Friday, February 27, 2004

Our Right to Remain Mentally Ill

I received weekly news updates from the Treatment Advocacy Center. Most of the time, they contain editorials regarding the challenges of getting treatment for loved ones or articles about individuals with mental illness killing someone or being killed by cops. Sometimes I just skip the whole issue because it's too depressing. But this week there's a great article that discusses the challenges of treating the mentally ill in Florida. Several groups, including law enforcement, have been trying to change the laws in Florida to make it easier to involuntarily commit, and thus get treatment for, the mentally ill. This article spells out the key problems with the mental health system in Florida.

TAMPA TRIBUNE, February 21, 2004

[Editor’s Note: This starkly compelling piece by psychiatrist Nestor Milian reads like a hypothetical in a graduate school exam; it just lays out the facts. One difference from a test question: in the last line Dr. Milian gives the answer, an answer now moving through the Florida legislature.]


By Nestor E. Milian

Nestor E. Milian, M.D., is a Tampa-based general psychiatrist.

The mentally ill have gained much in the way of their rights and personal liberties in the last 25 years. What they have lost on the way is the possibility of reasonable treatment when they become so ill that they do not realize they are in danger.

Consider a hypothetical patient, Frank. Frank, who is chronically and severely mentally ill, has been violent and has difficulty caring for himself. The few members of his family who were willing to help him have given up because of his violence, repeated hospitalizations, repeated incarcerations or self-negligence.

Today, Florida Statutes do not provide for adequate involuntary outpatient treatment of patients such as Frank. Our societal pendulum has swung too far to the patients' rights side. For instance, Frank has the right to not take his medications as soon as he is discharged from the hospital. He has the right to be discharged if he is able to demonstrate the capacity to remain calm and cooperate with hospital staff. Indeed, Frank can do this for short periods when taking his medications in a controlled environment. If the attending psychiatrist and hospital do not discharge him, Frank has the right to sue the physician and hospital for illegally holding him against his will. So Frank is discharged when he is "safe enough" to leave, and within days, he has stopped his medications. Sooner or later, his paranoid thoughts will overwhelm him, and he will begin to act on them. His violent or bizarre behavior will be reported to authorities and he will be back in jail or, more appropr!
iately, back in the hospital.

Patients Are "Too Sick'

When Frank is admitted to an acute care facility awaiting state hospitalization, then, and only then, will he be considered for involuntary treatment in local residential treatment centers. These centers are funded by the state of Florida and Hillsborough County to "divert" the severely mentally ill from state hospitalization. Frank must be "assessed" by local residential treatment centers while he is still in hospital. In the majority, patients like Frank are turned down because they are "too sick" for these diversion programs. Since space in these programs is severely limited, they can choose the patients who will participate most cooperatively. Once turned down, Frank must be treated in the acute care setting until stable enough to be discharged to an outpatient program, unless transfer to the state hospital can be arranged. People like Frank are very sick and need not only medications and safe environments, but also months, possibly years, of closely monitored psychiatri!
c care in order to even begin to see a change.

The Florida Assertive Community Treatment teams are an example of outpatient programs for the mentally ill. FACT teams are state-funded groups that include psychiatrists, social workers and mental health counselors, geared toward the close outpatient monitoring of severely mentally ill Florida residents. These teams will send representatives to the patient's place of residence and attempt to help these patients take their medication and get appropriate education and counseling. However, even these teams are powerless to help patients who refuse to open their doors or simply refuse to take their prescribed medications. Once one of the clients refuses medications, the FACT team must wait until there is an "imminent risk" to the patient or others before it can invoke Florida laws to take the patient into protective custody and then to an acute care hospital for involuntary examination.

If Frank seems to improve enough to be discharged to an outpatient setting, he will not be able to see a psychiatrist in the community mental health system for months after discharge. Even with a two-month prescription from a hospital psychiatrist, Frank may not have enough to last until his appointment. No wonder Frank soon is off his medications and on the street again, looking fearful and hearing voices.

Need Involuntary Treatment

Frank has the right under Florida Statutes to continue to be psychotic. He has a right not to be given reasonable outpatient treatment against his will. This is true even if he has broken the law or violated another person's safety in the past as a consequence of his illness. Next time you read about a tragedy perpetrated on an innocent by Frank, do not wonder why "these people aren't given treatment." Frank has rights.

A message to the Florida Legislature: We need involuntary outpatient treatment laws in the state of Florida before the rights of the mentally ill render them hopelessly mentally ill.

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