Advocates Response to the Boston Globe's Spotlight on Mental Health

The Globe Spotlight report on the current state of the Massachusetts mental health system raises important issues, but the main solution offered – Involuntary Outpatient Commitment (IOC) – in our view is simplistic and dangerous to the rights of many people with mental health conditions, and would actually drive many people away from care.

We understand the pain of families whose loved ones refuse psychiatric care, and we know from our colleagues at the National Alliance for the Mentally Ill (NAMI) that this is an all-too-common occurrence. We appreciate that families in these circumstances can feel desperate for a solution that will return their loved one to them. We share these families’ experience that the current system of care is inadequately funded and under-resourced.  People facing serious mental health challenges and their families deserve an accessible, friendly, comprehensive and coordinated system of care.  Although the problem of suffering people refusing care is a complex issue, deserving deep analysis, we oppose IOC for four reasons:

1. IOC is a blunt instrument for dealing with the situation of people refusing care. Unless it were enacted with great care and attention to the legal rights and legitimate preferences of the persons involved, and unless it were focused on the tiny minority of people who refuse medications and who pose substantial risks of harm, it runs a great risk of depriving many people of the fundamental liberty of making their own health care decisions, and potentially driving people away from care.  A Duke University study noted that mandated treatment may serve as a barrier to care, adversely affecting both treatment adherence and therapeutic alliance.
    
2. To enact IOC with such proper care and attention would require a vast infrastructure – both legal and clinical – which does not currently exist, and which would be enormously expensive to build, requiring resources that would be more effectively spent on a full array of community based, non-coercive services that include alternatives to traditional care. 
    
3. To a great extent, the suffering of the families described in the Globe article reflects the dearth of non-coercive, recovery-based, and family-oriented services currently available to individuals and families experiencing these struggles. Suffering alone at home, waiting until the situation meets the bar of imminent dangerousness, only to be admitted to a short-term unit where clinicians have little to offer other than medications and no way of connecting the person or family to real resources in the community, represents a failure of our community system that we must vow to remedy.  This will require an investment of resources.
    
4. The evidence for IOC is not strong.  The longstanding involuntary outpatient commitment laws in states such as Virginia and Colorado have not helped to avoid tragedy.   In the Virginia Tech tragedy, the perpetrator was under an involuntary outpatient commitment order and a clinician and the court made a determination that he was not dangerous.  Similarly, in Colorado, it has been reported that the gunman in the 2012 Aurora movie theater shooting had seen at least three mental health professionals prior to the shooting and apparently none had determined that he met the standard for inpatient or outpatient commitment.

Studies that have shown some positive outcomes from IOC emphasize that IOC is only one aspect of broad reforms that include resources to support a comprehensive array of community based services.  In New York, for example, the implementation of Kendra’s Law also included $125 million to fund more than 60 Assertive Community Treatment Teams and 2,000 supported housing beds. 

Most people who decline psychiatric medications do so because they are exercising a choice – they find the medications unhelpful, toxic, or simply that the benefits do not outweigh the risks to their health and wellbeing, as they understand them. Very few refuse medications in a way that is truly dangerous, as the tragic stories in the Globe illustrate.

Rather than implement a blunt and costly approach like IOC, which may hurt and alienate many in an attempt to address this limited but real risk, we call for a comprehensive conversation – ideally championed by the Governor in the spirit of the effort devoted to the opioid crisis – to bring together people with lived experience, families, providers, NAMI, and funders to find solutions that will promote safety, protect rights and effectively support the individuals and families who are suffering. Together, surely we can find a way.

Christopher Gordon, MD
Medical Director and Senior Vice President of Clinical Services

Diane Gould, LICSW
President and CEO

Keith Scott
Vice President of Peer Supports and Self Advocacy