Martin Kohl

Several incidents of serious violence, including the death of one woman, have pushed the issue of involuntary commitment of the noncompliant mentally ill higher on the priority list of the government of New York State.

In January 1999 Kendra Webdale, a young woman living and working in New York City, was killed after being pushed in front of an onrushing subway train by a mentally disturbed man. Several months later a man lost both his legs after he was pushed by a psychotic individual in front of an onrushing train.

Since then, members of the New York State Legislature have passed a bill called Kendra's Law, which will allow the courts to commit mentally ill people who do not voluntarily comply with treatment at residential outpatient facilities. Current state law allows the commitment to a hospital for people who are judged to be a danger to themselves or to others. And, although a variety of commitment laws exist in many states, the issues of cost and civil liberty are still at the forefront of the discussion in New York.

"The problem that you have is that the decision to commit somebody, which deprives them of their liberty on the basis that they are not mentally competent, is a very subjective one. There are no objective tests," explained Jerome Levy, J.D., former General Counsel for the New York State Department of Health.

For example, he continued, the criteria for commitment-whether the person is dangerous to themselves or others or will be so in the future if they don't follow treatment-is entirely predictive.

While he admits a law for involuntary commitment "sounds good on paper," Levy, currently a partner in the law firm of Arent, Fox, Kintner, Plotkin and Kahn in Washington, D.C., and New York, said he didn't think such a law would work.

"The trouble is we're going to have to build an exponential number of residential treatment facilities for the mentally ill and there's no public will to do that."

The state of New York, he added, had to pass a law superseding local zoning laws because people did not want residential treatment facilities in their neighborhoods.

"The fact is that if New York state had a billion dollar surplus the Legislature would rather give people a tax cut than they would construct 25 group homes," Levy said.

Kendra's Law, according to Lorrie Smith, spokesperson for Assemblyman James Brennan, one of the bill's sponsors, was to be matched to an appropriations bill of $210 million for additional facilities. The appropriation was not passed, and any necessary funds to implement the law must be approved by the governor of the state of New York.

Questions of civil liberties are equally important to the need for funding treatment centers, according to advocate groups such as the Bazelon Center for Mental Health Law, located in Washington, D.C. Although Bazelon's director, Robert Bernstein, Ph.D., acknowledges that there are situations where involuntary care is warranted, he went on to say, "It is highly speculative to say that someone may become violent two weeks from now because they're noncompliant with treatment today. There is really no good empirical body of knowledge that supports a judgment of that nature."

Bernstein, who is a psychologist, added that the very small proportion of schizophrenic people who become violent is not a reason to construct an entire social policy based on a small handful of tragic events. Other mental health advocacy groups, including the National Alliance for the Mentally Ill (NAMI), offer support to the idea behind Kendra's Law.

"Court-ordered outpatient treatment," according to NAMI statements, "should be considered as a less restrictive, more beneficial and less costly treatment alternative to involuntary inpatient treatment."

While he does not disagree with the idea of court-ordered commitment, Paul Appelbaum, M.D., vice president of the American Psychiatric Association, is not optimistic about it as a money-saving plan.

"That's a matter of active debate. And there's been data published that cuts both ways there. It is unlikely to cost more, but I wouldn't hold it out as a way of saving major dollars," Appelbaum said during a recent interview with 

. "We ought to talk about these programs as ways of providing better care for people [and] ensuring that more people receive the care they need."

Another national group that supports Kendra's Law is the Treatment Advocacy Center. D.J. Jaffe, a Treatment Advocacy Center board member from New York, explained during an interview, "For the mentally ill who have a past history of noncompliance it is the best predictor of future history, and it certainly is information we should be using when we're making these decisions."

Kendra's Law, he added, had many things in common with the Bellevue Outpatient Commitment Pilot Program. 

The significant differences between the new law and the existing program, he continued, involve patient eligibility.

Under the Bellevue program-currently the only hospital in the state that is involved in involuntary outpatient commitment-only a hospital may request that a patient currently hospitalized due to noncompliance be committed. Under Kendra's Law, a whole list of others can petition for incarceration, according to Jaffe. Another difference lies in the length of time between previous hospitalizations for noncompliance. The Bellevue program allows involuntary commitment of a patient with two hospitalizations for noncompliance in an 18-month period; Kendra's Law doubles that period to two hospitalizations in 36 months, Jaffe noted.

Although some advocates may question the fairness of involuntary commitment laws because of a lack of empirical evidence for their efficacy, these questions have not been a hindrance to such laws in more than 20 states and localities in the United States.

In the District of Columbia, for example, the law completely avoids the need for additional criteria that civil libertarians often seek for outpatient commitment. Instead, District of Columbia law calls for a court hearing after 30 days for patients who have been admitted to St. Elizabeth's Hospital by involuntary emergency admission, explained Roger Peele, M.D., professor of psychiatry at George Washington University, during an interview with 

"They are already inpatients. The decision is whether to commit them as an inpatient or an outpatient, or let them go home well, when they arrived at that 30-day mark."

Involuntary emergency admissions occur when a person is seen as someone who will harm themselves or others, or who does not take care of themselves by eating properly or having a domicile.

"It's regarded as being dangerous to oneself. When you read the law you won't see that, but when you read the court decisions you will see it," Peele said.

In general, Peele noted, the outpatient commitment program in the District of Columbia has been a success.

"Since 1973, the District of Columbia has done more outpatient commitment than inpatient...It involves a judge telling the patient that they must follow treatment while they are outpatients in a group home or other residence. If they don't show up for treatment, the U.S. marshals will come by and pick them up and take them to St. Elizabeth's Hospital, the large public mental health hospital here. It's often the hospital they were in when this decision came up."

About 80% or 90% of those admitted on an emergency basis never even reach that 30-day mark, added Peele, who was involved with the program for several years. In addition to the emergency admissions that circumvent civil liberties arguments, the Washington, D.C., program is a success because commitment does not have an endpoint and is followed by a team approach.

"As an inpatient or outpatient doctor, I am seen as part of the team. In a lot of states there is not this unity, because very frequently the states are responsible for the hospitalization, but the city or county or a local contractor is running the clinic. So you don't have this sense of unity. It's more like a shotgun marriage," Peele said, adding that without unity, patients often slip through the cracks.

Predicting outcomes, a problem for both advocates and mental health providers, is less of a burden in North Carolina's program, according to Jeffrey W. Swanson, Ph.D., assistant professor in the department of psychiatry and behavioral science at Duke University, Durham, N.C.

In a study of the North Carolina outpatient commitment program by Swanson and colleagues, he found that the law was "designed as a less restrictive alternative to hospitalization for people who have a pattern of revolving-door admissions to psychiatric hospitals." This was accomplished by using past admissions as criteria to predict that without treatment the person would pose a danger to themselves or someone else.

Swanson added that the people who were placed on outpatient commitment and had their time extended beyond the minimal period allowed by the law "have about one-half the likelihood of committing any violent act compared to those who didn't get outpatient commitment or only got a brief period of that which was not renewed."  

Articles

New York State Moves Toward Involuntary Residential Commitment of the Mentally Ill

Meeting the mental health needs of the millions of immigrants from diverse cultural backgrounds and homelands who now live in the United States may require more than a thorough knowledge of psychiatry or psychology, according to a number of cultural psychiatric practitioners.

A recent presentation by Joseph Aponte, Ph.D., of the department of psychology at the University of Louisville, Louisville, Ky., indicates that populations such as Native Americans, African Americans, Asian/Pacific Islanders and Hispanic currently make up at least 25.1% of the total U.S. population. Immigration from the former Soviet Union and Eastern European satellite countries adds even greater cultural complexity to the situation.

For example, how do physicians diagnose Hispanic patients complaining of anxiety and insomnia as well as physical ailments? Are they depressed or are they experiencing an attack of "nervios," an ailment that is simply translated as nerves and may or may not be depression, anxiety or another condition?

The only comprehensive study of the physical and mental health of Hispanics was done in 1984. Called the Hispanic Health and Nutrition Examination Survey (HHANES), it offers epidemiological clues about its subjects but few answers, according to medical anthropologist Peter J. Guarnaccia, Ph.D., of the Institute for Health at Rutgers University, New Brunswick, N.J.

Using two depression measures, the Center for Epidemiological Studies Depression Scale (CES-D) and the major depression section of the diagnostic interview schedule, the HHANES study found that the rates of depressive symptoms and depression were much higher among Puerto Ricans than among Mexican Americans or Cubans.

Guarnaccia explained, "I think that the point we drew from examining the HHANES data is that you need to look at different Latino groups differently, and that the problems Puerto Ricans face are much worse."Nervios, he added, "in some cases is its own expression of distress, which really isn't the same as a psychiatric disorder."

Although nervios and other culture-specific symptoms are defined in 

, extracting symptoms of depression or anxiety from a patient's description often cuts off the patient's full experience in order to fit a category, Guarnaccia noted.

Even behavior that doesn't conform to American ideals can be considered mental illness, said Horacio Fabrega Jr., M.D., of the department of psychiatry at the University of Pittsburgh and co-editor of

When some behaviors such as seeing visions or speaking in tongues are looked at in a clinical setting, they can seem bizarre, Fabrega said. But, he argued, "It's absolutely anathema to say that people who are deviant have psychiatric problems." When such nonconformists "logically and systematically connect their beliefs with a cultural or subcultural tradition," they are not psychotic. 

Functionality, Fabrega added, is a key issue and is judged not only by whether patients are eating well and otherwise taking care of themselves, but by the opinions of other members of their particular group. 

One patient, a minister on a fast "to the death" as part of a religious quest, was referred to Fabrega by a member of the congregation. 

"It's difficult to say [whether or not] she was deluded. But, nevertheless, [fasting to the death is] not something in which most ministers engage or believe," he said.

An important factor in the physician's diagnosis involved discussions with other people from the church. "They viewed her as off the deep end," he said.

Cultural complications abound, even in situations where conformity, terminology or language is less of a problem, according to Robert Abramovitz, M.D., chief psychiatrist at the Jewish Board of Family and Children's Services, New York. The Jewish Board has several programs to aid Russian Jews who have left the former Soviet Union. 

Although the clinics run by the Jewish Board of Family and Children's Services employ therapists fluent in both Russian and English, cultural differences have made treatment difficult.

"Many people coming from the former Soviet Union are concerned about psychiatry and those instances when it was used as a form of political repression," Abramovitz said. 

The migr's present their concerns in several ways, including a reluctance to enter treatment either in a hospital or as outpatients, he continued. 

"One of the dilemmas we face is we don't have records. All we know is [the migr's] representations that they've 'had very bad experiences' and they're reluctant to go to the hospital," he explained. 

Even the use of social workers as primary therapists is questioned by the migrs, who consider medical doctors the genuine experts. Their prior experience has involved getting advice and medication from physicians. There were no social workers in the Soviet Union. 

To overcome some of these difficulties, the organization has established "acculturation groups" that provide support, group therapy, and an introduction to American ways and medication. 

"We say 'We're not treating you for mental illness, we're helping you with a normal life transition. You just moved to a new culture.' It allows people to come and do something that otherwise would have been very difficult," Abramovitz said.

Depression and anxiety are the major problems brought to the groups. Most of the clients are middle-aged people who have left everything behind to join their adult children in the United States.

In addition to helping the migrs cope with the high levels of depression, stress and anxiety often created by immigration, the acculturation groups, which use standard group therapy, encourage all participants to enroll in English classes. Frequently, participants in the group compare the reality of life in the United States with what they had expected, according to Adele Nikolsky, consultant with the Jewish Board of Family and Children's Services.

Sometimes the lack of orthodox psychiatric services in foreign countries can also raise negative perceptions of psychiatry, said Nikolsky. She noted that in Moscow, genuine treatment for mental disorders was often restricted to prescribing medication and assigning the patient to one of 15 clinics in the city, where they would be given menial work, such as stuffing envelopes.

Other countries, notably Sierra Leone and Tanzania, have only one psychiatrist for the whole country, said Ellen Mercer, director of the Office of International Affairs for the American Psychiatric Association.

Mercer added that the use of psychiatry for political repression in the former Soviet Union and, to a lesser extent, in the People's Republic of China, is changing. 

"In most of the countries of the former Soviet Union, there's no longer great evidence of systematic abuses of psychiatry," she said. 

 Although Western medical approaches have spread around the world, the diffusion of non-Western culture has also penetrated the United States, according to Jefferson Fish, Ph.D., St. John's University, New York. "The use of medicinal plants, formerly used by traditional healers, is being investigated by drug companies, and is one example of the spread of non-Western medicine. The belief in magic and magical thinking that some cultures engage in is not indicative of ineffective treatment," Fish noted. 

"The term magic is a Western term. Magic is science to them," Fish explained in discussing a Brazilian tribe where headaches are treated by shaving the head and painting it red. 

"People in the West say...Western culture...is scientific and other cultures are not  scientific. No culture is scientific," said Fish, who co-organized the New York Academy of Sciences workshop on culture, therapy and healing.

Additional cultural differences, such as the perception of mental illness, as well as popular trends in medicine, can further complicate the treatment difficulties for American mental health professionals, said psychologist Jeffrey B. Rubin, Ph.D., author of 

Psychotherapy and Buddhism: Toward an Integration

In a recent conversation,  Rubin explained that the 'Eurocentric perspective,' or the belief that things European and Western were the center of the intellectual universe, had been replaced in the popular mind by the "mirror-opposite danger that things Oriental and non-Western are assumed to be the acme of health and civilization," he said. 

Such a perspective, he noted, leads to skepticism about the value of Western psychology.

For example, "There are several things Western psychology could offer a Buddhist," Rubin contended."The whole notion of the unconscious throws into question the idea of self-transcendence and self-mastery. And it brings into play the way we all labor under self-deceptions at times. So Western psychology could help a Buddhist understand some of the obstacles that are arising in their own spiritual practice," he explained.

Potential difficulties in accurate diagnosis and treatment of people from other cultures may be exacerbated by the therapists themselves, said Rose Yu-Chin, M.D., M.P.H., chief of adult partial-hospitalization day hospital and community psychiatry, Cabrini Medical Center, New York. 

"Therapists," Yu-Chin explained during a recent interview, "may be uncomfortable with people who look different, who have a different color skin, speak with an accent or have a different kind of last name."

This discomfort, coupled with a laser-like focus on the patient to the exclusion of the patient's extended family relationships, cultural issues or religion may cause the potential patient to leave the office thinking "That idiot didn't understand me at all," according to Yu-Chin.

Understanding the cultural factors that shape the patient may take more time, a precious commodity with the advent ofmanaged care, but it is well worth it, she continued.

"Managed care is interested in culture because they're interested in presenting  programs relevant to their members, who are often people of different ethnic backgrounds. Usually they [managed care groups] will allow you to have more sessions as long as you're able to justify the rationale for doing these sessions," she said.

In addition to more detailed interviews, Yu-Chin, who chaired several sessions on culture and therapy at the 10th Annual Research Conference of the New York State Office of Mental Health, suggested that therapists also familiarize themselves with other cultures.

First, she suggested, therapists should "learn to be uncomfortable" with unfamiliar cultures. "We have a tendency to confine ourselves to what's safe and comfortable." 

Another important task involves expanding social networks. The way to do this, she added, might involve organizing teach-ins, conferences or social events. 

"Third, read world history. American psychiatrists and psychologists may think they're well-educated, but they're among the most poorly educated in the world about world history," Yu-Chin added

Martin Kohl

Articles

New York State Moves Toward Involuntary Residential Commitment of the Mentally Ill

Cultural Sensitivity for Psychiatrists