Need for Community Based Mental Health Practices

Involuntary Treatment and the Failed Responses to De-Institutionalization and the Need for Community Based Mental Health Practices

Purpose

The historical realities and current policies that allow for institutionalization and involuntary hospitalization and treatment have often held positive intent but horrific impact on the mental health community. These policies mainly affect people living with mental health needs, neurodevelopmental disabilities, and substance use disorders. Involuntary treatment in its current form is influenced by the de-institutionalization movement of the mid-to-late 20^th century. The contemporary Rev. Code WASH. § 71.05.150 revised in 2015 is the legal foundation of involuntary treatment (Washington State Legislature, 2018).

This paper will explore the current state laws, their impact, the historical foundation of these policies, and examine advocates concerns and suggested reforms. Advocates argue for centering the voices of those living with disabilities who regularly experience these systems as the patient. Advocates also urge building a system and culture that prevents the need for involuntary treatment by normalizing mental health, reforming the criminal justice system, and creating affordable care options. These solutions can be realized by emphasizing community centered practices and funding.

A Historical Problem in Modern Times:

Figure 1: Table of legal precedent impacting mental health systems

In Washington (WA) policies that impact involuntary treatment are regulatory codes RCW WASH § 71.05.150 and RCW WASH. § 71.05.230.  RCW WASH. § 71.05.230 is the foundation for extending holds by 14-days, 90-days, or 180-days (Washington State Legislature, 2018). RCW WASH 71.05.360 is the legal rights for people involuntarily detained (Washington State Legislature, 2018).

These rights include the right to refuse medication including an antipsychotic drug, to have all possessions remain on them or with them unless harmful (an essential protection for those experiencing housing turbulence), and the right to mental health services and professionals while hospitalized (Washington State Legislature, 2018). The Treatment Advocacy Center rates WA’s use of laws related to institutions and involuntary holds as a C- citing involuntary holds regularly approved for reasons that do not meet harm to self or harm to others, the removal of patients property, and forced medication for reasons that do not meet the legal criteria. Also, patients are forced to experience long wait times due to a lack of psych beds. There is also too little connection to continued care (Treatment Advocacy Center, 2018).

 In short, advocacy organizations have severe concerns that involuntary laws are being misused to remove the rights of patients while not meeting basic care and human rights requirements. The Treatment Advocacy Center is not alone; in 2014 the American College of Emergency Physicians graded every state’s health care and gave the state a D+.  One of the most pressing concerns being the lack of psychiatric beds and emergency mental health care (Schinder, 2014).  Washington is in the bottom three states of psychiatric beds per state despite our booming population (Groover, 2018).  Much of these concerns come from lack of funding holistically in the mental health field which prevents a lack of access to care. This lack of funding for services can result in a high need for involuntary treatment due to a lack of early intervention.

Long wait times, being placed in improper beds while waiting for access, the need for criminal justice reform and treatment have all resulted in severe problems. Involuntary treatment is shown to often result in trauma while also it does not connect clients to continual support regularly (RAND, 2000). This results in many patients being released and destabilizing to the point of needing another involuntary hospitalization. The lack of services can create a cycle of lack of care after discharge, and then a patient experiencing multiple involuntary holds (RAND, 2000).  While revisions such as Ricky’s Law has expanded what qualified for service, there is still little actual access to services (Washington State Legislature, 2018).

There is also a far too common trend of those with mental health needs ending up in prison or suffering police violence (Smith, 2016). Advocates are urging police understanding of de-escalation through mental health lenses and a criminal justice system based on restorative care. Criminal justice systems have become the new “institutions” for many people with mental health needs.

Historical Institutions to Modern Institutionalization

Involuntary treatment and the historical precedent for institutionalizing people with mental health needs are tied. National and state law has for much of United States history encouraged warehousing patients with mental health needs.  Contextualizing Washington state current law in the history of US law which was built on a foundation of institutionalizing those with disabilities is essential in understanding the current failures (Pan, 2013). Washington state law is occurring during the movement of de-institutionalization and the rise of the criminal justice system as a mental health ‘provider’  (Pan, 2013).

Historically, the housing of people with mental illness was the norm in the United States and Europe. There is an increasing resurgence in discussion and growing movement to reintroduce mainstreaming institutions, and there is still one active mental health institution in Washington (Stroh, 2018). What is becoming less discussed is why the de-institutionalization movement was founded.

Patients and parents voiced continued alarm at the quality of health care in institutions noting forced medication, including experimental medicine, abuse and neglect, and the forced shock therapy and lobotomization of people with disabilities (Fabian, 2017). The concerns of what was occurring within the walls of institutions combined with growing concern over eugenics forced political pressure on policymakers to respond (Pfeiffer, 1994). Concern grew after President Kennedy toured a series of facilities and films such as One Flew Over the Cuckoo’s Nest brought attention to the plight of people with mental illness. Advocates in the disability community after decades of struggle were able to force the de-institutionalization movement onto the public and policy arena.

While it easy to look at criminal justice statistics and current ITA problems and be allured back to the ‘continued care’ institutions brought we must examine the disability community and why they have been consistent in citing institutions not providing care (Disability Justice 2016).

Framing history in its entirety to understand this resistance can allow for a way forward. During Kennedy’s administration, considerable funds were allocated to community health clinics and universities to fund research, prevention care, and mental health support. The goal of the of the Community Mental Health Act was simple, to provide support and funding to keep people with disabilities in their communities and homes (National Council). Over 400 million was funded in immediate community mental health creation (Smith, 2016). 

The law had profound impacts. By 1980 75% of institutions were emptied (Sharfstein, 2000).  President Johnson coupled the Community Mental Health Act with changes to Medicare, Medicaid, and Social Security and the goal of inpatient services, outpatient services, day treatment, education, continued care at home, emergency services, consultation, and incentivization of research through community funds and affordable care were put into policy (Sharfstein, 2000). Over 600 mental health community centers were built serving nearly 2 million patients with the aim to double services (Amadeo, 2019).

This dream was never met. By the 1970’s President Nixon and Democrats were debating using public funds to provide mental health services and with Reagan election came the removal of the community-based seed funding and instead blocked funding that closed most mental health centers. This block funding pitted communities in competition forcing closures of those who lost the grants and combined with criminal justice reform the shift of care moved from community care to jails (Smith, 2013). This criminal justice and mental health crisis coupled with lack of funds remains a modern problem that much of WA law was built under.

Social Justice Implications and the Removal of Patient Voice

If we are to build effective services we must honor the disability communities perspective of institutionalization as a form of systemic ableism. Often institutions have been used as a way to segregate people based on ability status and not based on medical need. Framing institutions as historically connected to ableism are vital as is the call to avoid institutions if possible. Far too often mental health care policies decisions have not centered on patients’ voices. Creating a health care system accountable to patients is key in solving our current mental health crisis (Arc of Washington).

Advocates suggest provisions that include; allocating more beds specifically for mental health, increased community supports, de-institutionalizing the criminal justice system, employment (or other funds), housing support, and providing community education to support people with varying mental health disabilities to prevent the need of involuntary holds  (WHO, 2003).

Disability advocates have long advocated for community-based care, criminal justice reform, and early support (Arc of Washington). As providers placing historical reality at the center of our discussion can offer a way forward. We do have an example of a system that made significant improvements rapidly that align with disability justice advocates mission. Removing block grants and returning to seed funding used under Kennedy and Johnson that successfully built over 600 health care centers and incentive research in universities can be a tangible first step.

Furthermore, education and home-based support for people with mental illness can both prevent caretaker burnout while also promoting norms that mental illness is not a failure. By allowing a community-centered practice that encourages people with mental illness to be part of their communities we can normalize the reality of mental health needs (Arc of Washington).

The most critical recommendation is radical inclusion. Funding and care decisions have long been driven by ‘stakeholders’ that include insurance companies, policymakers, hospitals, and medical organizations. The central voice for mental illness care is those living with mental health needs. These communities have been consistent in advocating needs of access to early care, community-centered practices, criminal justice reform, and emergency services funding and any model of care must meet those demands. To ignore the voices of patients is re-enforcing a system of ableism that has allowed for the current mental health crisis in WA and the nation.

Conclusion

The failures in current mental health practices come from an array of system failures and funding problems. There is no simple policy fix to eliminate these problems. However, disability advocates offer policy suggestions built on history and facts. By removing block grants and moving to seed funding based on community need, there can be an increase in mental health services. These services can act as early support to prevent the need for involuntary treatment.

Increasing emergency funding and psychiatric beds that fully respect the rights of patients under WA state law can reduce trauma and offer more consistent and available services.  Combined with criminal justice reforms that focus on restorative care and training on de-escalation can lower incarceration rates and police brutality. 

All of these changes must be practiced in community-focused ways that center community care and the voices of patients. Enshrining these changes through policy amendments in funding streams and regulatory expectation of compliance with state law of patients can improve our community and those living in it that experience mental health needs. 

Works Cited

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• Washington State Legislature. (2018). Retrieved from Commitment beyond initial seventy-two-hour evaluation and treatment period—Petition for fourteen-day involuntary treatment or ninety days of less restrictive alternative treatment—Procedure.: https://app.leg.wa.gov/RCW/default.aspx?cite=71.05.230
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