate and focus on reforms that significantly increase the range and raise the bar for community outreach and supportive services.

Fixing Not Forcing Services

Over the past year, we’ve seen an intensified focus on our nation’s and state mental health systems that has drawn a broad array of advocacy groups to weigh in on the merits of two legislative proposals put forward by House members Rep. Tim Murphy (R-Pennsylvania) and Ron Barber (D-Arizona).

Central to Congressman Murphy’s bill is a provision that would require states to adopt or expand court-mandated outpatient commitment programs like New York’s Kendra’s Law in order to access federal block grant dollars. These and several other provisions have generated much controversy. While it now appears that contentious provisions like these will not be moved by the House GOP leadership this year, it is imperative that we address a number of challenges that the bills present.

Getting mired in a debate over outpatient civil commitment distracts us from what should be our greatest focus—the need for fundamental reform of state mental health service systems.

While both bills call for the greater availability of services that have been or are beginning to show evidence of their effectiveness, this is really the responsibility of state governments. They determine how the vast majority of service dollars are spent. They have the opportunity and the responsibility to ensure that people with the most serious mental health needs get access to state of the art voluntary community outreach and engagement strategies that feature real-time crisis and harm reduction approaches and far greater access to peer support, housing, employment and educational supports.   

Forced treatment is not the answer

Expanding coercion is an unacceptable substitute for getting much more out of our mental health systems and practice. We now know so much more about how to help even the most distressed individuals and families, but these approaches are scantly available and represent the exception rather than the rule for the $113 billion dollars we spend each year on mental health services.

Rather than forcing patients to conform to one standard treatment course, we should offer a diversity of paths to stability and recovery, with increased community-based support and outreach for those who have found traditional treatment approaches to be ineffective, impersonal, and too often as spirit breaking.

Outpatient commitment should be considered as system failure not “patient failure.”

But this will require much greater persistence, creativity, flexibility, and a systemic willingness to accept responsibility when our current efforts don’t succeed. When once asked by a director of a large NYC mental health agency what to do when someone consistently rejected the care that they were being offered by their community worker, I replied “send somebody else and offer something better.”

In our next post, Mr. Rosenthal will provide recommended alternatives to coercive commitment into traditional care.

Your Turn

  • To what extent should legislators rely on civil commitment or involuntary treatment as the key to fixing the mental health care system?
  • What kinds of programs do you think legislators should consider as part of mental health care reform?

 


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7 comments
nickdelmarwilliamson
nickdelmarwilliamson

I thought that I would take u up on asking me if I would like to post my blog, well you ask for it! /   enddepressionstigma.blogspot.com

kimgallen
kimgallen

I agree with MHA that "involuntary treatment should only occur as a last resort and should be limited to instances where persons pose a serious risk of physical harm to themselves or others". In my opinion and experience, mental health care reform should include prevention and early intervention supports and services. As a Licensed Chemical Dependency Counselor, Certified Peer Support Specialist and as a consumer myself, it is clear to me that most people lack immediate and affordable access to care when they need it. Community based programs offering support groups for individuals with MH concerns, as well as support and education for families, will empower people to help themselves, when access to care is needed. Other programs needed include accessible training for peer advocates, as well as resources to train all BH professionals. This is a vital component for the protection and care of individuals with mental health concerns. One example of such a solution is SAMSHA's Recovery To Practice (RTP) Resources for Behavioral Health Professionals, which includes the curriculum for six BH professions. 

afish
afish

As someone who is both a clinician and a patient dx with bipolar/ptsd, all of my hospitalizations were voluntary.  Involuntary committment may serve some patients who have no support groups available to them, family members, etc., and lack any real kind of trained mental health specialist.  I have been involved while living in Seattle wherein I was involved with involuntary commitment and although all of my hospitalizations were voluntary, for some of these folks, involuntary commitment was the only way they were going to get help.  So i'm kinda on both sides of the fence and believe each patient's situation has to be studied individually.  Of course it is imperative that when someone is admitted to a psych unit, be it voluntary or involuntary, there must be trained, experienced staff on board.  We all know this is not the case, especially in state run hospitals.  I think of St. Elizabeth's hospital in D. C. where patients languish for years and survive only with the huge amount of meds they are given along with food,clothing and shelter.


Hopefully we are entering a"New age" for mental health treatment, be it in an outpatient setting or in a psych unit wherein patients can only stay for about 7 days and its used for safety reasons - monitor meds and make sure the patient is not suicidal.  Believe me I am well aware of those situations!!!  Further, since 98% of mental health professionals, no matter their backgrounds, are dropping out of Medicare, Medicaid and other networks, which leaves us with what I feel are not well trained folks to do the therapy, meds, etc. etc. And then it is essential that each patient has a good discharge plan and follow-up with a social worker and psych doc if needed to provide meds.  Its might not be a bad idea for some patients to transfer from an inpatient unit to a group home type of setting wherein continued support is provided and various learning/life skills can continue.  No one really gets this type of behavioral change in an inpatient unit.  Again, I know this personally but i'm somewhat different due to my professional background.

StephenBonin
StephenBonin

In the third paragraph of Rosenthal's essay, he provides a link to Mental Health America's criticism of Murphy's bill. Before focusing on the questions, I note that the last two paragraphs of MHA's article would have held more positively effective position at the beginning of the article, for it is wise to commend and affirm readiness to work along side with before criticizing. That said, question #1 of our assignment must alert us that no matter how a patient gets into treatment, we need to ensure that our treatment programs align with current, proven methods. Specifically, here in Texas we have inpatient treatment centers in which time in the sun--for its value alone and for the opportunity to exercise--Is not included. Also, we have at least one treatment center in Texas in which carbonated beverages, chocolates, and other snacks are available on the floor in a vending machine. Finally, televisions running almost constantly is a major problem. Therefore, we see examples of sloth and comfort. Thus, the answer does seem to be in outpatient programs coordinated by regions under a state authorization. Looking at the economy, we see a plethora of Home Health Aid positions. Transferring this dynamic to outpatient care for persons with mental illness issues, trained individuals could conduct the outpatient treatment by going to homes--eating a healthy snack with the patient in the sun, for example, and having substantial conversation with some lightheartedness, then talking a walk. There would be teaching and relationship building. We need to take action fast, and prevent the horrible tragedies of mental illness ignored until too late. I believe states will find within their budgets for home mental health professionals. One observation from one of the bills, the call for a Mental Health authority in the White House is most fascinating, offering a prestige that could prove significantly beneficial. Let's give it a try.

pnelson48
pnelson48

As someone who suffers from bipolar disorder myself I feel strongly that expanding involuntary civil commitment alone is NOT the answer. We need to put more resources into community-based outpatient treatment with more pathways to choose from. This will make it more likely we can convince the client to voluntarily access treatment. The mentally ill are no more likely to be violent than the general community.

StephenBonin
StephenBonin

@pnelson48 I agree with you about developing positive outpatient programs. The paradigm of locking away is of the past, is gruesome. Removed from that and an improvement, inpatient programs, the spaces inherently unfriendly to a patient's progress today because they're old, noisy, and not aligned with current research. What do you regard as most effective in outpatient services? For me, support group meetings, counseling when needed, and the love of friends and family (including receiving education from them) in freedom! Ability to move about in the beautiful creation that nourishes us so, with people who  nourish us so. Thank you for contributing your thought.

pnelson48
pnelson48

@StephenBonin @pnelson48  You're spot on. I have the support of my wife, my bible study group of 40 years and my folk club open-mike. Unfortunately, when I'm depressed I dig a hole and jump into it. I drop out of all these things until my mood swings up again. I'd really like to cope better with my black moods.

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