Involuntary Outpatient Commitment

The Mental Health Association in New Jersey (MHANJ) has publicly taken a strong position against Involuntary Outpatient Commitment (IOC) and, over the past three years, has opposed a number of bills that would establish it in New Jersey. We believe that this form of forced treatment would not solve the problems of severely ill individuals being unable to access services in the community or rejecting treatment that they believe does not help them. And many legislators, after hearing both sides of the issue, have agreed with us and concluded that IOC is not the answer. (Visit www.mhanj.org to read MHANJ’s full policy position on IOC.)

With the release of the Governor’s Mental Health Task Force report in March, 2005, MHANJ learned that the task force included an “additional recommendation” in favor of IOC, based on the principles “that no move to IOC should take place in New Jersey unless and until adequate, appropriate services are available in the community for those who voluntarily seek them,” and “that the development of an adequate system of community care is an absolute precondition for the adoption of IOC.”

During July, the task force held a special hearing of the Senate Health and Senior Services Committee meant to educate the committee members about this complicated issue in anticipation of the task force’s IOC bill being formally introduced in the legislature in the fall. Unfortunately, no consumers were asked to testify.

On September 26, 2005, Senate Bill S2760 (Co-Sponsors Senator Richard Codey (D-27) and Senator Gerry Cardinale (R-39)) was formally introduced in the Senate and referred to the Senate Health Committee. MHANJ and the Consumer Advocacy Partnership testified in opposition to the bill, in addition to consumers George Brice, who is the Vice Chairman of the Governor’s Mental Health Task Force, Peggy Swarbrick, and Marta Espinvera.

MHANJ has reviewed Senate Bill 2760 and has notified the Governor’s office that we will continue to work vigorously to inform the legislature about our serious opposition to the practice of IOC, and S2760 in particular. After analyzing the bill with consumers, our policy committee, and supportive partner organizations, MHANJ remains opposed to the concept of IOC and believes that this bill has many shortcomings:

Capacity of New Jersey’s Mental Health System

If we accept that the purpose of IOC is to bring treatment to the seriously mentally ill, we must also accept that, before we establish such legislation, we must implement services with the additional $40 million added in the FY’05—’06 budget in June of this year. And because of the critical nature of the problem, we must then evaluate the effect that these new services have on efforts to solve it. Then, and only then, should New Jersey even consider establishing a practice as complicated, as expensive and as unproven as IOC. While $40 million is not enough to establish an “adequate system of community care,” it will add significant resources in critical areas, such as screening centers. Rushing to implement a coercive system with inadequate resources is self-defeating.

While 42 other states have some form of IOC, most claim not to use the legislation because they haven’t made the necessary increases in services, especially integrated treatment for substance abuse and mental illness. (See Lack of Integrated Treatment for Co-Occurring Disorders.) In New York, where supporters claim that IOC is working, the legislature voted to add $180 million annually to the state’s mental health budget, more than four times the $40 million just added months ago to New Jersey’s system.

Too Broad of a Standard for “Dangerousness”

S2760 changes New Jersey’s current standard for dangerousness (to oneself, others, or property) in two critical, and potentially harmful ways: 1) It establishes one standard for both inpatient and outpatient commitment and 2) It broadens the standard to such an extent that a judge would be able to commit someone without any specific data about how he or she poses a danger now. The proposed bill allows a person’s history to enter into the decision without any guidelines about how long ago the person may have been dangerous. And, it allows the judge to consider that a person may become dangerous with far less evidence of that inevitability. Even more troublesome, S2760 directs the judge to consider “the generally accepted professional literature” that indicates that a person’s clinical indications are “associated with a significantly increased likelihood of behavior harmful to self or others.”

Abuse of Civil Rights

Unfortunately, the standard leaves much room for abuse of the civil liberties of people who are competent, yet refuse treatment for any of a number of valid reasons. And it seriously puts at risk the civil rights of people who are members of minority cultures, who live in poverty and are already over-represented in jails, prisons, psychiatric institutions, shelters and on the streets. In New York, where IOC has been in place for five years, data shows that disproportionately more people of color were involuntarily committed to outpatient services than other groups. This trend is likely to continue with the standard proposed in S2760.

Lack of an Appropriation for the Cost of Administration

In states where IOC exists and is used, such as New York, budgets must also include the cost of administration. In its Fiscal Year 2000-2001 budget alone, New York included $9.6 million just for the costs of implementing the law. That number closely approaches the $10 million we just added to the Screening Center budgets in June, and all experts agree that those programs need more than the FY’05-‘06 appropriation that finally begins to fund the centers as planned when the Screening and Commitment Law was passed in 1987. S2760 offers no plan for how New Jersey will pay for these costs.

Lack of Integrated Treatment for Co-Occurring Disorders

The Governor’s Mental Health Task Force recommended that New Jersey wait until the Fiscal Year ’06-’07 budget to increase funding for co-occurring programs and services, despite the fact that 100% of the estimated 400 people the task force wants to involuntarily commit to outpatient treatment suffers from both mental illness and substance abuse.

MHANJ has long advocated for New Jersey to significantly increase funding for integrated programs that treat both conditions. Here in New Jersey, we know anecdotally from county systems review teams, that 75% to 85% of people brought to screening centers for psychiatric evaluation have substance abuse as the most recent factor leading to the existing crisis. Substance abuse plays a major role in both disrupting people’s lives and precipitating violence. It is more difficult for people with co-occurring disorders to recover than any group with a single diagnosis. This population fits the description of the “most difficult to treat” and that of the “resistant to treatment” group who allegedly would benefit from IOC. Before New Jersey considers establishing IOC, we should respond to this critical need by funding integrated treatment services.

Lack of Participation of the Consumer

S2760 fails to include the consumers themselves in plans for treatment and for progression to less restrictive settings. In the year 2005, this oversight is unconscionable and unacceptable.

Abuse of Rights to Due Process

S2760 calls for procedures that screeners, doctors, judges, court personnel, caseworkers, and police would follow in the process of committing a person to outpatient treatment that actually provide lesser rights than those already in place: S2760 calls for fair hearings at less frequent intervals and puts the onus on the consumer to request a hearing to be moved from an inpatient to an outpatient setting. It calls for an inordinate amount of time before a consumer gets even an initial hearing and it fails to define a process whereby a consumer could ever be released from IOC.

Lack of an Evaluation Plan

S2760 includes no plans for evaluating IOC’s effectiveness, or lack thereof. Given the controversial nature of this debate, and the lack of national data supporting measurable outcomes, MHANJ would expect to see a quality, unbiased plan for evaluating IOC.

No Evidence Base

MHANJ has studied all research—controlled and uncontrolled, anecdotal and scientifically based, randomized and not. No evidence exists that IOC leads to better outcomes for people with mental illness. In simple terms, there is no relationship between IOC and recovery. In fact, according to a review of the research in 2005 by the Cochran Collaboration, an organization that maintains a database of systematic reviews of clinical trials:

“Only two relevant trials were found and these provided little evidence of efficacy on any outcomes such as health service use, social functioning, mental state, quality of life or satisfaction with care. No data were available for cost and unclear presentation of data made it impossible to assess the effect on mental state and most aspects of satisfaction with care. In terms of numbers needed to treat, it would take 85 outpatient commitment orders to prevent 1 readmission, 27 to prevent 1 episode of homelessness and 238 to prevent 1 arrest."

For more information about MHANJ’s efforts to block the passage of S2760, please contact our offices in Verona (973-571-4100) or Trenton (609-656-0110). Our Government Affairs staff is available at any time to present our policy on this issue and our serious and growing concerns about establishing IOC in New Jersey.

“The Lien Law”

As you know, MHANJ worked relentlessly with our partners (NAMI-NJ, Community Health Law Project, NJ Protection and Advocacy, NJ Association of Mental Health Agencies and the Consumer Advocacy Partnership) to amend “the lien law” in such a way that consumers and family members could be treated fairly when liens were placed against their assets and property as a result of stays in our state hospitals. The amended law, Senate Bill 880 (Turner (D-15) and Kavanaugh (R-16)) and its Assembly companion, A 779 (Gusciora (D-15), Weinberg (D-37), Watson-Coleman (D-15) and Wisniewski (D-19)) were passed in time for the entire mental health community to celebrate its signing by Governor Codey at the Mental Health Summit held on March 31, 2005.

The new legislation goes into effect on September 21, 2005. After that date, people who are hospitalized and who are issued liens for the cost of that care will be subject to Charity Care guidelines when it comes to repaying the debt.

If you’ve already incurred a debt and have a lien against you, and want to remove those burdens from your life as you recover, you can write to the Department of Human Services (DHS) requesting “discharge” of both the lien and the debt. (Please note that discharge does not happen automatically; citizens must “affirmatively request” the discharge by contacting DHS.)

The Department will then ask you to supply specific forms of financial information that will help them determine whether you can afford to repay the debt. They’ll also check the original Court Order of Support that would have been completed by your county adjuster when you were originally admitted. In many cases, these orders will show that you were not able to afford the hospital costs for the care you needed. Other documents will most likely show that you are not able to repay the debt now that you’ve been discharged.

With this information, DHS will invite you to compromise using standards that MHANJ and our partners believe are fair. During this compromise process, you will learn how much, if any, you need to pay the state to “satisfy” your obligations.

MHANJ and our partners strongly urge you to discuss your individual case with an attorney at NJ Protection and Advocacy before engaging in the process of discharging your lien. These experts can help you decide whether it’s beneficial to you to attempt to discharge your lien and remove your debt. You can reach these attorneys by calling their offices in Trenton:
800-922-7233.

Consumers Prevail

MHANJ welcomes back New Jersey’s most beloved consumer advocate, Jack Bucher, after a serious illness that prevented him from participating in the FY ‘05-’06 Budget battle, in which consumers, once again, prevailed. In addition to persuading the legislature to pass Governor Codey’s $40 million to fund new mental health initiatives, consumers once again made the case for open access to medication. We convinced the legislature to remove the co-pays from Medicaid, paving the way for New Jersey to lead the nation’s fight to prevent federal cuts now being proposed to Medicaid. And consumers who are “dually eligible” for Medicare and Medicaid, most notably Bonnie Rosenthal and Jeff Sherzer, convinced the legislature that New Jersey must fund a $20 million “wraparound” to cover the costs of their medications when the federal Medicare Modernization Act goes into effect on January 1, 2006.

The Loss of an Advocate

The entire consumer community joins in saying goodbye to Donna Nicholls, longtime advocate from Mercer County, who passed away on June 17, 2005. Donna was a tireless leader at the Reach Out/Speak Out Self-Help Center in Trenton, where she mobilized consumers to participate in all major hearings, rallies, and legislative forums. Even from a wheelchair, Donna rallied the members of the center to make their voices heard. We mourn her loss together.