Helping Families Deal with Mental Illness, with Jonathan Stanley, J.D.
An estimated 4.5 million Americans today suffer from the severest forms of mental illness, schizophrenia (2.2 million) and bipolar disorder (2.3 million). According to the National Advisory Mental Health Council, an estimated 1.8 million people of these individuals are not receiving treatment on any given day, resulting in homelessness, incarceration, victimization, and violence. The reasons for this are many, and include fragmented mental health systems, economic factors, the failure of deinstitutionalization, civil liberty issues as well as the effects of the illnesses themselves.
The legal criteria that must be met in order for a person with a severe mental illness to be hospitalized are very stringent. When a person is overcome by the symptoms of a mental illness and refuses needed psychiatric care, the law will only permit a intervention to provide treatment if there is an extreme crisis. This is normally the case even when the person is rendered incapable of making rational treatment decisions. Although the language differs from state to state, most commitment laws require that the person’s condition manifest an immediate danger of physical harm to himself or others before being placed in treatment. This is the standard in New York for involuntary hospitalization. Being forced to wait until a person incapacitated by a severe mental illness presents an actual danger most often leaves family members and treatment providers waiting for an extreme crisis in order to take action.
In 1999, New York’s legislature established Kendra’s Law, which offers a less restrictive community treatment as an alternative to inpatient hospitalization. Kendra’s Law (New York Mental Hygiene Law § 9.60) allows courts to order certain individuals with severe psychiatric disorders to comply with treatment while living in the community. This court-ordered treatment is called assisted outpatient treatment.
The criteria to place someone in assisted outpatient treatment are easier to meet than the “imminent dangerousness” required for inpatient commitment in New York. The key eligibility requirement of Kendra’s Law allows someone to be ordered into treatment “to prevent a relapse or deterioration which would likely result in serious harm to the patient or others.” In other words, there is no need to wait until a deteriorating consumer actually is dangerous to self or others, as in the inpatient standard; under Kendra’s Law you can start procedures to “prevent a relapse” that could lead to dangerousness.
The New York State Office of Mental Health reports that, of those in its AOT program, 74% fewer experienced homelessness, 77% less psychiatric hospitalization, 83% fewer arrest, and 87% percent less incarceration. Moreover, 55% fewer recipients engaged in suicide attempts or physical harm to themselves; 47% fewer harmed others Three out of every four of the program participants reported that Kendra’s Law had helped them regain control of their lives; four out of five said that AOT helped them to get and stay well.
Preparing for a Crisis
Assisted outpatient treatment is a new and effective tool, but it is not a panacea. Even with the availability of Kendra’s Law, most families must still wait for an extraordinary crisis before the law permits an intervention with needed psychiatric care for a loved one who is incapacitated by a mental illness. The events necessary to trigger commitment laws can be among the most trying and hectic imaginable. Distraught family members have to react minute by minute to a deluge of circumstances. It is not a time for either efficient thought or strategizing, which is why preparing for a possible crisis is critical.
Possible ways to become “ready” for a psychiatric crisis:
- Know your state’s standard for intervention and familiarize yourself with its provisions for commitments. The pertinent statutes for each state are in the Legal Resource section at www.psychlaws.org. Your state or local mental health departments may be able to provide materials summarizing them. Some jurisdictions allow direct petitioning for commitments. In these jurisdictions, the clerk at the local court should have copies of the petition form.
- Learn the screening facility or local emergency room that performs emergency psychiatric evaluations. When a crisis arises, provide the treating staff with treatment history, including past responses to various medications. It is best to provide information both in person and in writing
- Alert the local mental health crisis units. These outreach workers typically conduct on site evaluations and often are empowered to initiate commitments. They are also likely to be called by law enforcement to assist in crises involving an individual overcome by a psychiatric disorder. It is best to provide information both in person and in writinSimilarly, make your local law enforcement agency aware of the person’s condition in case officers or deputies are called to initiate an emergency evaluation or to respond to a disturbance. Eliminating the element of surprise will reduce risk of a call escalating into a crisis. If the agency has a crisis intervention team or other types of dedicated mental health officers, you should try to arrange for them to respond to any call. Again, giving the information in person and in writing will increase the chance that it is available to responding personnel.
- Document the person’s psychiatric history as fully as possible. It is unlikely that treating professionals will have access to the full medical records of a person brought in for an emergency evaluation, especially at first. Documentation of past treatment can also be used as evidence in commitment hearings.
- Keep a journal that documents the person’s illness and significant problems it causes. Journal entries should concentrate on observable facts. Being able to provide specific dates and contemporaneous descriptions of events is a substantial advantage for someone testifying in a treatment hearing or trying to convince a treating professional of the severity of a person’s illness.
- Have ready both a recent picture of your loved one as well as a list of vital statistics, such as height, age, weight, hair color, clothing, and any pertinent physical medical conditions (like allergies or diabetes). Ideally, keep these in format that allows them to be either faxed or e-mailed to police and mental health agencies.
- Keep a lt of emergency numbers, including those for the treating psychiatrist, emergency psychiatric receiving facility, local emergency room, mental health crisis unit, other mental health professionals, crisis intervention team, law enforcement, etc.
- Contact your local NAMI chapter. NAMI (formerly the National Alliance for the Mentally Ill) is the largest support and advocacy organization devoted to the care of people with severe mental illness. It is mainly made up of people with psychiatric disorders and, most especially, their families. A local chapter will usually have bi-weekly or monthly support meetings and its leaders are almost always willing to advise on the treatment system and procedures in their area. NAMI’s national website, which includes contact information for its state and local chapters, is at www.NAMI.org. NAMI-NY’s website is at www.naminys.org