To treat or not
Tuesday, February 22, 2005
by Jessica Adler
Herald News
In the kitchen of Chet O'Brien's cramped attic apartment, 30 pigeons preen inside bird cages stacked floor to ceiling. Their cooing fills the room. O'Brien faces eviction at the end of February, for the fifth time in less than 10 years. It always comes down to the pigeons, he says - the pigeons and his two pit bulls, whose barking contributes to the cacophony. He just won't give them up.
"The way I live, I love it," says O'Brien, 34. He holds his favorite bird, Chico, in the palm of his hand, stroking its white feathers.
His mother, Corraine Conoway, will no longer visit his Section 8 apartment in Nutley. She can't stand it: the clothing and blankets strewn about the living room; the fly strip hanging in the kitchen, speckled with months' worth of catches; the stench of the birds, the dogs, the cats. Conoway thinks her son's mental health explains the way he lives. He has been diagnosed with schizo-affective disorder, an illness characterized by mood swings and thought disorders. If he were on medication and in a structured and monitored living situation, she believes, both their lives would improve dramatically. Recently, Conoway glimpsed a ray of hope: N.J. Senate bill 1640 (S1640). The proposed legislation, which was introduced in June, would make New Jersey one of 42 states to legalize involuntary outpatient commitment (IOC). If it eventually passes both houses of the Legislature and is signed by the governor, individuals with mental illness could be court-mandated to take medication and undergo treatment to control their symptoms. A community mental health or social services agency would assume responsibility for administering medication and treatment on an outpatient basis.
"It's a way to stop the madness," Conoway says. "All the information will be presented to a judge, and a judge will make the ruling and the ruling will be enforced."
But S1640 may prove to be a disappointment for Conoway and others like her. The law is likely to be less far-reaching than the buzz surrounding it.
Involuntary outpatient commitment is one of the biggest issues in the mental health field. On Wednesday, in Trenton, the state's Mental Health Task Force will hear from experts on the subject. (IOC is one of nearly two dozen mental health issues being examined by the task force, which will deliver its recommendations to Acting Gov. Richard Codey on March 31.)
Opponents of S1640 are likely to call IOC an intrusion on civil rights and an insufficient quick fix for people who do not meet the requirements for inpatient care and will not seek help for themselves. Its supporters will argue that it can help those incapable of helping themselves - those who cycle in and out of state psychiatric hospitals and jails because they fail to take prescribed medications or follow through with treatment.
There is a middle ground in the debate. It comes from the National Alliance for the Mentally Ill (NAMI), which argues that IOC legislation should be passed, provided it comes with enough money to fund the services it promises and ensures adequate protection of patients' rights.
"It's very clear there is a group of people who are desperately in need of mental health treatment and either don't recognize it or don't access it," says Phillip Lubitz, director of advocacy programs at NAMI.
Lubitz can understand the frustration of caretakers like Conoway and the relief they perceive in IOC. "Parents have the mental health system there to help them," he says. "But they have to stand by and watch their children deteriorate. It's is an enormously emotional issue. And I think that's because the mental health system has really failed people at both ends."
Conoway knows that only too well. She has spent much of her son's life fighting to get him the psychiatric help she feels he needs. The first time she took him for inpatient psychiatric care was in 1986, when he was 15. She remembers driving away from St. Clare's Hospital in Denville and looking back to see her son pressed against a window, his arms spread wide "like Jesus on the cross." She still cries when she thinks about it.
O'Brien - he kept the name of Conoway's first husband - detests structured living. He does not work (Supplemental Security Income provides for his expenses) and likes to stay up late and sleep late; he likes to come and go as he pleases. Over the years, psychiatrists have prescribed antidepressants and anti-psychotic medications for him. He says they cause unpleasant side effects - blackouts and sexual dysfunction, among them — so he stopped taking them. Once he turned 18, he gained control of how much, or how little, medicine and therapy he would accept. The result, his mother says, has meant chaos for both of them.
"It's year after year of situations - involvement with hospitals, doctor referrals, evaluations," she says.
Conoway's sentiments echo those of countless caretakers seeking to navigate a fragmented and underfunded mental health system for a resistant patient. But S1640 is far from the panacea they are hoping for.
As S1640 now stands, IOC can be applied only to mentally ill individuals who are incapable of making an informed medical decision, have a history of noncompliance with treatment or may become a danger to themselves, others or property, and for whom no other services are appropriate. All of these requirements must be met. They will likely need to be altered if IOC is to gain support, says Robert N. Davison, director of the Mental Health Task Force and executive director of the Mental Health Association of Essex County.
New York's "Kendra's Law," which officials are using as a model for New Jersey's legislation, has stricter requirements for applying IOC, including violent behavior or hospitalization resulting from treatment non-compliance. Under both states' laws, an individual can be involuntarily committed to a state psychiatric hospital if he or she fails to comply with a court order.
Kendra's Law provides "another level of care for the most difficult cases in the community," says Jeff Keller, deputy director of NAMI New York State, which is based in Albany. Keller, who is writing a report to be released in March about the successes and shortfalls of New York's IOC law, says a court-ordered treatment plan has an important effect, beyond providing guidelines for a patient.
"Historically, providers have cherry-picked cases," he says. "They're reluctant to treat the most difficult cases. A treatment plan binds providers to provide treatment. It gets the consumer to collaborate, and it gets the providers to collaborate."
Last month, at public hearings sponsored by the Mental Health Task Force, the mother of an 11-year-old Marlton, N.J., boy testified that outpatient commitment might have saved her son, who was murdered in 2002 by a man diagnosed with paranoid schizophrenia.
The IOC laws in New York and California - "Kendra's Law" and "Laura's Law," respectively - are named after victims murdered by mentally ill people who reportedly refused to comply with treatment. New Jersey's pending law is known by some as "Gregory's Law" for Gregory Katsnelson, the murdered child.
"Most people with mental illness are able to manage their illness, but there is a group of people who don't have that benefit," says Mary Zdanowicz, executive director of the Virginia-based Treatment Advocacy Center (TAC), a strong proponent of IOC. "We are talking about a very small number of people."
Since its enactment in 1999, for example, New York's "Kendra's Law" has led to the court-ordered treatment of 3,908 patients - fewer than 1 percent of New York's mentally ill population. If New Jersey's law mirrors New York's, it would result in court-ordered treatment for 330 people per year, says Zdanowicz.
Chet O'Brien probably would not be one of them. Several mental health professionals to whom his situation was described said it seemed as though his history would not meet the criteria for involuntary commitment.
Regardless of how few people IOC may affect, some detractors still oppose it. They say S1640 could overtax an already strapped mental health system, jeopardizing care for voluntary patients.
Furthermore, they say, if the system were better funded and more cohesive, involuntary outpatient commitment wouldn't be necessary, because existing outpatient services would be adequate.
"It blames the victim for what's going wrong with the system," says Carolyn Beauchamp, president and chief executive officer of the Mental Health Association of New Jersey.
Opponents also express concern about the underlying principal of S1640, which they call a gross infringement on civil liberties that undermines decades of progress toward protecting the rights of the mentally ill."One thing we cherish when we talk about constitutional protections is the right to choose which medical treatment to take," says Michael Allen, senior staff attorney at the Bazelon Center for Mental Health Law in Washington, D.C.
Conoway, for one, is tired of hearing arguments about civil liberties. She believes caregivers have rights, too. She shakes her head when her son says, "People should be able to make their own decisions."She has watched him cycle in and out of special-needs schools and psychiatric programs. Last year alone, she went to court nearly a dozen times to deal with his latest eviction. She says she has left hundreds of messages for counselors and community mental health advocates, trying to avert the next mishap before it happens. It's gotten her nowhere, she says. But she can't, and won't, turn her back on him. He is, after all, her son.
Conoway grows impatient hearing S1640 being called an underfunded "Band-aid" solution to a systemic problem. Even though IOC probably won't apply to her son, she clings to the hope that S1640 will pass in a form that could help him gain control over his mental health and his living conditions. And, in turn, bring some normalcy to her life.
"This could affect a lot of people," she says with a stubborn optimism. "Not just the (patient), but the caretakers, too."
Reach Jessica Adler at (973) 569-7169 or adler@northjersey.com.