Online NewsLetter

The Case For Caring Coercion

Recently, half the patients on the dual-diagnosis unit at Sheppard Pratt were homeless. Even if staff could begin meaningful treatment in the three to four days their managed care companies allowed, it was clear that discharge would lead to readmission in the near future. It is becoming alarmingly apparent that as inpatient care wanes, vigorous outpatient treatment must take its place. But how will this work for those patients who do not take their medications or defy therapeutic efforts? They, too, stay a shorter time in the hospital. The revolving door of hospitalization for mental illness has already become a huge turnstile, disgorging mental patients onto the street or into jails. What is to be done?

One solution is that of involuntary outpatient treatment. Thus, a paranoid schizophrenic with a history of multiple rehospitalizations for dangerousness will be informed by authorities that he must comply with outpatient treatment and take his medication or he will be detained against his will. A welfare recipient with substance abuse will be told that he must submit to urine testing and therapy or face the cut off of his welfare benefits. And an attorney is warned that she must have treatment for alcoholism or suffer the loss of her license to practice law. These and other constraints on the freedoms of patients already comprise the elements of mandatory therapy in such states as Massachusetts and Washington. Yet society remains troubled by coercive treatment. Legislatures are loathe to impose such regulations on constituencies. Ironically, it is the patient advocacy groups such as NAMI who press for coercive treatments even more than victims of crimes such as pedophilia.

Historically, most of the seriously mentally ill in Western society have been confined to institutions against their will. Fear of violence-to self or others-especially from delusional individuals or those behaving erratically has traditionally justified the concept of involuntary hospitalization. But in recent decades, the civil rights of those very mentally ill have triumphed. These victories have led to grave deficiencies in treatment as patients are released from the hospital prematurely. Paralleling this phenomenon is the very essence of hospitalization, an event which has changed dramatically with managed care. Patients are now admitted not simply because they are ill, but because they are dangerous. The criteria for retention within the hospital is continued risk, but nothing more. Thus after a few days of what is called "crisis stabilization," the patient's insurance is halted and he is put out or, in severe cases, transferred to a state hospital. There, too, stays are shortened. Fashioning itself like the private counterpart, the public sector has eliminated any semblance of refuge. Once functioning as a community haven for the ill, state hospitals are barren real estate with boarded up units, empty recreation halls, and vending machines instead of kitchens.

The psychopharmacologic treatment of severe mental illness has had a paradoxically contributing effect to abrupt hospital stays. Rather than augmenting care, drug treatment has counterintuitively undercut it by effecting acute symptomatic relief at the price of long term treatment. Patients are rapidly medicated, then released as if the core illness was abolished. The truth is otherwise. Core illness takes great time to effect and requires the full range of individual and social therapies. But few hospitals have full-time art or occupational therapists on their staffs any more. Psychosocial therapies are seen as luxuries, not necessities. Leaves of absence to test improvement are no longer allowed.

Discharge without adequate treatment has created a vast new set of problems. In the last four decades, hundreds of thousands of patients have been deinstitutionalized. Some have managed well with supporting housing, rehabilitation, and community outpatient settings. But for others, the return to the community is a phantom concept. Many have gone from the hospital to the street, and from the street to jail. As long ago as 1939, Penrose demonstrated a negative correlation between the portion of people in a given nation placed in mental hospitals and the portion held in jail. In 1999 the Department of Justice reported that as much as 16 percent of the population of state jails and prisons suffer from several mental illnesses. This translates to more than 250,000 individuals. Housing 3,500 and 2,800 mentally ill inmates respectively, the Los Angeles County jail and New York Riker's Island jail are currently the two largest psychiatric inpatient treatment facilities in the country. This warehousing of the mentally ill in jails and prisons harkens back to the deplorable conditions in the nineteenth century which prompted Dorothea Dix and the Quakers, who founded Sheppard Pratt in Baltimore, to develop asylum care.

We have, then, expanding populations of partially treated severely ill patients flowing into our communities. In 1995, Torrey and Kaplan estimated that 250,000 individuals were living in the community who just a few decades before would have been patients in state psychiatric hospitals. Yet we know full well that an episode of mental illness may last many months, if not years. What, then, is the recourse for patients who need help to remain functional?

As of today, 40 states and the District of Columbia have outpatient commitment statutes, although most of these states implement this authority in a haphazard and inconsistent manner. Generally, some form of tragedy has spawned the creation of an outpatient law; for instance, the case of Andrew Goldstein who pushed Kendra Webdale onto the subway tracks in New York ultimately led to the passage of "Kendra's Law" establishing mandatory outpatient treatment in New York. But this is a drastic case. Are less extreme cases eligible for coercive treatment?

I believe we have little choice in the matter if we are to meaningfully treat the mental patients in our country. Doing something to someone else for "their own good" is fraught with ethical and moral dangers. To insure a democracy, there must be checks and balances, rights to hearings, advocates, and judges. I call for a "caring coercion." I believe rather than abandon our mentally ill, we can thoughtfully attempt to treat them outside the hospital. Day and partial care facilities can be constructed. The hospital milieu-once a haven of healing-will need to be resurrected in spaces once bordered by locked doors and shatter-proof windows. And novelty and innovation will be requisite; simple legislation is not enough. In November of this year, President Clinton signed a bill that authorized funding of up to 100 mental health courts for nonviolent offenders who are mentally ill. Building on models from Broward County, Florida and King County, Washington, this initiative would have special judges hear cases involving persons with mental illness who committed nonviolent crimes. These judges would decide whether the offender should be placed in outpatient or inpatient treatment programs to be monitored closely. Simultaneously, grants also will be awarded to local governments to set up the training of law enforcement officials and judiciary personnel to identify and address the unique needs of mentally ill offenders. These alternatives, though far superior to simple incarceration, still await meaningful implementation. Most community mental health centers are not equipped to handle mentally ill offenders. There must exist all those techniques and modalities which would be available within a hospital. This is hardly a casual undertaking. The coercion must be a caring one insofar as there is present a panoply of services-a full hospital without walls. If we can erect such institutions, we can begin to erase the shame of our untreated mentally ill.

Steven S. Sharfstein, M.D.
President, Medical Director & Chief Executive Officer
Sheppard Pratt Health System


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