Outpatient Commitment Garners Broad Support

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.

The law, signed by Gov. Jennifer Granholm (D) late last month, goes into effect immediately.

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 into difficulties.

“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 doctor.”

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.” ▪