04/21/23 1

INVOLUNTARY TREATMENTIN THE 21ST CENTURY

MAKING THE RECOVERY MODEL REAL

Honorable Milton L. Mack, Jr.Chief JudgeChief Judge

Wayne County Probate CourtWayne County Probate CourtDetroit, MichiganDetroit, Michigan

December 10, 2010December 10, 2010

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CURRENT CONDITION

NationallyNationally

Over 340,000 with mental illness are Over 340,000 with mental illness are incarceratedincarcerated

2/3 of prisoners with mental illness were 2/3 of prisoners with mental illness were off their medication*off their medication*

25% of prisoners have history of chronic 25% of prisoners have history of chronic mental illnesses*mental illnesses* SchizophreniaSchizophrenia Bipolar disorderBipolar disorder DepressionDepression*The Health and Health Care of U.S. Prisoners: Results of a Nationwide Survey, American Journal *The Health and Health Care of U.S. Prisoners: Results of a Nationwide Survey, American Journal

of Public Health, 2009. Harvard Medical Schoolof Public Health, 2009. Harvard Medical School

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IN THE BEGINNING . . .

Generally cared for in homesGenerally cared for in homes Kept in:Kept in:

– AtticsAttics– BasementsBasements– Backyard iron cagesBackyard iron cages

Less fortunateLess fortunate– Jails Jails – AlmshousesAlmshouses

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DOROTHEA DIXDOROTHEA DIX

Believed improving conditions would Believed improving conditions would helphelp

Lobbied legislatures and Congress to Lobbied legislatures and Congress to establish asylumsestablish asylums

Architect of first generation asylumsArchitect of first generation asylums

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INSTITUTIONAL MODELINSTITUTIONAL MODEL

Governed Mental Health Care Governed Mental Health Care Delivery Across the CountryDelivery Across the Country

Mental IllnessMental Illness

– Considered Lifelong disabilityConsidered Lifelong disability

– Little, if any, hope for recoveryLittle, if any, hope for recovery

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HISTORICALLY – HISTORICALLY – 1950s1950s

Institutionalized with Mental Institutionalized with Mental IllnessIllness

– 559,000 people in the United States559,000 people in the United States

– Over 20,000 people in MichiganOver 20,000 people in Michigan

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HISTORICALLY – HISTORICALLY – 1960s1960s Community Mental Health Act of Community Mental Health Act of

19631963

– Triggering eventTriggering event

– New federal roleNew federal role

– Agreement to pay for mental health Agreement to pay for mental health treatment UNLESStreatment UNLESS an adult patient an adult patient in a psychiatric hospitalin a psychiatric hospital

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HISTORICALLY – HISTORICALLY – 1960s1960s GoalsGoals

– Reduce hospital population by 50%Reduce hospital population by 50%– Within 10 yearsWithin 10 years

IncentiveIncentive– Federal $$$ for Outpatient Federal $$$ for Outpatient

TreatmentTreatment– State funds freed-upState funds freed-up

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HISTORICALLY – HISTORICALLY – 1970s1970s

Michigan’s Mental Health Code - Michigan’s Mental Health Code - 19741974

Enabled the Conversion of Enabled the Conversion of

Institutional ModelInstitutional Model

ToTo

Community Treatment & SupportCommunity Treatment & Support

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HISTORICALLY – HISTORICALLY – 1970s1970s Barriers to Involuntary Barriers to Involuntary

HospitalizationHospitalization

– Due process standardsDue process standards

– Civil commitment standardsCivil commitment standards Threat of imminent harm Threat of imminent harm

– Most States have similar standardsMost States have similar standards

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RECOVERY MODELRECOVERY MODEL

Mental Illness is seen as:Mental Illness is seen as:

– Responsive to Specific TreatmentResponsive to Specific Treatment

– RecoverableRecoverable

Productive LifeProductive Life

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RECOVERY MODELRECOVERY MODEL

Timely Treatment:Timely Treatment:– Speeds recoverySpeeds recovery

– Promotes wellnessPromotes wellness

– Promotes quality of lifePromotes quality of life

– Preserves resiliencyPreserves resiliency

– Reduces costsReduces costs

– Reduced need for intensive careReduced need for intensive care

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RECOVERY MODELRECOVERY MODEL

Barriers to Timely Treatment RemainBarriers to Timely Treatment Remain– Wait for crisis Wait for crisis

– Delayed delivery of right care at the right Delayed delivery of right care at the right timetime

– Law enforcement knows treatment is not Law enforcement knows treatment is not an option, making jail the only optionan option, making jail the only option

– Common assumption that persons must be Common assumption that persons must be homicidal or suicidal to get treatmenthomicidal or suicidal to get treatment

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MISALIGNMENTMISALIGNMENT

Current Mental Health CodeCurrent Mental Health Code

An Inpatient Model in anAn Inpatient Model in an

Outpatient WorldOutpatient World

OrOr

A Community Treatment and A Community Treatment and Support Model in a Recovery EraSupport Model in a Recovery Era

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PERSON PERSON REQUIRING TREATMENTREQUIRING TREATMENT MCLA 330.1401MCLA 330.1401

(c) (c) An individual who has mental illness, whose An individual who has mental illness, whose judgment is so impaired that he or she is unable judgment is so impaired that he or she is unable to understand his or her need for treatmentto understand his or her need for treatment

to result in significant physical harm to himself, to result in significant physical harm to himself, herself, or others. This individual shall receive herself, or others. This individual shall receive involuntary mental health treatment initially only involuntary mental health treatment initially only under the provisions of sections 434 through 438.under the provisions of sections 434 through 438.

on the basis of competent clinical opinion,on the basis of competent clinical opinion,

and whose continued behavior as the result and whose continued behavior as the result of this mental illness can reasonably be of this mental illness can reasonably be expected,expected,

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PERSON PERSON REQUIRING TREATMENTREQUIRING TREATMENT MCLA 330.1401MCLA 330.1401

(c) (c) An individual who has mental illness, whose An individual who has mental illness, whose judgment is so impaired that he or she is judgment is so impaired that he or she is unable unable

to understand his or her need for treatment to understand his or her need for treatment

on the basis of competent clinical opinion. on the basis of competent clinical opinion.

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ALIGNING THE ALIGNING THE SYSTEMSYSTEM

Early TreatmentEarly Treatment– Allows a person to recover from illnessAllows a person to recover from illness– Frees the person from the illness Frees the person from the illness

preventing the exercise of free choicepreventing the exercise of free choice– Early treatment supports freedom from the Early treatment supports freedom from the

devastating consequences of untreated devastating consequences of untreated mental illnessmental illness

– Opportunity to restore capacity beforeOpportunity to restore capacity before JoblessnessJoblessness HomelessnessHomelessness IncarcerationIncarceration

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ALIGNING THE ALIGNING THE SYSTEMSYSTEMWhat is the real fear of early What is the real fear of early

intervention? intervention?

– Protecting choice?Protecting choice?

– Stuck in 1974?Stuck in 1974?

– Lack of confidence in treatment Lack of confidence in treatment modalities?modalities?

– Lack of continuity in the public Lack of continuity in the public system? system?

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WHAT IS WORKINGWHAT IS WORKING

Connecticut ProgramConnecticut Program

– Links Probate Court with CMHLinks Probate Court with CMH

– Guardians have help from case Guardians have help from case workersworkers

– Help wards navigate systemHelp wards navigate system

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ARRESTS BEFORE & AFTER INVOLVEMENT

16 People Arrested, 46 Arrests 12 People Arrested, 22 Arrests

N = 54

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INCARCERATION / JAIL DAYS

13 Incarcerated, 985 Total Jail Days 4 Incarcerated, 362 Total Jail Days

N = 54

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EMERGENCY ROOM

23 People, 322 Total Visits 23 People, 150 Total Visits

N = 54

04/21/2304/21/23 2323

HOSPITAL EVENTS

30 People, 287 Total Visits 27 People, 240 Total Visits

N = 54

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WHAT DOES THIS WHAT DOES THIS MEAN?MEAN?

The Right Care at the Right TimeThe Right Care at the Right Time

– Speeds recoverySpeeds recovery

– Reduces CrimeReduces Crime