Pursuant to Public Act 96-215
January 1, 1997
Sheryl Breetz, Co-Chair
Raymond J Gorman, Co-Chair
TABLE OF CONTENTS
I. Executive Summary
Value of Alternatives
II. Brief History
Proposal for Involuntary Outpatient Commitment Bill, 1995-96
Opposition to Involuntary Outpatient Commitment Bill
Requests for a Task Force to Study Issues
III. Mission of Task Force
Population of Concern
Focus on Alternatives
Alternatives vs. Involuntary Outpatient Commitment Bill
Concepts of Danger
IV. Task Force Process
Task Force Members
Task Force Meetings
V. Scope of Problems
A Divergence of Opinion
Impact of Deinstitutionalization
VI. Assessment of Danger/Risk
VII. Alternatives to Involuntary Outpatient Commitment Bill
Rationale for Recommendation #1
Guidelines for Recommendation #1
Guidelines for Program Elements in Recommendation #1
Better Assessment of Risks
Intensive Case Management
Consumer Involvement in Treatment and Support
Other Program Elements
Evaluation of Effectiveness of Program
Rationale for Recommendation #2
Guidelines for Establishing Recommendation #2
Guidelines for Elements to Address in Recommendation #2
Rationale for Recommendation #3
Guidelines for Establishing Recommendation #3
VIII. Review of Involuntary Outpatient Commitment
A Remaining Question
Difference in Expectations
Value of Recommendations
REPORT OF TASK FORCE TO STUDY ISSUES RELATING TO INVOLUNTARY OUTPATIENT COMMITMENT AND ALTERNATIVES
I. EXECUTIVE SUMMARY
During the 1995-96 Legislative Session, the Connecticut Department of Mental Health and Addiction Services (DMHAS) introduced an involuntary outpatient commitment bill to address public safety concerns relating to a small group of persons whom they served. The individuals of concern were considered of high risk of violence when they did not follow recommended community treatment. The proposed bill, however, produced a public outcry citing practical obstacles, as well as basic questions of civil liberties.
In response the General Assembly enacted Public Act No. 96-215 which established a Task Force "to study issues relating to involuntary outpatient commitment and alternatives, including the impact on community mental health service programs and clients." Members of the Task Force thank the Judiciary Committee and other legislators for facilitating this study.
The Task Force has reached consensus on major recommendations to resolve key problems. Mentioned briefly in this summary, they will be detailed in the accompanying report. The Task Force is hopeful that the Judiciary Committee and related committees will support the recommendations and assist in their immediate implementation.
The following report is structured to give legislators an accurate but brief overview of important issues arising from the Task Force's study of involuntary outpatient commitment and alternatives. More detailed information was assembled for Task Force review and it is available for further study. (See acknowledgments in Appendix A).
The hallmark of the report is that despite divergent viewpoints on a number of issues, the Task Force agreed on major recommendations. These recommendations, moreover, will create a model program for the population of concern, enhance communication between state agencies, provide empirical evidence to help resolve divergent theories, and serve as a model for addressing a serious issue in the mental health field.
Rather than accept or reject an involuntary outpatient commitment bill, the Task Force reached consensus on three major recommendations that would establish an alternative, preventive, programmatic approach to the problem and enhance the use of several existing Connecticut laws.
The major recommendations are as follows:
The Task Force recommends that DMHAS establish a systematic approach to the population of concern that would include application of risk assessment strategies, implementation of program options identified by the Task Force, staff training, and systematic evaluation of results.
The Task Force recommends that DMHAS further study connections with other agencies and groups that might be instrumental in reducing the risks associated with the population of concern.
The Task Force recommends that during the program implementation and evaluation suggested in Recommendation #1, DMHAS also study how the temporary leave statute, criminal justice statutes, and other current statutes could be used more effectively to reduce the danger and risk associated with the population of concern.
Further details of the recommendations, rationale, and guidelines for implementation are presented in the report.
VALUE OF ALTERNATIVES
All of the recommended alternatives to involuntary outpatient commitment have one vital feature. Each requires voluntary agreement by the consumer of the services. This is a major strength of the alternative approach which avoids legal, often emotion-fraught, counter-therapeutic questions of infringing an individual's civil rights.
Consumers who have recovered are viewed as integral in promoting the follow through of other consumers in the program envisioned in Recommendation #1. Reliance on peer advocates to use empathy and persuasive talents in reaching other consumers is an invaluable component.
Funding to support several of these promising, preventive alternatives could save much more than the investment itself. Significant savings could be realized by police, courts and corrections. If successful, other savings could arise in DMHAS because of reduced need for repeated hospitalizations and enhanced prospects of recovery in the community.
Because of continued scrutiny recommended in evaluating the effectiveness of alternatives, the need for additional coercive measures will be tested with empirical evidence.
II. BRIEF HISTORY
PROPOSAL FOR INVOLUNTARY OUTPATIENT COMMITMENT BILL, 1995-96
The Connecticut Department of Mental Health and Addiction Services (DMHAS) proposed an involuntary outpatient commitment bill for adoption during the 1995-96 legislative session. They proposed the bill to address a serious problem they described in responding to a small number of individuals with psychiatric disabilities whom they considered at high risk of dangerous behavior in the community when they were not in treatment.
The individuals of concern had responded well to medications and other treatments during psychiatric hospitalizations and were discharged for community treatment because they no longer met the criteria under state statutes for civil commitment to a hospital. Indeed, because of their positive response to recommended treatments, community treatment was considered most appropriate and beneficial for the individual. DMHAS reported that once living in the community, however, some of these individuals did not remain in treatment, relapsed and posed a serious risk to oneself or community. Often substance abuse was cited as a contributing factor.
DMHAS had reported that only a small subgroup (approximately 50) of the 35,000 individuals they serve exhibited this pattern. They felt, nevertheless, that there were sufficient safety concerns to warrant action.
DMHAS maintained that they were unable to respond effectively to such individuals until the person once again met the stringent criteria for involuntary civil commitment. DMHAS further reported that since the person had been refusing treatment, DMHAS was unable to determine when the point of decline had reached dangerous proportions. DMHAS reported that, in fact, violent incidents had occurred and that intervention after an incident was sometimes seen as the only alternative. This reactive instead of preventive response sometimes resulted in the individuals committing crimes and dangerous behaviors which led to their arrest and incarceration.
The outpatient commitment bill was designed to allow DMHAS to provide treatment on an outpatient basis under court order to this select group of high risk individuals whom DMHAS contends do not engage in treatment on a voluntary basis. It was intended as a measure to provide needed treatment, ensure public safety, and reduce the stigma that arises for all persons with psychiatric disabilities when violent incidents occur. The bill was modeled after similar legislation in other states. (Some published reports maintain that thirty-six states have some form of outpatient commitment provisions, some dating back to 1985 and others enacted within the last year.)
OPPOSITION TO INVOLUNTARY OUTPATIENT COMMITMENT BILL
During a Public Hearing for the bill, opposition was based upon the civil rights of consumers, negative consequences on long term treatment outcome and therapeutic relationships, stigmatizing effects on consumers, practical difficulties for implementation, liability for community providers, and resources required for implementation. While some opposition arose in response to the particular drafting of the proposed bill rather than its concept, most opposition was directed against the basic concept of involuntary outpatient commitment.
Some opponents considered involuntary outpatient commitment a deep invasion of liberty. Involuntary commitment places the individual's interest in liberty (encompassing rights of privacy, self-determination, and freedom from confinement) against the state's interests in preventing harm to the individual and/or society. For them, such a massive curtailment of liberty was not justified. In addition, fears were raised about possible abuses of court ordered treatment, such as ever increasing applications to wider populations of people with psychiatric disabilities, not just those of danger to selves or others. There were objections to orders that would mandate where a person lives, participation in a particular treatment program, and use of medication with offensive and dangerous side effects. Furthermore, there were concerns that such court orders would be applied unevenly in different jurisdictions or with different populations, such as minorities.
Some opponents also contended that mandated treatment would undermine more long term treatment goals. Such orders, they argued, could be substituted for more beneficial but costly services or become a crutch for unskilled therapists. Such orders, moreover, could undercut the long term therapeutic relationship that is needed for psychiatric stabilization and recovery.
Some providers of service were concerned about the liability that community commitment would place on their agencies in the event that someone court ordered fro treatment committed a violent act. They also questioned how they could manage to involuntarily treat people in the community as they do in a hospital. They were also concerned that costs for involuntary commitment procedures would reduce their already slim treatment resources.
Some opponents asserted that DMHAS services were not functioning as designed or that current community services were simply not designed or funded to adequately treat the individuals of concern; for example, some people did not believe that DMHAS provided "intensive case management" as DMHAS contended. Other maintained a belief that there was, in fact, no way to treat some difficult chronic hospital patients in the community, and that involuntary outpatient commitment would not make community treatment effective for these individuals.
REQUESTS FOR A TASK FORCE TO STUDY ISSUES
Because of the seriousness of the issues presented both in terms of public safety and civil rights, and because of the divisive views expressed within the mental health community, some individuals, including DMHAS officials, asked legislators to consider appointing a Task Force to study the issues raised during the introduction of the bill and public hearing.
III. MISSION OF TASK FORCE
Public Act No. 96-215 enacted during the 1995-96 legislative session established a Task Force "to study issues relating to involuntary outpatient commitment and alternatives, including the impact on community mental health service programs and clients."
POPULATION OF CONCERN
The Task Force defined a subgroup of persons with psychiatric disabilities that were of primary concern and would be the focus of the Task Force. They stated: "We are concerned about the instances where a breakdown in the therapeutic relationship between the consumer of mental health services and the provider results in a severance of services that presents a danger of severe bodily injury to others."
The Task Force restricted their focus to those individuals who presented a danger of severe bodily injury to others and expressly did not include those individuals who either presented dangers of a lesser magnitude or danger to self. While some members of the Task Force wanted to include individuals who might be dangerous to themselves, there was a clear message from other members that they would focus upon outpatient commitment and its alternatives only in relation to:
a. Public safety issues and not as a protective measure for consumers.
b. The most serious threats and not for minor transgressions which could be over interpreted, misused, or broadened;
c. A very narrow subgroup of the population of people who have psychiatric disabilities.
FOCUS ON ALTERNATIVES
The Task Force described their intent with regard to studying alternatives to involuntary outpatient commitment. They stated that "we will identify a variety of alternatives, tailored to individual needs that are mutually acceptable to the consumer and provider of community mental health services." While all members felt that mutually acceptable alternatives were clearly the ideal, some members envisioned that some alternatives may be needed that would be coercive in nature and thereby not acceptable to the individual consumer. The will of the majority was to focus on alternatives that were mutually acceptable.
ALTERNATIVES VERSUS INVOLUNTARY OUTPATIENT COMMITMENT
Task Force members agreed that the ideal was to design effective alternatives to involuntary outpatient commitment that would protect public safety and respect the civil rights of consumers. There was agreement that members would first discuss the alternatives. Discussions of involuntary outpatient commitment would logically follow as the group addressed the final question: "Are there situations of perceived danger/risk to public safety which cannot be addressed through the current statutes or thought modifications to current statutes?"
Similarly, Task Force members agreed to first discuss more effective use and modifications of current statutes before considering any recommendations for new statutes. Discussions of involuntary outpatient commitment, which would require statutory change, would again logically follow as the group addressed the question: "Are there situations of perceived danger/risk to public safety which cannot be addressed through the current statutes or thought modifications to current statutes?"
CONCEPTS OF DANGER
The Task Force proceeded with a common language understanding of "danger" and did not attempt to further define the term. Legal terms employed in defining danger in Connecticut statutes were researched and are available for further study.
IV. TASK FORCE PROCESS
TASK FORCE MEMBERS
Eighteen (18) members were appointed to the Task Force; twelve (12) members regularly attended meetings and formed the content of this report. Public Act No. 96-215 directed that membership would include various legislative members or their designees and would further include other representatives appointed by legislators. Such individuals would be chosen to represent the Office of Protection and Advocacy, Regional Mental Health Boards, Department of Mental Health and Addiction Services, consumers, Connecticut Alliance for the Mentally Ill, Connecticut Legal Rights Project, service providers, and Connecticut Psychiatric Society. The Speaker of the House of Representatives and the President Pro Tempore of the Senate appointed the Chairpersons. Members are listed in Appendix B.
TASK FORCE MEETINGS
Regular Task Force meetings were held twice monthly beginning September 11, 1996 though December 18, 1996. All meetings were publicly announced. Meetings were open to the public and interested individuals were encouraged to attend. In addition, four sets of subcommittee meetings were held, again open to the public.
Journal articles were distributed to all members as submitted by individual members. A listing of forty-five journal articles published on related topics was also distributed. Individual members were asked to submit drafts of any alternatives they wished to have reviewed. They were asked as well to submit draft sections of the report for review in accordance with areas of special expertise or position statements they wanted to explain.
V. SCOPE OF PROBLEMS
Because of the unwarranted stigma that exists in society against people with psychiatric disabilities or mental illness, any discussion of dangerousness associated with persons with mental illness (1) must proceed with acknowledgment of the following facts:
a. Most people with mental illness are not dangerous.
b. The number of people with mental illness who commit violence is small.
c. The public has an exaggerated perception of dangerousness associated with mental illness; for example, 77% of people depicted as mentally ill in television are also depicted as dangerous (Resnick).
A DIVERGENCE OF OPINION
While all Task Force members agreed that the statements presented above were true, there was no such consensus about the scope of violence related to mental illness, reliability of data, and acceptable methods for describing problems. There was disagreement, for example, regarding the basic issue of whether people with mental illness are or are not more likely to commit violence than the general population or other population subgroups. National studies that some members found clear and convincing evidence were viewed by others as inconclusive.
The report does not attempt to resolve these differences, which are not resolved in the field of mental health itself. The main focus of the report remains the major recommendations reached despite a divergence of opinion regarding the scope of problems. The report does, however, present various views cited by members of the Task Force as examples of issues being debated.
IMPACT OF DEINSTITUTIONALIZATION
Nationwide, an estimated 559,000 individuals were in state psychiatric hospitals in 1955; by 1992, the number had been reduced to 83,320 (Atay et al.). In Connecticut, DMHAS reports that the number of individuals in state hospitals has been reduced from a high of 9,000 in the 1950s to 350 individuals today.
While widely heralded as dramatically successful for most individuals with mental illness, this change has prompted some mental health experts, however, to re-examine issues of violence associated with mental illness. With an estimated 750,000 individuals now living in the community nationwide, who forty years ago would have been inpatients in state psychiatric hospitals, an increase in number of incidents for this population would be expected based upon their increased numbers in the community. More incidents would be expected even if the rate of incidents remained constant. Recent debate has focused on whether there is now a greater incidence of violence for person with mental illness than in the general population and whether the frequency and/or magnitude of incidents is cause for concern.
National data are significant as an illustration that concerns raised in Connecticut are voiced and studied in many other states. Response to national data also helps frame issues of concern and debate in Connecticut.
DMHAS officials maintain that understanding the relationship between mental illness and dangerousness and/or violence is evolving based upon the research of experts in the areas of clinical risk assessment and data from large scale epidemiological studies. Earlier studies led John Monahan, one of the foremost authorities on this issue, to conclude in 1980 that there was no increased incidence of violence associated with mental illness. A large scale, multi site study,, the Epidemiological Catchment Area (ECA) Study, is currently in progress. DMHAS reports that the study has yielded data that has caused Dr. Monahan to revise his earlier opinion and suggest that a relationship does exist between some mental disorder and violent behavior; other members of the Task Force and some clinicians report that the findings are still inconclusive. While DMHAS reports that associations between mental illness and violence appear to be caused exclusively by a small subgroups of individuals with serious mental illness who are not receiving treatment, others on the Task Force report that associations are produced largely by substance abuse among a sub-population and do not result from the mental illness itself.
These varying views cannot be resolved at this time. They do, however, illustrate that such issues are being debated and researched nationally because there is concern.
Concerns about violence on the part of professional mental health providers are often framed in terms of consumers not following recommended treatment. That is, an individual who is stabilized and functioning well in an inpatient setting is released into the community, stops or refuses medications and other treatment, and becomes dangerous. Concerns on the part of some providers and consumer advocates are often framed in terms of inadequate services to keep persons engaged in treatment in the community. No data, however, is currently available that records the number and type of violent episodes committed by persons in Connecticut who were not following through with available treatment versus persons who were not offered adequate service.
DMHAS offers what they consider relevant data that does exist from their department, the Department of Corrections, and Office of Adult Probation. Their report is summarized as follows:
a. The vast majority of consumers in DMHAS' most intensive community based programs were judged by professionals to demonstrate good community adjustment.
b. A small group of consumers (50) in the study were judged by professionals to have significant problems in the community as evidenced by clinical instability, not taking medications, and a history of aggressive or threatening behavior in the past year.
c. A portion of the fifty (50) consumers identified above had frequent involvement with the criminal justice system and were in and out of psychiatric hospitals, courts and jails.
The following data also presented by DMHAS do not differentiate between violent and nonviolent individuals, but do provide evidence of the overlap between mental health and criminal justice systems:
a. About 70% of the 800 annual court ordered evaluations for mental competency to stand trail pertain to individuals who have had prior treatment though DMHAS.
b. Several surveys who that about 1,500 correctional inmates (10%) on any given day have significant mental health needs, although there is not a clear definition of mental health needs.
c. No data is available on the percentage of these inmates who pose a danger upon release.
d. A national survey in 1995 indicated that Connecticut had approximately 12,000 offenders with mental illness (23% of the probation population) under supervision by Probation: however this data was not based on a clear definition of the term "mentally ill offender" or upon a clinical evaluation of mental illness.
e. There are approximately 500 probationers with psychiatric treatment as a condition of their probation.
The major concern for public safety is the frequency of violence considered of a great magnitude. Although there is not agreement on data reports, concerns have been raised in a number of sectors in response to incidents that have occurred.
During 1996, newspapers reported instances both nationally and within Connecticut where individuals with mental illness were charged with crimes that would be considered of great magnitude and caused public alarm. After instances reported by the press, allegations often proliferate. Some mental health providers allege that their hands were tied when people refused treatment in the community, and that they had no way to observe the consumer's decline into dangerousness when the person refused to see them or talk with them. Some consumer advocates and providers allege that the mental health system did not provide adequate or acceptable treatment to meet the consumer's needs, either due to lack of resources, diligence, or creativity. Some family members allege that both the mental health system and the police reported that due to legal constraints they were powerless to intervene until the person committed some discrete act that demonstrated a clear danger to others.
During 1995 and 1996, several members of Connecticut's State Board of Mental Health and Addiction Services became concerned about violent instances that were known to them and had occurred in a number of mental health regions in the state. The Hartford Catchment Area Council, part of the Regional mental Health Board system, for example, had been concerned because of two recent and highly publicized incidents. The State Board formed a committee to study issues related to violence. The committee held meetings during FY 1995-96. DMHAS submitted its proposal for an involuntary outpatient commitment bill to the committee. The committee as a whole decided not to approve or oppose the bill due to the divergent opinions on the committee.
VI. ASSESSMENT OF DANGER/RISK
Increased study of the relationship of violence to mental illness has isolated factors related to risk. These results have influenced the field of psychiatry to move from the framework of predicting if and when a person will become dangerous to thinking in terms of identification of risk factors and developing an appropriate treatment plan to address risks.
Researchers are attempting to determine risk factors associated with dangerous behavior in order to better estimate the risk of dangerous behavior occurring. A fuller discussion of risk was presented in a recent article ("Quality Management in Mental Health. II. Managing Risk of Dangerousness") published in part by Roger Coleman, a member of the Task Force. The article addresses management of risk assessment. Some summary points are as follows:
a. We can ascertain risk factors that point to increased probability of risk of dangerous behavior.
b. Those people with the risk factors will have a greater probability of exhibiting dangerous behavior.
c. We cannot predict with certainty who will display dangerous behavior.
d. Although we can estimate the risk for dangerous behavior, there is also a risk that an estimate will be wrong.
e. We can overestimate or underestimate the risk of dangerousness.
f. Although someone may be placed in an "at risk" population, individual issues can still affect outcome in complex ways.
g. There is a cumulative effect for risk factors, with a greater number of risk factors generally increasing the probability of risk for dangerous behavior.
There is hope that with increased study, there will be better assessments of risk to guide clinical care. Attempts to standardize risk assessment using a behavior checklist produced better management of treatment and outcome of care at Cedarcrest Hospital (Coleman et al). Others have found that statistical predictions based upon the use of standard assessments are more accurate than clinical judgment (Harris et al).
Resnick lists a number of factors that have been studied as risk factors. The list includes detailed behaviors which together raise the likelihood of violence. He concludes, however, that currently the best single predictor of future violence is past violence. This statement has widespread support throughout the mental health community.
While risk assessment methods shows promise, Coleman warns that even with the most expert assessment of risk of dangerousness, developing safe and effective approaches to care remains a challenge. Task Force members clearly identified the need to better understand concepts of statis
tically based risk factors and their clinical, programmatic and legal implications.
VII. ALTERNATIVES TO INVOLUNTARY OUTPATIENT COMMITMENT
The Task Force was guided by the question, "What alternatives could be recommended to reduce the danger or risk associated with the population of concern?" Clearly there was a preference among members to use non-coercive alternatives rather than outpatient commitment. There was also a preference to work within current statutes rather than enact new legislation. Three questions guided the search for alternatives:
1. Are there programs or procedures that could be developed or enhanced within DMHAS?
2. Are there education programs or procedures that could be developed or enhanced between DMHAS and other agencies or groups?
3. Could current statutes be used more effectively?
Are there programs or procedures that could be developed or enhanced within DMHAS that would reduce the danger or risk associated with the population of concern?
The Task Force recommends that DMHAS establish a systematic approach to the population of concern that would include application of risk assessment strategies, implementation of program options identified by the Task Force, staff training, and systematic evaluation of results.
RATIONALE FOR RECOMMENDATION #1
This recommendation would simultaneously result in the implementation of a model program for the population of concern and create an opportunity to study two strong and opposing assertions regarding the need for involuntary outpatient commitment or other involuntary measures. In the opinion of DMHAS officials, the population of concern has already been offered intensive levels of care, consumes disproportionate levels of recourses due to repeated hospital stays upon relapse,, and continues to present considerable risk to society because of their rejection of mental health services. An opposing view is offered by some consumer advocates and providers, who contend that DMHAS has failed to offer appropriate services that are tailored to individual needs and acceptable to consumers in question. The above recommendation would help resolve these opposing views and provide evidence to guide further decision making regarding the need for involuntary measures.
There were on the Task Force strongly held and opposing opinions regarding the need for involuntary measures. There was agreement among Task Force members, however, that existing and yet untried alternatives should be employed and ruled out before resorting to involuntary outpatient commitment and the serious deprivation of liberty it entails. There was further agreement that the alternatives should be implemented systematically and uniformly. With such implementation of services, we will be better able to address the question of whether in our social and legal judgment, the potential for doing harm is great enough to justify widening the standards for curtailment of liberty.
Currently, this question cannot be answered by citing the professional opinion, literature, or statistics. In response to DMHAS' proposed outpatient commitment bill, for example, one professor of psychiatry at Yale University offered support, while another voiced opposition. Literature reviewed by the Task Force reflected the same diversity of opinion represented among members. Given the diversity of opinion, the proposed implementation of services and evaluation would make a major contribution to understanding treatment and safety issues for the State of Connecticut.
GUIDELINES FOR ESTABLISHING RECOMMENDATION #1
The Task Force asks for legislative support from the Judiciary Committee in directing DMHAS to undertake this organized approach, implementation, and study of the population of concern and in assuring that resources are available to support the project. The majority of Task Force members have demonstrated their commitment and ask to continue as a Task Force to guide the project. Within one year, the Task Force should report its findings to the State Board of Mental Health and Addiction Services and to the Judiciary Committee. The Task Force should report the outcome of the service implementation and evaluation project and address the question, "Are there situations of perceived danger/risks to public safety which cannot be addressed through the recommended alternatives and current state statutes?" The Task Force is also asked to study costs for programs enacted for this population; it is anticipated that significant savings would take place with police, courts, corrections, hospitalizations, etc., if community programs are able to effectively manage the problem and prevent violent incidents. Funding for such programs should be weighed against these other costs.
GUIDELINES FOR PROGRAM ELEMENTS IN RECOMMENDATION #1
The Task Force identified program elements that should be included in an organized implementation of services and study of the population of concern. Such an organized approach would seek to combine efforts of recipients of services, family members, case managers, advocates, and clinicians. These participants will develop a plan comprised of existing and new options, including consumer-developed and consumer-run services.
Essential to this approach is the recruitment and training of service providers who are sensitive to the issues faced by this consumer population and who also believe in their recovery.
Current recommended program elements are not intended to be comprehensive, and the Task Force is asked to continue to generate service recommendations. The alternatives recommended by the Task Force include better assessment of risks, intensive case management, consumer involvement in treatment and support, and advance directives as described below.
BETTER ASSESSMENT OF RISKS
Task Force member recommend that DMHAS give increased attention to systematic assessment of risk using standardized approaches for individuals in the community. Coleman et al report that such assessments were made at Cedarcrest Hospital and proved successful in producing better management and outcome of care during hospitalization. A report on this approach is available for further study of how similar assessments can be used in the community.
INTENSIVE CASE MANAGEMENT
Task Force members recommend that DMHAS utilize intensive case management with all individuals assessed to be at risk of violence. Dvoskin & Steadman report that aggressive and intensive case management include management of small caseloads, 24-hour availability of managers, and "strong linkages to agencies providing mental health services, substance abuse treatment, and social services as well as to the criminal justice system." DMHAS contends that it currently offers intensive case management, but perceptions vary among Task Force members as to its uniformity in quality among providers and its consistent application in response to consumers at risk of violence. Some Task Force members, moreover, do not believe that DMHAS offers what they would call "intensive case management."
CONSUMER INVOLVEMENT IN TREATMENT AND SUPPORT
Task Force members recommend greater use of consumers as peer specialists on case management and treatment teams. Felton et all report that "integration of peer specialists into intensive case management programs appears to lead to...more effective case management" and engagement in treatment for other consumers. DMHAS has initiated some consumer involvement in treatment, for example, as mentors (in Danbury) or peer companions (in Waterbury). Models need to be developed for consumers at risk of violence.
Task Force members recommend considering increased use of advance directives. Advance directives can be used for directing interventions for mental illness using the same statutory provisions used in advance directives for medical care for physical illness. At a time of competency and psychiatric stability, the individual would be encouraged to give advance directives for the event the person was in crisis or became incompetent. The Task Force recommends that the availability of advance directives be expanded, their use encouraged, and that current efforts to educate consumers and providers regarding advance directives be increased.
OTHER PROGRAM ELEMENTS
Various other program elements have been suggested by individual members, such as specially trained treatment teams for individuals at risk of violence, more extensive use of injected medications, and supervised housing. While these and other suggestions will not be analyzed here, Task Force members recommend continued review of other elements in the mental health system that could be enhanced for people at risk of violence.
EVALUATION OF EFFECTIVENESS OF PROGRAM
This recommendation for an organized approach to alternatives to outpatient commitment entails changing an existing process and assessing the results of this change. In this proposal the process change would be the new coordinated approach to the target population. The change in outcome would be measured by improved functioning of consumers, particularly their ability to function outside a hospital. Outcome measures would maintain a central focus on a holistic view of the individual and include consideration of quality of life issues. Part of the work of the continuing Task Force would be to oversee the evaluation process.
Are there education programs or procedures between DMHAS and other agencies or groups that could be developed or enhanced that would reduce the danger or risks associated with the population of concern?
The Task Force recommends that DMHAS further study connections with other agencies and groups that might be instrumental in reducing the risks associated with this population.
RATIONALE FOR RECOMMENDATION #2
DMHAS reports that for the population of concern, there is often involvement with the corrections and judicial system. A 1996 North Central Regional Mental health Board study, for example, reported that communications were lacking between the local state mental health provider and the probation officials. The Board was concerned about two recent and highly publicized violent incidents in Hartford involving people with mental illness who had been involved both in state mental health and in judicial and corrections systems. While the Board commended DMHAS providers for their connections with the Public Defender's Office and their jail diversion project, they observed that other important connections were lacking with the corrections and judicial systems.
Recently, both DMHAS and criminal justice agencies in Connecticut acknowledged that a significant overlap of clients warrants the development of collaborative strategies to more effectively coordinate services and resources which will enhance public safety and improve quality of care. The absence of such coordination across agency boundaries in the past has been cited by some individuals as failing to prevent some serious incidents that may have been preventable had interagency communication existed.
The Task Force requests that these connections be established and reviewed in order to better use the powerful tools available in the judicial and probation systems.
GUIDELINES FOR ESTABLISHING RECOMMENDATION #2
The Task Force recognizes that DMHAS has already undertaken important steps to enhance connections with probation. A report on those developments is available. DMHAS has been involved in an interagency committee convened earlier this year to develop recommendations to improve coordination related to offenders and defenders with psychiatric disabilities. The committee includes senior representatives of DMHAS, Office of Alternative Sanctions, Office of Adult Probation, Board of Parole, Office of the Chief State's Attorney, Office of the Chief Public Defender, Department of Corrections, and the Department of Mental Retardation.
The report of the interagency committee described above is in final stages of drafting and has identified significant ways in which to improve interagency coordination of services. the Task Force asks for review by the Judiciary Committee in order to establish the connections between DMHAS and other state agencies that could be instrumental in reducing the risks associated with the population of concern.
GUIDELINES FOR ELEMENTS TO ADDRESS IN RECOMMENDATION #2
The Task Force recommends that DMHAS continue working with the current interagency committee and examine further connections with other agencies and groups that could enhance the state's response to the population of concern. The Task Force asks that communications with families about issues of violence also be considered.
Could current statutes be used more effectively?
The Task Force recommends that during the program implementation and evaluation suggested in Recommendation #1, DMHAS also study how the temporarily leave statute, criminal justice statutes, and other current statutes could be used more effectively to reduce the danger and risk associated with the population of concern.
RATIONALE FOR RECOMMENDATION #3
The Task Force expressed a clear preference to explore how current statutes could be used more effectively or modified, rather than adopting new statutes such as an outpatient commitment statute. The Task Force examined one statute: C.G.S. Sec. 17a-521 Temporary Leaves From Institution. The statute appears to give DMHAS rather broad authority to grant a temporary leave of absence from one of its facilities to individuals who are committed to DMHAS and still retain the original commitment order. One reason cited by DMHAS for not using this statute has been the effect on the entitlements the individual will need to live in the community on a temporary leave. It was DMHAS' understanding that an individual on temporary leave would lose all entitlements and DMHAS would be responsible for all support needed to live in the community, including lodging, food, and medical costs. Two memoranda researching entitlement issues were generated by DMHAS at the request of the Task Force. The memoranda report that the use of temporary leave has no appreciable impact on an individual's eligibility for SSI, SSDI, Medicare and/or Medicaid. These memoranda open possibilities for using this statute for the population of concern.
Given that a number of high risk consumers have intermittent involvement with the criminal justice system, current statutes should be reviewed as they pertain to mental health needs of offenders with mental illness. An initial review and recommendations for some of the statutes is being undertaken by DMHAS.
GUIDELINES FOR ESTABLISHING RECOMMENDATION #3
The Task Force recommends that DMHAS evaluate the feasibility of using C.G.S. 17a-521 as a mechanism for discharging individuals in the population of concern and, if warranted, write policies and procedures for the use of this statute. The continuing Task Force discussed in Recommendation #1 should review this and other statutes with DMHAS. Other statutes that should be examined include civil commitment, conservatorship, and PSRB. Relevant Connecticut statutes were researched and are available in a report. The Task Force and DMHAS should also study what modifications to current statutes might make them more effective to address this population.
VIII. REVIEW OF INVOLUNTARY OUTPATIENT COMMITMENT
A REMAINING QUESTION
The Task Force did not recommend either adoption or dismissal of the concept of involuntary commitment. The question remains, "Is there a case for some form of involuntary outpatient commitment for a very narrow target population considered to represent a risk of violence in the community?"
DIFFERENCE IN EXPECTATIONS
Members of the Task Force reflect considerable differences in their expectations for the outcome of the program to be established under Recommendation #1. While all Task Force members believe that the project will significantly shrink the pool of individuals that will remain of concern for potential violence in the community, there are differences in expected effectiveness of the project. Some believe that the pool of potentially violent individuals will shrink to an insignificant number. Others believe that despite the best efforts to provide a model program, some individuals will still reject all voluntary mental health services. They further believe that some of these individuals would, however, respond to coerced treatment ordered by outpatient commitment or other coercive measures. Some individuals believe that the people who do not respond voluntarily to the extensive program offered by the project and are considered at risk of violence should not be entrusted to the community but should reside in an institution.
Task Force members who favor coerced treatment for some individuals cite providers in other states who report that for some consumers, the added weight of the law compels them to remain in community treatment. Some consumers in these states, moreover, have reported that they benefited from the treatment that was court ordered but previously rejected. Several Task Force members, however, warned that some consumers would simply avoid forced treatment by disappearing. Concerns were voiced that forced outpatient treatment would result in more overall harm than benefits for consumers and society. They argue there would be an overall stigmatizing effect on all persons with psychiatric disabilities.
VALUE OF RECOMMENDATIONS
Whatever measures are employed, most members of the Task Force believe it is unrealistic to expect 100% success. They are hopeful, however, that the measures they have recommended will produce significant improvements in reducing violence on the part of a subset of individuals with psychiatric disabilities, provide empirical information needed to make future decisions, help resolve opposing views, and preserve the civil rights of all individuals.
(1) "Psychiatric disabilities" is a term preferred by some individuals; "mental illness" is often used in psychiatric literature. Both terms are reflected in Connecticut statutes.