July 21, 1999


Panelists: Paul Stavis, Xavier Amador , Howard Telson

MARILYN MOSES: Today, this afternoon, we're here to hear about the issues surrounding securing compliance for persons with mental illness. And I'm very happy to be moderating this panel today.

My name is Marilyn Moses. I'm with the National Institute of Justice. And one of my reasons for being so thrilled about being asked to moderate this panel is that recently I learned, within the past 30 to 60 days, that in the development division, I will be taking over all of the correctional health care for NIJ in the development division, and that includes all of medical and mental health.

So that is going to be a very new and exciting thing for me. I have had a long history in corrections, but nothing really specifically relating to this area of corrections. So, again, it's been an exciting time for me in the past 30 days to be learning more and more about the complexities of this issue, and I look forward to hearing from our panelists today and learning, as I know you will.

Before I introduce the panelists, I did want to bring to your attention the most recent publications that are out. And I know that, again, some of you who were in the earlier session know about these, but those of you who weren't, are not, I wanted to bring these to your attention. Actually, this publication is an NIJ research preview and it's entitled "Adolescent Girls - The Role of Depression in the Development of Delinquency." And this is really just a day old. It's hot off the press. So you might want to see if you can pick this up at NCJRS booth downstairs, or you might want to find another way through the web site or some other way to pick this up, or just give us a call.

Also, if you were in the last presentation, you probably heard about this particular program, and this is an NIJ program focus on Maryland's Community Criminal Justice Treatment Program. And the last publication I wanted to draw to your attention, which is also relatively new, is the BJS report on mental health and treatment of inmates and probationers. So these are three of the latest publications that we've had come out from agencies within the OJP family.

And now, without further delay, I would like to introduce our panelists, and I will introduce them in the order in which they will speak to you. The first is Paul Stavis. Mr. Stavis is the Director of the Law and Psychiatry Center and an Associate Professor of Law and Psychiatry at the George Mason University School of Law.

In addition to its academic responsibilities, the Law and Psychiatry Center is devoted to developing new statutes, programs, and policies to enhance the treatment of persons with mental illness. Mr. Stavis will be speaking to us today about a number of issues, transinstitutionalization and, more specifically, statutes and legal issues that help to create the dilemma that we find ourselves in today.

Our second speaker will be Dr. Xavier Amador.

XAVIER AMADOR: Xavier. Sorry.

MARILYN MOSES: Okay. He is an Associate Professor of Psychiatry at Columbia University and at the College of Physicians and Surgeons at Columbia University. He is the Director of the Diagnosis and Evaluation Center at Columbia and the New York State Psychiatric Institute. The title of his presentation today is "I am not sick, I do not need help." And he'll be speaking specifically about compliance issues among schizophrenics and the issue generally.

And our final speaker this afternoon is Dr. Howard Telson. Dr. Telson has an extensive experience as a community psychiatrist. He has spent seven years as a Unit Chief at Bellevue Continuing Treatment Program, which provides comprehensive psychiatric treatment, case management, and transitional housing to homeless men with severe mental illness. Since 1995 he has been the Clinical Director of the Bellevue Outpatient Commitment Pilot Program. He's also the Clinical Director of the Visiting Nurse Service of New York's Intensive Case Management Program, which currently serves about 400 mentally ill individuals throughout Manhattan. And he will be talking about his experiences out in the field.

Again, I'm very grateful for all of you for coming today, and I'm sure that we're anxious to hear what they have to say. And I'd like to get out of the way because I'm kind of fearing that there might be some sort of AV stuff that might transpire and they'll need time to kind of make sure that that all clicks for you. So thank you.

PAUL STAVIS: Good morning, ladies and gentlemen. It's my pleasure to be here on behalf of the Law and Psychiatry Center to talk to you about some of the issues that I'll be dealing with and that I'm concerned with.

I'd like to start with a story about Sherlock Holmes, where Holmes and Watson were on a camping trip. And after a good meal and a bottle of wine, they lay down for the night to go to sleep. Some hours later, Holmes awoke and he nudged his faithful friend. "Watson, look up at the sky and tell me what you see," he said. Watson replied, "Well, Holmes, I see millions and millions of stars." "Very good, very good," replied the master. "And what does that tell you?"

Watson pondered for a minute and, with a smile, he gave Holmes a full accounting, saying, "Well, astronomically, it tells me there are millions and millions of galaxies and potentially billions of planets. Astrologically, I observe that Saturn is in Leo. Horologically, I deduce that the time is approximately a quarter past three. "Theologically, I can see that God is all powerful and that we are small and insignificant. And meteorologically, I suspect we will have a beautiful day tomorrow. What does it tell you, Holmes?" Well, the master paused in silence for a minute and then spoke, saying, "Watson, you idiot, it means someone stole our tent."

Now, I think what the story illustrates is that we can get so caught up in concepts and principles and systems that we forget that we have a lot of homeless out there without tents. Indeed, it is ironic that there was no government mental health policy and no institutions and no asylums before the early 1800s. Benjamin Franklin, as a matter of fact, started one of the first ones in the world. Before that, the mentally ill wandered from town to town without government help or treatment. They relied on charity and individuals. And it seems 200 years later, we're in a very similar position of having the homeless, mentally ill wander from town to town.

So, therefore, I want to talk about this phenomenon called deinstitutionalization or transinstitutionalization. I wanted to find the problem and, perhaps, the social mess we've created. Secondly, I want to talk about the fundamental change in government policies that I believe has brought a lot of this about, including legislative policies and judicial involvement. And thirdly, I would like to suggest some ameliorative ideas.

The problem. You will all undoubtedly remember the scene from the movie "The Graduate" where Mr. Robinson gives the Dustin Hoffman character one word of advice: "Plastics." Unfortunately, I didn't take that advice but went into law. That's the bad news. But the good news is that my own career in law began with another one-word description as a young lawyer, and that was "deinstitutionalization."

I was principally responsible for representing the State of New York in the seminal deinstitutionalization case known as Willowbrook, where things were at their worst. How much worse can you get when the federal judge is threatening to hold the governor of the state and the commissioner in contempt of court? That's when they brought me on to solve that problem.

The Willowbrook Developmental Center, if you don't know, was the largest institution for persons with mental disability -- in this case, retardation -- in the entire world. You might also know that it really made Geraldo Rivera's career, because he was the one that exposed the horrors, and these horrors included medical experiments, one of which being injecting the residents with hepatitis.

So Willowbrook and many other health institutions gave themselves a very bad reputation not only over the decades, but over the centuries for care and treatment, and unforgivable scandals were uncovered. Indeed, if you study the history of mental hospitals since their creation in the early 18th and 19th Century, you will see that these major scandals often were the impetus for reform and, eventually, for deinstitutionalization. So let's take a quick snapshot of institutionalization, what was it and what is it.

If you look at this pie chart, you will see what it was like as best we know in 1880. And you will see that the mentally ill or, as they were called, the insane, half were at home, roughly half were in hospitals, and a very small portion were in jails. Only about 4 percent.

Now we skip ahead to the present time. This is the pie chart. You will see that 93 percent are in communities. That's the institutionalization. We've gone from over half a million people, which, if you extrapolate it today, would be a million people in institutions if we took the 1950s numbers, and 93 percent of them are out. Only 2 percent are in hospitals and 5 percent are in jails, although that figure is probably wrong given the recent DOJ study that just came out. It's probably more like 15 to 20 percent are in jails.

Consequently, the people who are in the community are -- this is another column chart of it. These are the people who are in the community and not receiving treatment. You'll see that approximately 40 percent of the people with mental illnesses that should be treated are not being treated. Consequently, they're winding up in jail. As one recent article by a New York State Supreme Court Justice said, "Jails have become the dumping ground for the mentally ill." Indeed, jails are now the only place where many of these individuals can get treatment. So we've really gone back to the future, as the movie says.

Point two. What happened? Well, if you want a very good eyewitness account, then you must read Senator Daniel Patrick Moynihan's account of the institutionalization in a monogram he wrote for the American Scholar entitled "Defining Deviancy Down." Senator Moynihan tells of being on New York Governor Harriman's staff in the early 1950s when the psychotropic drug Rolwolfo was discovered.

Before this discovery of this category or family of phenothiazine drugs, there were two techniques for controlling patients with severe mental illness that manifests in violent or uncontrolled behavior. It was known as B and B, brutality and barbiturates. But now with the discovery of these drugs, it was thought, as Moynihan discusses, that they could be released from the hospitals and put in the hospital.

Moynihan then goes on to talk about his membership in the John F. Kennedy Brain Trust, when the Community Mental Health Systems Act was created in 1963, which, by the way, was the last public law that President Kennedy signed before he was assassinated. This law heavily skewed federal funding and derogation of institutions and in favor of community care. Institutions were believed to be evil and had no purpose and would be shut down, and they were choked off from federal funding.

Now, on the judicial front, the federal courts became a potent force in setting state policy toward the mentally ill. The only common denominator between the courts and the federal executive legislative policy was that both deplored and sought to extinguish the institution. Otherwise, there was no coordination. Many lawsuits were filed under the Civil Rights Act of 1871. 1871. A rediscovered, very old law captioned 42 United States Code Section 1983. It's known as 1983 Lawsuits. And these challenged institutional care, as well as other state policies on mental illness, not without some cynicism and irony.

States entered into consent judgments not only conceding what were the rights of patients that were violated, but, quizzically, often conceding more than they were required to by the law, by the court, and by the plaintiffs themselves. States actually used these lawsuits to help expedite the closing of institutions. And there were other motivations, not the least of which was economic.

Institutions were financial dinosaurs, fantastically expensive and requiring the heavy support of state labor unions and work forces. There was little constituency for continuing them and no federal funding to do so. Surprisingly, however, when some of these cases were contested by appeal to the United States Supreme Court, the high court refused to find or expand constitutional rights that necessitated better or more treatment. Rather, the Supreme Court erected barriers to treatment, much in the same tile of Miranda Warnings; that is, judge-invented due process. The same phenomenon occurred, which I'll describe to you.

The court held that institutions did not have to be closed as a matter of constitutional law. The court also set very minimum quality of care standards, but this was little more than longstanding law that had been developed in the prison cases and in human rights standards. Indeed, the court only required that the states not substantially deviate from professional standards. Thus, in terms of substantive due process law -- substantive meaning affecting the treatment itself -- the court did very little. However, in the Miranda type due process, the high court jumped in with both feet. The court's involvement had, in my judgment, a disastrous effect and greatly contributed to the problems we have now.

Last Sunday my parish priest taught of teaching the Ten Commandments to a class of fourth-graders. "What commandment, he asked the congregation, "tells us how to treat our parents?" A precocious little girl answered quickly, "Honor thy father and mother." Very good," said the priest to the little girl. "And now can you tell me what commandment tells you how to treat your big brother?" The little girl said, "Sure. I know that. Do not kill."

Now, what the court has done in terms of the parents is they've made government a one-parent family. They have, in the words of the film a few years ago, thrown mama from the train. That's what the Supreme Court did, and it did it in a case called O'Connor versus Donaldson. Before the Donaldson case, government had a fatherly power and a motherly power. They had the power to treat people under the police power, that if people were violent, disruptive, to keep order as a father does. And they have power as a mother to nurture, to educate, and to cure disease. But the O'Connor versus Donaldson case -- let me say also that this is not a distant analogy. If you read the preamble to the Constitution, the police power, fatherly power, and the motherly power are talked about. The government's inherent power to provide for the common defense, to ensure domestic tranquility is the police power and the fatherly power. The motherly power is the welfare power, to nurture, educate. In the preamble's words, "to promote the general welfare and provide the blessings of liberty for ourselves and our prosperity."

Government's power to compulsorily treat a person with mental illness has historically been accomplished under both powers. For persons who are dangerous but not criminal, as having non compos mentis, not the mental awareness to be evil, the government used its civil powers. For persons who are mentally ill and in need of care and treatment and incompetent to recognize the need, the government acted as a mother would with a young child who would refuse a polio shot. Given the choice, the child obviously -- and I have a one-year-old who just had one -- would not want that shot, but you force the child to have it because you know it's in their best interest and they do not have right reason at that age.

That's the principle which goes back, I'm sure you can realize, into ancient history, and that's the power which O'Connor versus Donaldson killed, because that case held that someone must be found dangerous to themselves or others for the state to have authority to act. So the motherly power is thrown off the train.

Now, a person may be dangerous to others or not, but what about the person who is just generally mentally ill The agoraphobic who won't leave the house. The manic depressive person who's really not a danger. Indeed, this distinction came to very sharp light in a case you might remember called the case of Billie Boggs, from New York City, also known as Joyce Brown. This became a national case. She lived on 2nd Avenue and 65th Street near Swinson's Restaurant for two years. Summer, winter, spring, and fall, she peed in the streets, she yelled at people, yet she survived and she was fairly healthy. And she was taken by Mayor Koch's program to be treated for three days before the Civil Liberties Union commenced litigation to liberate her. While under treatment, as a result of the treatment, she appeared at Harvard to lecture the law students there and appeared on the Phil Donahue show to decry the treatment she had been made to accept. She was freed by the trial judge, but his decision was later reversed by the appellate courts.

The essence of the case was that the courts couldn't make up their mind as to whether Ms. Boggs was a danger to herself and others. After all, she camped on a sidewalk grate, toileted in the streets, screamed at various passers-by, but stayed physically healthy all the while. It created a terrible ambiguity, because I will bet that neither you nor I could do that.

The judiciary's taken a peculiar position on mental illness. Given that the courts are usually the front line repository of the state's parens patriae power, its motherly power, the position has been one of erecting barriers to treatment and refusing to scrutinize the treatment that's rendered. Post O'Connor versus Donaldson decision -- and that was decided in '75 -- the courts, especially the Supreme Court, have erected --and judicially erected, like Miranda -- a mandated pseudocriminal model for the treatment of the mentally and severely ill. Note well the similarities.

Evidence. The court mandates that the state must carry a very heavy burden of proof to justify treatment, which is the civil law equivalent of beyond a reasonable doubt. It's called clear and convincing, but it's the same thing. In most other civil matters, particularly when the government is behaving benevolently, courts give states a lesser than standard burden of proof.

They presume the state's regularity, and they don't make the state waste a lot of resources -- not waste -- strike that word -- use a lot of resources of lawyers and money and courts to meet the high standard, which, in effect, is a presumption against treatment. It's like a presumption of innocence. You're presumed not to need this treatment, even though the state's experts say you do. And that's the decision of the Supreme Court.

Defense lawyers were assigned any patient who's going to be treated by the state. Now, the United States has 5 percent of the world's population. We have 75 percent of the lawyers. And being a lawyer, I am not against assigning lawyers to these individuals -- it's a serious decision -- if society's willing to pay for it, and pay for it in a way that -- it's a zero sum gain. It takes money away from treatment. Fine. But the problem here is not that itself. The problem is that these lawyers, by and large, have accepted a criminal law model of the rule of ethics; that is, they zealously resist the treatment, even when in their own hearts they know it's correct and even when their patient is incompetent to direct them. They will assume the patient should not get the treatment.

Other problems is that in some states, like Virginia, no lawyer is provided for the proponent of care, for the state, the hospital, the parents, the social worker. So, in effect, you've got Pete Sampras playing tennis against me. There's no contest.

One thing the Law and Psychiatry Center is doing is, we have paid for a clinic program where we have third-year law students practicing under the supervision of a professor, who we pay for, go into the courts and represent the components of care. It's made a difference in 95 percent of the cases you've got a lawyer versus lawyer. In fact, it's estimated by the students to make a difference in the 95 percent of the cases.

New civil liabilities have been created under constitutional law and, thus, automatically have federal jurisdiction. So if you're a professional, the state has, in effect, put the sword of Damocles over your head that you might have more treatment areas of potential liability to the patient.

The big case was Zinnermon versus Burch. This is a quote from the case: "The characteristics of mental illness create special problems regarding informed consent. Even if the state usually might be justified in taking at face value a person's request for admission to a hospital for medical treatment, it may not be justified in doing so without further inquiry as to the mentally ill person's request for admission and treatment at a mental hospital."

So, in effect, the court is saying that you can't rely on your own professional judgment. You might need more due process. You might need a committee at the hospital. You might need a second opinion. They didn't say what, but it's another barrier to treatment. And if you make a mistake here, you will find yourself being sued for money damages in federal court, which is not a pleasant experience, even though the state or your care provider might provide reimbursement or indemnity or lawyers and so forth. So another barrier to treatment the court has raised.

Most recently, courts have been requiring -- not the Supreme Court, but -- well, to some extent the Supreme Court, but mostly state courts -- have been requiring hearings for those already committed pursuant to hearing and already found by the high standard of evidence to need psychiatric care, yet they hold another hearing on the issue of whether they should be given drug A or drug B. And it's all over again the same type of hearing.

The Supreme Court has gotten involved in that issue, but not heavily. As I say, all they require is no substantial deviation from professional standards. But what's ironic about these drug cases is that in about 90 to 98 percent of the time, the judge just ratifies what was proposed in the first place, and they cost $10,000 and more each to do it. The question arises from public policy view, does it make any sense? Are we spending money on these formal court proceedings that require lawyers and papers and judges' time and law clerks' time to ratify decisions already made, not even counting the cost in treatment and delayed treatment and so forth?

The last and most pernicious effect is an ironic one, too, that comes from these health decisions, and I've alluded to it before, that many times the bureaucracy welcomes these and cooperates with the lawsuit. Why? Well, it gives a bureaucracy great leverage over the legislative and executive branches and invariably enhances their budgets, because they need money to comply with the judgments.

I could tell you a funny story -- I don't have time for it -- when I was a young lawyer, but I didn't understand that when I was 27 years old. I wanted to get the commission off of a consent judgment. I went through the whole strategy, and he put his arm around me and said, "Well, kid, just keep me out of jail." He was being cited for contempt. And I said to my boss, "I don't understand this. I can nullify this judgment. He wants to stay under the jurisdiction of the court." I was 27 years old. I didn't realize he was getting another 100 million dollars for his department and so forth and so on. So that's an irony of this.

Secondly, the states are trying to back out of the direct care treatment, and to the extent that these cases make treatment more difficult, the patients fall into the criminal justice system. And that's less money out of the mental hygiene budget and more money for them to spend on other things.

So a quick summary, then I'm going to give you four -- if I have time for this -- this is just a summary. It's the lack of federal funding. Here are the cases I'm talking about, but I can give you those afterwards. I want to get to the most important thing, I think, and that's, you know, what would I do about it, and that's in part what I'm doing, being Director of the Law and Psychiatry Center, I came down here to do. Here are some of my ideas, which we can talk about later.

First, we've got to make -- my overall idea I call spectrum of care. There's got to be care for the appropriate person. I often explain this in the simplest terms I can as parents. We all know about parents. You want your kid to eat spinach. You say, "Please eat your spinach." If he says, "No," you say, "Well, I'll take you to the Great Escape Park on Saturday." If he doesn't do it then, you kind of, you know, lecture him and get angry. If that doesn't work, so forth and so forth and so on, and he's going to put his hand on the stove. You might even whack him in the rear end. Got forbid we hit a kid today. But something really, you know, immediate and serious. You might even go to that extent. That's how you respond.

That's how we should respond to patients who need treatment. We should try to persuade them. We should try to get their cooperation and then work-up the chain. But institutions, some people need to be hospitalized, will need to be hospitalized all their lives. We ought to make hospitals decent places. It's not a question of their inherent evilness. It's a question of mismanagement. We need oversight bodies and so forth. That's all I'm going to say about institutions.

From there we need outpatient institutional treatment because it's a lot better than being in a hospital, and oftentimes, as I think, Dr. Telson's going to talk about, you'll see in his Bellevue study, which he ran wonderfully I might add, is that most patients could be persuaded to do the right thing. All right. That's number three.

I'm working on a very new approach to advanced directives. They're called living wills, where I hope at the appropriate time, when the patient is feeling good, when the patient is rational, when the patient realizes the benefits of being sane, of being healthy, of feeling good, that you sit and say, "Hey, isn't that nice?" Why don't we sit down and make an agreement for treatment if you ever decompensate again. We will give you reasonable terms, reasonable discretion into choosing your treatment, as long as it isn't worse from our point of view."

And lastly, alternative dispute resolution. This is a very big issue, but summarize it very quickly by saying there is no case decision that requires court hearings, drug hearings to be held by a court of law. In fact, the Supreme Court and high federal courts have recently approved informal panels to do it as long as they are properly appointed by the legislature, and they do it better. So I think that what we should do in the future is come up with special kind of dispute resolutions to determine competency, determine appropriate treatment with the kind of independent review that the courts have required. These would comply with all statutory mandates. So those are some of my ideas, and those are some problems that I see, and I thank very much for you attention.

MARILYN MOSES: Thank you very much. That was a very energetic presentation that I could tell you spent a lot of time on, and I appreciate that. It also kind of took me back to my six years in a law practice. So I don't know whether that was good or bad, but it did bring back memories for me. Thank you, Mr. Stavis. And this sets us up for our next presentation that is entitled "I am not sick, I don't need help." Thank you.

XAVIER AMADOR: I forgot that I called the talk "I'm not sick, I don't need help." And I'm not referring to myself, just so you know. Yeah. I'm going to make an assumption that you're in this room because you understand something about the problem of the seriously mentally ill and the need for ongoing treatment, so I'm going to give a short shrift to some of the data that's related to why this is so important.

You know, Paul said something very quickly off the cuff; if they don't take their medications, they end up in jail. And I can give you at least one reference for very good data and bibliographies. It's E. Fuller Torry's book Out of the Shadows: Confronting America's Mental Illness Crisis. And I'd encourage you to look at that book. There are other sources. If you contact me, I'll e-mail some web sites to you as well.

You're coming here from diverse positions, I saw from the attendees' list. Some of you are running various types of programs that are involved in law enforcement and other agencies. So I think the thing that ties us all together here is some acknowledgment of the problem and what can we do about it. I'm reminded as I'm standing here -- and by the way, I'm very happy to be invited to be here, extremely happy for one particular reason. I get called upon a lot over the last year and a half by public defenders mostly, federal public defenders and local public defenders to consult and to help them out with cases.

I'm not a forensic psychologist, never wanted to be a forensic psychologist, but as it turns out, my area of research, which has been on poor insight into illness and non-compliance with medication, is very meaningful to people who are defending defendants like Ted Kaczynski or -- I was not involved in the Russell Weston case, but that's a prime example of somebody who really -- the two men that he shot and killed I am absolutely certain would be alive today had Russell Weston been in treatment. I think it would be very difficult to make a case otherwise.

Ted Kaczynski, which is a case that I did consult on and ended up making friends with his brother -- and I'll tell you why at the end of my talk very briefly and why this is such an important issue to me. David Kaczynski said to me that "My mother and I, for about 10 years, tried desperately to get him help. There was absolutely no way we can do it. We contacted local authorities in Montana. My mom wanted to camp out in his land for three years."

How many people and how many millions of dollars spent on finding this man and prosecuting this man and defending this man could have been saved, and much more importantly, the lives that would have been saved. So this is an issue that, unfortunately, because of the headlines, there is some interest in finally, I think, on a national level, and there is very good data that can be used for anyone who wants to make a difference, who want to put people who would otherwise either be on the streets or holed up in their apartments planning their defense based on some delusion they have into treatment.

So that's what I'm going to focus on today, which is basically some key data that I think is valuable and important. And the missing tent, by the way, from my perspective, is understanding why these people don't want to take their medication. The facts are there. One out of two people with a serious mental illness -- I'm talking about schizophrenia, manic depression, other psychotic disorders. One out of two typically do not take their medications, or if they do, they're erratic about it. That translates, by the way, into over two and a half million people in this country. The number one cause of poor compliance is lack of awareness of the illness.

Now, think about that for a moment. It has a lot of implications for policy. It has a lot of implications for the kinds of solutions that Paul was suggesting and for the program that Dr. Telson ran, which I think is a model program. These are people who are being told, "You're ill. Sir, you're ill. You need to take this medication." So I want to start with, to me, the missing tent, which is -- it's the person who doesn't believe they're ill and what we can do about that.

Some solutions were talked about earlier this morning. I'm reminded that my first -- by the way, my very first job in mental health was working for the Tucson Police Department in a mobile acute crisis team and going out and meeting the officers on the scene who thought that maybe they were dealing with a mentally ill patient. It was a diversion program. Highly effective in every way that it was evaluated. Certainly financially it was effective. What they realized in Tucson at that time -- this is almost 20 years ago now -- was that they were dealing with people who didn't understand that they were ill, weren't taking their medication, and as a result were breaking the law.

What I'd like to do is just briefly show a couple minutes of a tape. And this is somebody -- just let me give you a one minute or less description of this man who has had a 10-year history of schizophrenia. This tape's about nine years old. But at the time he had had a 10-year history of schizophrenia, multiple involuntary admissions to the hospital, processed through the judicial system twice for attacks on his mother, consequence of a delusion that he had that she was, at various times, trying to kill him, trying to steal money from him.

Now, I'm interviewing him on a schizophrenia research unit. He had gone to a city hospital in New York City involuntarily. After a month, he voluntarily signed himself into this Columbia University. We get a lot of patients that's way. It's kind of coerced admission, I think. Not that we're coercing them, but they're in the situation where they're involuntarily being treated and they're told, "If you go to this unit voluntarily, you can get out of here." So that's this gentleman's situation. Hallucinations, delusions, long history of schizophrenia, multiple hospitalizations. And let's hear just quickly what he has to say about why he's in the hospital.


XAVIER AMADOR: He says, "I've been pretty much cooperating." This is somebody who's now stable, does not think his mother is the threat. What does he say about why he's in the hospital? It's kind of bizarre, isn't it? He's there for a general physical. He knows he's in a psychiatric hospital, but he's there because of an argument with his mother. I can't tell you how many times I've heard that, that reasoning for why I'm in the hospital.

Now, when I was in training, people told me this was defensiveness. These are people with serious mental illness. They just -- they don't get it or they're being stubborn or too proud. After all, in this country, and in most countries, it's very stigmatizing to be mentally ill. That, to me, doesn't look like defensiveness.

And let me share a premise I have about these disorders that comes from 15 years of doing research with people with psychotic disorders. These are brain disorders. There is no question anymore in the scientific community that we're dealing with structural abnormalities of the brain and functional abnormalities of the brain. The brain's working differently. It's clear. It's obvious. Schizophrenia, bipolar disorder is not caused by hard knocks growing up. It's not caused by bad parenting. The laws that have been written both for competency to stand trial, competency to confess, competency to refuse treatment, all those laws were written during a period of time when American psychiatry and, for that matter, global psychiatry didn't have the tools that we have today. So we need to close the gap between science and practice. We need to get the information out there.

So with that introduction, let me talk briefly just about the prevalence and some of the causes of the problem that I just demonstrated with this particular interview. Could I have the slide projector?

One of the first things that I was interested in finding out -- because clinically I saw how common the problem with poor insight was. You know, here you are trying to help somebody with getting treatment. They say, "I don't need treatment. I'm not sick. I don't need help. Go away."

Other literature -- and back in 1973 there was an international study by the World Health Organization, and they just asked one question among the dozens of question; "Do you think you're ill?" And they reported that 81 percent of over 800 patients from around the world with schizophrenia did not think they were ill. I think it a little bit of an overestimate, and I'm not going to go into the details now as to why. But that study was replicated in 1986. Very similar methodology, worldwide study, multi-national. And they found of 768 patients, nearly 90 percent said, "I'm not ill." Now, these are people who are going to psychiatric hospitals. Everyone around them says they're ill. What's going on here?

Well, we had an opportunity to ask the question in a lot more detail. And this study was published in the Archives of General Psychiatry in 1995, I think. And what we did was, during what were called field trials for the revision of the Diagnostic and Statistical Manual for Mental Disorders; that is the main manual used to diagnose mental illness in this country. We attached an assessment, a very detailed assessment of awareness of the illness. Can I have the next slide?

The first question I had was, "How many of these patients" -- now, I'm just talking about schizophrenia patients here, but, by the way, this --in the interest of time, I just ask you to take my word for it -- generalizes to psychotic patients more generally, these numbers. There's a reason I'm focusing on schizophrenia, which will become apparent in a moment. Approximately 60 percent were moderately to severely unaware of the illness. Now, what does that mean? Nothing's wrong with me. They were like this gentleman. It has nothing to do with any kind of emotional problem, nervous breakdown. We didn't make them say, "I have schizophrenia." Very, very clearly they thought nothing was wrong with them. Forty percent said, "Something's wrong with me." Doesn't mean they necessarily accept the treatment. We did something else that nobody had ever done before, which was to evaluate awareness of the signs and symptoms of the illness. Could I have the next slide?

There's one error here on the delusions, but let me just quickly walk you through it. Fifty percent of the patients were unaware of their hallucinations. It's actually 60 percent were unaware of their delusions, which is really interesting by the way. Think about it. Over 50 percent of what I'm not showing of -- this was 221 patients with schizophrenia. Over 50 percent knew they had hallucinations. If you started hallucinating today, what would you do? Go to your neurologist, wouldn't you? If you don't have a neurologist, you'd get one. Well, in a similar kind of way, half of the patients, over 100 of these patients, knew that something's weird; these voices aren't real.

Delusions. It's complex. How do you evaluate knowledge of a false belief? But, in fact, we found that about 47 percent -- this is an error, sorry. It's an old slide. -- 47 percent knew they had delusions. They said, "I know the belief is crazy. I know it's implausible. Sometimes I'm not so sure it's true."

Thought disorder. This guy had some thought disorder. Right? That confused disorganized speech. About 45 percent unaware. And these are negative symptoms. Flat affect, ambigonia, associality, symptoms that we often evaluate even to make the diagnosis of schizophrenia. And very large proportions of the patients just weren't aware of the symptoms that we use to diagnose and to recommend treatment. So that creates a big problem. If they don't even see the signs and symptoms, how the heck are they going to say, "I'm ill, yes, sure, give me these powerful psychiatric medications"? Next slide?

This is -- I'm very sorry. In looking for slides, content is exactly the same, but I didn't bring my updated slides. This is pretty old. This is 10 years old. There have been easily, I would say, 50 studies since that time. There's been a real explosion of research on this topic in American psychiatry -- actually, worldwide in psychiatric research.

But basically these various studies indicate that no matter how you measure insight, there's a variety of ways to measure it. No matter how you measure compliance with medication, pill counts, blood levels, a variety of different ways -- and for those of you who do research, you know that when you measure something in a variety of different ways, you often get garage. You know, garbage in, garbage out. But if it's a robust finding -- in other words, if the phenomenon is out there, if the relationship exists and it's really strong -- it almost doesn't matter how you measure it. May I have the next slide?

So what's causing this? What are the determinants? Is it psychological defense? I won't tell you about the data, but we have data, and also from my clinical experience I don't think it is. Is it culturally determined or is this a neuropsychological deficit? In other words, another symptom of the disorder. Now, by culturally determined -- actually, in the interest of time, let's skip over to the next slide. Just keep going.

Let me tell you why I first wondered if this was neuropsychologically determined. I worked in a neurology department during an externship at Beth- Israel Hospital in New York and worked with a lot of patients with stroke, head injury, cancer. And many patients with these kinds of brain disorders suffer a syndrome called anosognosia where they are literally unaware of the illness. This is something that's been cited for a long, long time. Even people with cortical blindness can go through a period of not being aware that they're blind.

This is an example that I thought was really nice. Seneca commenting. This is 2,000 years ago. On the moral implications of self-beliefs describe what appears to be a case of hemianopia, cortical blindness. And he writes, "Incredible as it might appear, she does not know that she's blind. Therefore, again and again she asks her guardian to take her elsewhere. She claims that my home is dark."

Now, neurological terms, we call that a confabulation, that last comment. She's trying to understand how this conception of herself isn't fitting with what's happening. She doesn't understand that she can no longer see. And we see that in schizophrenia. The more classic examples of anosognosia come from stroke patients who are paralyzed on one side of their body. They don't know they're paralyzed. When you ask them to move their arm, they say things like, "Well, I don't feel like it." They confabulate.

I think that the patient that I showed you does a very similar thing when he says things like, "I'm in here for a general physical." He's not lying. He has a normal IQ, by the way, slightly above average IQ. This is not somebody who's got general intellectual decline. Turns out in schizophrenia research, a lot of people are finding that the frontal lobes, among other areas, aren't working properly. Well, it turns out that in the neurological literature, patients with anosognosia, with this syndrome, can develop the syndrome after injury to the frontal lobes. So we threw that out to the research community about 10 years ago, and very quickly the studies started coming in. In the interest of time, I won't review them in detail, but I'll tell you that there are now -- the original study, I think, was done in '93 by Donald Young and his colleagues from Toronto, and there have now been six replications of it.

What are they finding? That frontal lobe dysfunction and schizophrenia is associated with deficits in awareness of the illness. This has implications for, I think, policy, public policy, for law enforcement, for programs like advanced directives and assisted outpatient treatment, because now we're talking about people who, just like somebody with Alzheimer's, are refusing treatment because of the illness.

And I will say one last thing, which is that this is something -- this syndrome in schizophrenia and bipolar disorder is one that can be reliably assessed and evaluated. And the more people are aware of that, I think the less fear there will be that we're somehow doing harm to citizens when we incarcerate them in a hospital. Thank you.

MARILYN MOSES: Thank you very much. I know, as many of you know who were in the last session that we had on this issue, this program focus on Maryland's Community Criminal Justice Treatment Program, I actually managed the development of this publication. And as a part of that, I did spend several -- I'd say cumulatively almost half a month to a month travelling throughout Maryland's counties, 18 counties that were participating in this program, and I can tell you from the interviews that we had in those situations that that was what you were pointing out to; the lack of awareness and poor insight was abundantly clear. And it's a wonderful segue to Dr. Howard Telson, who will be speaking to us next about his experiences in Bellevue.

HOWARD TELSON: Thanks. A lot of the background for this talk I think has been covered in the previous two talks, so I just want to the highlight the way I view the historical development of what's occurred in this country in terms of caring for people with serious mental illness and to talk about our experience in New York City trying to develop a solution. Seems to me in the late 18th Century we recognized, really, more in Britain and France and Italy that there was such a thing as mental illness. Before that, it was clear that people acted in a strange way. There was even the term "insanity" and the notion that mental illness had existed historically for millennia, but physicians decided to define more carefully what constituted mental illness.

So the profession of psychiatry started, and we developed a notion that people who may be behaving strangely may not be morally responsible or morally negligent, but they may have an illness for which treatment is indicated.

In the early 19th Century we developed hospitals, and it turned out that treatment worked. We didn't have new psychotropic medications. It was clear that there there was something about the hospital environment, the humanitarian interest in helping people, milieu treatment, whatever, that made it clear that treatment worked. The next step was that people started asking during the reform period before the civil war, "If treatment works for people who can afford it, why aren't the indigent allowed to have treatment?" And there was great advocacy to have the states become responsible for caring for those who couldn't care for themselves.

Dorothy Addix, somebody you may have heard of, really developed her interest in this while working in the Cambridge City Jail. And what Mr. Stavis was saying before about how we've really come right around to that period is quite true. This was in the period before the civil war, and she recognized that people with mental illness were being terribly treated in jails and started a campaign going state to state, imploring legislatures to spend money to provide hospital treatment, medical treatment for those with mental illness.

Well, that happened, and it was successful, and all of those principles that were talked about in terms of the state's responsibility to provide treatment not only for those who were dangerous to self or others but also for those who needed treatment became well-established. And the almshouse population of people with mental illness diminished significantly. The jail population diminished significantly. People were treated in hospitals.

Well, flash to a century forward. The hospitals weren't funded well enough. There were new medical developments. There were new legal developments. And for a variety of reasons, there was a judgment that maybe community care would be better. That's not necessarily bad, although I think in the rejection of the hospitals and in the change of the notion about hospitals as therapeutic environments as opposed to incarceration environments, I think that we went too far. And that resulted in the policy of deinstitutionalization, where people with serious mental illness were thought to do better in the community. There was a presumption, though, they would accept voluntary treatment and that that treatment would be available.

The Community Mental Health Act that was discussed before was never really fully funded. Community resources were never put into place. But also the assumptions about people understanding their illness and their need for treatment, as Doctor Amador was talking about, was just absolutely neglected. So we wound up really, I think, losing a lot of the progress that we had gained. And basically with commitment law reform in the '70s falling on the heels of deinstitutionalization, what we said was parens patriae need for treatment was no longer reasonable, that people had to be dangerous. So we wound up with this vast population of people with serious mental illness for whom there were no hospital beds. They were not eligible for involuntary treatment because they were not felt to be dangerous. Everybody in the community knew that they were very sick. Where did they go?

Well, now we're looking at the statistics and recognizing that a lot of them are in jails and prisons now. Ten years ago we recognized a lot of them were homeless. I would assert that we really went too far and that the state maintains a responsibility to take care of those who can't care for themselves, and the obligation should be in the least restrictive setting; and if hospital care is not appropriate, then it's the obligation of the state to provide community care, and it's the obligation of the state to tell the patient, "Yes, you are ill, whether or not you believe that you're ill, and we have a treatment that we think is going to help you, and we're doing this in your best interest."

In New York there is a strong civil liberties tradition, and outpatient commitment is an intervention which has developed along with the institutionalization a little bit later. It's really one of the mechanisms to address the revolving door syndrome. And the revolving door syndrome basically is what we see with people who become dangerous, require involuntary hospitalization, do well, are stabilized, are discharged, don't follow up with treatment, and because there's no mechanism to keep them in treatment, they wind up decompensating, becoming dangerous and winding up back in the hospital, going through the revolving door. And various mechanisms have been developed.

I'm not going to go into detail about that, but informal coercive mechanisms are used, and it's important to recognize that; that if we don't make these mechanisms legal, people are going to use coercion anyway. It would be better not to deny that reality. Obviously, mechanisms like conditional release and guardianship are also available. They may not be used very much, but they're certainly legal.

Dr. Jeffrey Geller has written a paper on guidelines for the use of outpatient commitment, specifically which is defined as the use of a court order to require a patient to accept treatment. Dr. Geller indicates that to be eligible, the patient should have a history of failing in the community, express an interest in living in the community, have the degree of competence necessary to understand and abide by the court order, and not be dangerous when complying with the court order.

The treatment service must have demonstrated efficacy when used properly and be sufficient for the patient's needs and necessary for the patient to sustain community tenure. The outpatient system has to be capable of monitoring and enforcing compliance and be capable of delivering the necessary services, and the inpatient system has to support the outpatient system's participation in the provision of involuntary community treatment.

That requires a lot of coordination and a lot of collaboration, and I think some of Mr. Stavis' discussion about the reasons that things don't work properly, all of the hidden agendas and issues about whose budget does this problem land in are really what drives most of what happens, and it's phenomenal how much more effective we could be if we sat and talked to each other and just bit the bullet and say, "Somebody's got to have to pay for it, let's figure out who's going to do it," instead of playing these games, shifting the cost to different settings, because I think the cost of quality of life, not to mention what it's doing to our criminal justice system, is overwhelming.

Outpatient commitment is available now in about 40 states. It's not used in places where it's legal for a variety of reasons. Sometimes there aren't sufficient community resources. There's a concern sometimes among policy makers about increased hospitalization rates. The discussion of civil liberties I think is what is really most prominent, and I think it's a completely false argument. Concerns about provider liability I think is not necessarily so different from the concerns about civil liberties. I think there's a way to indemnify providers when they're doing what's in the best interest of patients. But I think the legal climate in the whole mental health field, medical field, I think has caused problems and appropriate provider concerns.

Some statutes -- actually, most statutes don't have consequences of non-compliance, making it questionable what the outpatient commitment law really is supposed to accomplish, although I'm not sure that you actually do need a consequence of non-compliance. I think that's something for future debate and research, and very often people aren't aware that outpatient commitment is available.

So New York, with its long civil liberties tradition, didn't have outpatient commitment. And you heard about Billie Boggs, Joyce Brown. That was a breakthrough in the 1980s, and it really came after -- at that point there was a recognition that there were vast numbers of homeless, mentally ill people living in the streets, and everybody knew it, and you couldn't deny it, and Mayor Koch came up with this initiative, Project Help, to bring people in off the streets, making the argument essentially that somebody like Billie Boggs was a danger to herself by living the way that she did and it was appropriate to involuntarily hospitalize her.

The next step after Project Help became established and that kind of commitment interpretation of the commitment law was accepted was to figure out, okay, well, how do you stop the revolving door? Now you're bringing in a population of people to hospitals who don't want treatment in the first place and aren't perceived as dangerous enough to get in by the usual mechanisms. What do you do to ensure compliance on an outpatient basis, and in addition to all of the services that were funded? And I have to say that it's very important to recognize. You need supported housing. You need case management. You need assertive community treatment. You need all the things that are going to make treatment possible. You can't deny the problem, let people out of the hospital and say you're not going to fund services.

In addition to the services, you need a legal mechanism to ensure that people who deny their illness and don't understand their need for treatment understand that there's a process, there's due process, there are other people interested, it's not just the doc saying, "Take your medicine." It may be a judgment saying, "You're sick. You need treatment. This is in your best interest. Let's negotiate it."

The proposal for outpatient commitment in New York died in the state assembly five years in a row after another well-known mentally ill individual appeared on 60 Minutes. That was Larry Hogue, the so-called "Wild Man of 96th Street." And after his case became more talked about -- here's a man with chronic paranoid schizophrenia, had a cocaine problem, who would cycle in and out of the hospitals, become dangerous in the community -- the community became outraged. And there was finally recognition in New York that, well, maybe we have to do something, although I think the ambivalence about the issue remains.

There was a lot of negotiations. Civil libertarians and other groups were opposed to it, but there was a compromise for a pilot program in one site in New York which would test outpatient commitment. There would also be an independent research study funded through this statute, and it was to evaluate the effectiveness of outpatient commitment in keeping people out of the hospital and improving quality of life, but the independent study also had to determine consumer satisfaction.

And I think some of the ambivalence and confusion that people have about these issues is all told in the statute. Commit them, make them stay in treatment, which they're not supposed to want, but patients are supposed to be happy about it, too. It was really confusing and frustrating, but I actually think, ultimately, they were right in forcing us to look at those issues. It's just important to recognize the mixed messages that we're getting. And I think, really, our task is to take into account all of the different mixed messages and to try to formulate something that makes sense for everybody. And that's really our challenge, and it's going to take work, but I think that it can be done.

The pilot program in New York was run out of the Bellevue Hospital, which is a public hospital in New York City. The criteria for eligibility were defined by the statute. The patient has to be over 18, suffering from a mental illness, be incapable of surviving safely in the community based on a clinical determination. The patient had to be hospitalized at Bellevue and had a history of non-compliance that resulted in at least two involuntary psychiatric hospitalizations in the last 18 months. The other criteria were that the patient was unlikely to voluntarily participate and be in need of and likely to benefit from outpatient commitment.

This is the flow chart. Bellevue ran the program. Policy Research Associates did the outcome study. We worked together, but we were independently funded and really had different responsibilities. Dr. Hank Steadman, president of PRA, is here in the audience.

Referrals came from the inpatient units because patients had to be eligible. Really, the law defined a lot of the way we operated. If patients didn't have to be hospitalized, we would have had a different pool of candidates. If they didn't have to be at Bellevue, we would have had a different pool of candidates. So it's very important -- and I'm not going to dwell on this -- just to recognize that this is one study with a lot of limitations and a lot of specific parameters which make its generalizability very limited. It tells us something. It tells us a little bit about outpatient commitment. I'm not sure it tells us a lot.

Basically, it was a prospective randomized study where patients, once they were referred, evaluated, determined to be eligible, we worked with the inpatient staff, tried to put together a treatment plan. In a lot of cases, patients that I would have gone forward with to court didn't have any appropriate housing available. That's a big issue. The resource availability is an issue of public policy. And if public policy determines the people who are MICAs, have mental illness and substance abuse disorders should be in supervised housing and MICA residences. It's a responsibility of policy makers to fund those settings. We can go to court and try to coerce people into accepting those services, but if those services don't exist, you can't force people to accept them. It's really a conundrum.

For those that we could get services, once we knew that they were going to the community and not going to a state hospital for ongoing inpatient care, they were approached by PRA for informed consent. Those who consented to participate were then randomized into one of two groups; either they would be brought to court, or they would not be brought to court. But with the same package of enhanced community services, and yet a year follow up. They were studied for one year afterwards.

So, again, there are limitations if you're requiring people who are resistant to consent to research, are you leaving out a population of people? Again, there are limitations. But with all the limitations -- oh, sorry about that. These are the categories of service that we could order. The orders state the specific category, not the treatment provider, and more details about court-ordered medication. The criteria for eligibility for medication also required a finding that a patient lacks capacity, which is another very complex legal issue that I'd be glad to talk about at another time.

Consequences of noncompliance. Basically, the law was somewhat vague about what happens. The legislature said to the clinicians, "You figure it out," and also said that the police should be able to bring back to the hospital if they may meet criteria for admission, but a lot of that was undefined. And I think a key point for people at this conference is that it took us over three years to negotiate with the New York City Police Department a mechanism for one pilot program to transport people in the community who were noncompliant back to the hospital. Finally, the New York City Sheriff's Department is responsible for that, and the mechanism is so cumbersome that we still have not used it. That is a limitation, also, to the research. If you have a law that says you can bring somebody back to the hospital if they're noncompliant, but you can't, in fact, do that, that makes the control group much more similar to the experimental group and, I think, limits the findings.

What did PRA find? Does report cover -- I'm just going to boil it down. One is that about 15 percent of people refused to consent to participate in the study. To my mind, that population probably has different characteristics than those who consented to participate. PRA and Bellevue disagree about that. That's something to look at further. I'm not going to go into the demographics too much. I just want to emphasize one point. The vast majority of patients had schizophrenia, schizo-effective disorder. Okay. People want to know about follow-up psychiatric hospitalization. If you look at the last line, the patients in the court-ordered group had a total median length of hospital time, acute and state hospital time, of 43 days. The people in the control group, who got the same package of services. The only difference was a court order that may or may not have been meaningful. But the median length of stay was 101 days.

PRA has indicated that this doesn't meet statistical significance of a P of less than .05 does indicate, I think, a trend that is very meaningful, and that's worth looking at further. I think with all of the shortcomings of what Bellevue and PRA had to work with, the findings are suggestive and give us a direction for the future.

I'm just going to quickly go through the conclusions that we reached. The PRA report is available. I could certainly let folks know how to get that. There's also a Bellevue report which is a response to that. It had many unique conditions which have to be appreciated in assessing the potential benefits of outpatient commitment.

A successful collaboration was achieved between Bellevue and over 80 other provider agencies. The providers sometimes had to be convinced, sometimes had liability concerns. But for the most part, there are only two provider agencies that didn't want to participate. For the most part, provider agencies that were committed to working with (unintelligible) population understood that this could help them work with people more effectively.

Outpatient commitment orders don't always work, but sometimes they really work. And it's astonishing to clinicians and the Mental Hygiene Legal Service, which represents the patients. Although, without saying anything publicly because they represent people who both agree and disagree. Mental Hygiene Legal Service clearly has indicated that they see the effectiveness of these orders in many cases.


Patients have often responded positively. The whole court process, for the most part, is kind of what Dr. Amador was saying about the illness, about being hospitalized. There's a lot of this stuff that patients just really don't care that much about. And they are usually not daunted by the court process. And those who really oppose the court order generally oppose the treatment. They're not opposed to having a court tell them something; they don't want to take the medicine. They think the medicine is something that's bad. And whether or not the court says so, that's the issue, or using drugs or whatever the compliance issue is. Or being housed. I mean, we've got patients who just will not accept housing, even in a shelter, anywhere. One of our patients wants to live under Grand Central Station, and there's almost nothing that I can do to prevent that. If I had someplace that was funded to actually make sure that he stayed there, I could do something different, perhaps.

It's an order to comply with treatment and services, and they have to be available. The whole debate that goes on, that's going on now in New York, about treatment or outpatient commitment, services or a court order, is completely beside the point and false. You need services, and for some people, you need a court order.

Monitoring. A coordinating function of the coordinating team was part of the reason that it worked. It's not a panacea, and lots and lots of families and providers are interested many this.

To wrap up, where do things stand? The pilot expired was supposed to expire on June 30th. With a couple of subway pushings in New York City, the public's awareness has been heightened again. The Attorney General of New York, the new Attorney General, proposed Outpatient Commitment legislation in January as his first act. Everybody's in on it now, the Democrats, Republicans, and the Governor. There are a variety of versions of the State Outpatient Commitment Legislation. New York operates, perhaps, somewhat differently from other states. The budget was due April 1st. There is still no budget in New York State. That's being negotiated by the legislature, and nothing's going to happen about statewide legislation until that gets resolved. Legislature is back in session, and on June 30th at the 11th hour, the 115 court orders that we were operating with with patients in the community were extended by a couple of weeks. And then on July 13th, there was another extension until Tuesday.

So I've got about 110 patients on court orders that will all expire on Tuesday if the legislature doesn't extend the pilot. How the patients in the Bellevue pilot are going to be mainstreamed into a state law is not quite clear. A state law may or may not be passed. I'm completely in limbo, and if you have any opinion and any contact with New York legislators, now's the time to call them. Thanks a lot.

MARILYN MOSES: Thank you to all of our panelists. Any questions or comments that anyone might have and would like to direct them? I would like to ask you to step forward. Even though that this room is small, we're recording this. And we'd like you to make sure we get your question on the record.

AUDIENCE: Hi. I believe Mr. Stavis commented briefly on the -- what I think is a relatively new idea, which is advanced directives --


AUDIENCE: -- for this particular type of problem. I wonder if the whole panel would care to elaborate a little further on that.

PANEL MEMBER: Clinically, in my experience, advanced directives work informally. Many, many times in working with patients acutely ill, like this gentleman who was stable, when they're stable, you can work with them toward making, you know, a deal with them and a support person in the community to say, "Well, next time this happens, you know, we should just bring you in"; right?

I mean, it's not legally binding, but I think the underlying principle is one that, in terms of the patient themselves would not -- much like the Bellevue finding -- be something that they would be opposed to doing.

PANEL MEMBER: Well, statutory-addressed directives are legally binding. Informal ones are not.

HOWARD TELSON: Yeah. There's a great article about advanced directives in psychiatry in this month's "Psychiatric Services," a review of the entire issue. And it indicates, basically, that psychiatric advanced directives are legal everywhere. There's really just no mechanism put into place in most places to use them. There are about, I believe they said about 10 states, that actually have specific statutes defining how advanced directives should be used in a psychiatric context.

The findings are similar to the outpatient commitment findings from years ago that even in those states, and about half of them use them. They're used very little. There's almost no research. There's no clear indication of what their value is, if at all. To my mind, it's something worth exploring, but with a caveat. If the authority resides with the person with serious mental illness who's got impaired thinking -………


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