FIG1 Michigan has joined 24
other states in giving courts, police officers, psychiatrists, mental health
professionals, and families with a means of forcing people with mental illness
into treatment rather than jail.
Wayne Creelman, M.D: "The outpatient commitment law...is
especially helpful in the care of patients when substance abuse is a
complication to underlying psychiatric pathology."
The law, signed by Gov. Jennifer Granholm (D) late last month, goes into
Named for a college student in Kalamazoo killed by a person who had been in
and out of mental health care, Kevin's Law allows judges to order treatment
for people who are not following a regimen recommended by a psychiatrist or
mental health professional.
People may be subject to such court orders only if they have been
hospitalized or imprisoned in the previous three years or acted violently
toward themselves or others in the previous four years.
Since the nationwide closing of psychiatric hospitals beginning in the
1970s, states have had little power to mandate mental health care, unless
someone is dangerous or convicted of a crime. Family members and advocates for
mentally ill individuals in Michigan have pushed for Kevin's Law since 2001.
Public awareness that the state's mental health care system is broken helped
create a consensus for the bill this year.
State Sen. Tom George (R), who introduced the bill, said that it will
improve public safety, especially in urban areas, where patient treatment is
concentrated, and provide the treatment that people with mental illness often
have trouble getting.
A similar law in New York State, Kendra's Law, resulted in a 83 percent
reduction in arrests, an 86 percent reduction in homelessness, and a 67
percent reduction in poor medication compliance among people ordered to
receive treatment, according to the New York State Office of Mental Health.
George is the only physician in the Michigan Senate and has a brother who
suffers from mental illness.
The constitutionality of similar laws in other states has been challenged,
so far without success.
"I think a good job was done by advocates in working with the
sponsors on rights protection issues under these new bills," Mark
Reinstein, Ph.D., president and CEO of the Mental Health Association in
Michigan, told Psychiatric News.
"The potential downside is that this area can't be perfectly
legislated. We could spend the rest of our lives always coming up with one
more `what if' that hadn't previously been covered. So the question becomes:
How well will our first crack at this work?"
While many in the mental health community believe the legislation is
needed, they also recognize that some fine-tuning may be in order in the next
couple of years.
Reinstein claimed that Michigan simply has way too many problems with
incarceration and homelessness of untreated mentally ill populations to sit
back and not take this step.
"I realize that some persons with mental illness are against mandated
treatment," the director of Michigan's Alliance for the Mentally Ill,
Hugh Huebl, M.D., told Psychiatric News. "But when you consider
that Kevin's Law pertains to persons who already have become a part of the
criminal justice system because of their illness, it is hard for me to see any
downside to mandated treatment under those circumstances."
Huebl thinks more attention should be directed to families struggling to
cope with members who are psychotic, delusional, and sometimes paranoid and
whose behavior is grossly detrimental, inappropriate, abusive, and socially
unacceptable. He said these individuals often do not realize they are ill.
"I have recently dealt with several such cases, and if they do get a
court order and their loved one is picked up by the police, most of time it is
fruitless because the criteria of imminent danger to self or others is too
stringent, and either the person is not admitted to a facility, or they are
kept for too short a period of time, or the judge turns the person loose and
they are back where they started from," he explained.
Huebl said that mothers are often left holding the bag, because of
estrangement of siblings, husbands, or ex-husbands. Some community mental
health agencies are opposed to providing more appropriate care, because it
will cost more money, which only complicates the problem.
"I think the present way of dealing with these situations is
unconscionable and inexcusable. I am all for rescuing and mandating care in
these circumstances. If it were me, and the person refused medications, I
would confine them indefinitely until they finally would come to realize that
they needed help."
In one judge's opinion, Kevin's Law needs to be fine-tuned to make it more
practicable. "Some requirements, such as the need for two additional
witnesses, could make it difficult to implement," Milton Mack, chief
judge of the Wayne County Probate Court, told Psychiatric News.
The law requires a lay witness to testify to the facts of the case and an
expert witness to determine whether the person is mentally ill and, if so,
whether the person meets the criteria for involuntary inpatient treatment. In
addition, testimony is needed from an expert witness aware of certain prior
acts by the person. The treating physician would know that but never appears
in court, according to Mack.
"Getting an expert witness to testify about the person's history
sounds simple, but you need to get someone on the stand who has intimate
knowledge of the person to do that," he said.
He believes the law would work better in some rural counties where
witnesses can be easier to find. But in high-population counties it might run
"Sometimes I think I need to be Dr. Mack as well as Judge Mack
because the statute appears to give me the authority to decide what kinds of
medications should be administered. And at the hearing I can enter a judgment
regarding case management."
Under the law a judge can decide whether blood and urine tests should be
used to check compliance with the effectiveness of medications, whether the
person gets individual or group therapy and attends a day or partial day
program, whether the person gets educational or vocational training, and
whether there should be supervised or unsupervised living arrangements.
"A doctor doesn't have to make these decisions. I do. And I'm not a
Mack agreed with the Mental Health Commission's recommendation that if
someone has a mental illness, the judge should get an order for treatment for
180 days. If the person gets better in the interim, he or she can have another
court appointment and have the order rescinded. After that the community
mental health agency would manage the patient.
"Being able to order outpatient treatment under Kevin's Law is a good
idea because we live in an outpatient world. But unfortunately the Mental
Health Code is an inpatient model," said Mack
Mack doesn't feel comfortable being so closely involved with what
medications a person with mental illness should have.
"It's not my role or expertise. I don't think the patient will be
well served by me making that decision."
The president of the Michigan Psychiatric Society, Wayne Creelman, M.D.,
told Psychiatric News that the district branch "has been very
supportive of Kevin's Law all along."
"As always with legislation, the devil is in the details of its
implementation," Creelman said. "The outpatient commitment law,
however, is especially helpful in the care of patients when substance abuse is
a complication to underlying psychiatric pathology in that [the law] allows
caregivers to assist their patient population in the least-restrictive
environment possible." ▪