COLUMN ONE : Treatment Against Their Will : More states are making it easier to force the mentally ill into hospitals. Some doctors, families and even patients back such changes, noting the delicate balance between civil rights and ‘the human right to live.’

The temperature had climbed above 90 degrees, but Tressa, a slender 20-year-old woman sitting on a park bench outside the Staten Island Ferry Terminal, was wearing five layers of clothing. The holes in her jeans were stuffed with cardboard. Her shoes were wrapped in silver duct tape.

She had occupied the same bench every day, all day, for the last five months. A psychiatrist and a nurse, members of an outreach organization called Project Help, were trying one last time to persuade her to enter the Bellevue Hospital Center psychiatric ward voluntarily.

Eyes wide with fear, Tressa refused, as she had for five months. “There’s a time and place for everything,” she told them. “Even though I’m just sitting here, I certainly hope I’m not drifting from reality. I have a strong belief in God. He has always let me know when the right moment comes.”

Within hours, Tressa became part of a quiet but significant change in the way American society is dealing with the mentally ill, especially those who are indigent and resist treatment. Invoking special authority recently granted to health professionals, a Project Help psychiatrist took Tressa to Bellevue, despite her pleas to be left alone in the tiny triangle park where she felt safe.

For more than three decades beginning in the 1950s, government policy, medical opinion and the law lined up together to enforce strict limits on the conditions under which such involuntary commitments could occur. But today, the situation is changing:

Under pressure from the public, from relatives of mental patients and from the medical community, the strict prohibitions against involuntary commitment are being reconsidered and several states have already relaxed their standards for involuntary treatment. This has made it easier to commit mental patients--especially the indigent--whether they agree or not.

“The pendulum is starting to swing back,” said E. Fuller Torrey, a clinical and research psychiatrist based in Washington who is a leading voice in support of involuntary treatment. “None of us are saying it should go back to where it was in the 1920s or ‘30s. But we’re definitely going back in the direction where you will be able to get people in the hospital who need treatment.”

Most jurisdictions still permit involuntary commitment only for people with severe mental illnesses--schizophrenia, manic-depression and major depression--and only when they pose a danger to themselves or others--the standard set in the 1950s during the movement away from involuntary commitments.

Recently, however, some states--including, Arizona, Hawaii, Oklahoma, Delaware, South Carolina and Iowa--have modified those criteria, allowing courts to order involuntary commitment based on other factors, including psychiatric history and potential emotional injury to a family. In effect, the new rules permit authorities to act where the need for treatment is very clear and individuals are unable to make a decision for themselves.

In part, the change is being driven by neighborhood groups and citizens who are frightened by--or fed up with--the growing numbers of homeless mentally ill people in their communities. The balance between the rights of society and the rights of individuals is out of kilter, these groups contend.

Moreover, relatives and friends of mentally ill people who refuse treatment are banding together to pressure lawmakers. Consigning such people to live on the streets, eat out of trash cans and suffer without care or medication--all in the name of protecting their civil liberties--is perverse, they argue.

“In the name of civil rights they are denying people like my son the human right to live,” said a 70-year-old engineer whose 40-year-old son has suffered from schizophrenia for 17 years and has lived for years on the streets of New York because he denies that he is sick and refuses to take medicine. “When my son is psychotic, he’s an animal. He can’t decide what is best for him,” his father says.

Families tell of being unable to get treatment for their loved ones, no matter how clearly psychotic, until they have crossed the line into violent behavior. Slicing one’s scalp, pulling one’s hair out or hurting another person are among the examples cited by relatives. Desperate to get help, family members say, they sometimes lie to authorities, claiming that violent acts have already occurred.

Adding to the pressure from neighbors and families is the fact that doctors have new tools for alleviating the problems of serious mental illness.

“This comes at a time when we have a new generation of anti-psychotic drugs that are more effective and have fewer side effects,” said Robert Levy, the Project Help psychiatrist who decided to treat Tressa. “It’s much more humane to give these people treatment.”

The movement to abolish involuntary commitment, a common practice throughout most of the nation’s history, began partly as a result of public horror over the “snake pit” conditions that existed in many mental institutions during the first half of this century.

It also reflected the difficulty in justifying mandatory commitment on medical grounds when the care patients received was little more than custodial and seldom made them better. Patients could be treated as well or more effectively in community-based mental health centers, reform-minded doctors argued.

Also, large-scale commitment was expensive; emptying the huge mental hospitals that existed in every state appealed to voters who, then as now, thirsted for tax relief.

Civil liberties groups mounted a series of successful court challenges to the old system. All across the country, the idea that individuals had an almost absolute right to refuse treatment began to replace the idea that a benevolent state had an obligation to treat those who were seriously mentally ill, even if they objected. From 1955 to 1992, the number of people in mental institutions plummeted from 559,000 to 90,000.

Now, as the tide of opinion swings back, civil liberties advocates and some legal experts warn that changing the laws could result in denying individuals their constitutional rights or overburden the inadequate services available for helping the mentally ill. Government officials also warn that financial resources are not available to expand services.

“Broadening the commitment laws is bad in terms of policy and bad in terms of constitutional principles,” said John Parry, chief of staff of the American Bar Assn.’s Commission on Mental and Physical Disability Law.

“The gut reaction is to solve the problem of homeless mentally ill by putting people back in institutions, instead of providing a more humane life for these people,” he said. “But given the resources that we have and given what institutions are able to do, it is not a good idea to put more people into institutions.”

Many mentally ill people who have been involuntarily treated in the past are also worried about changing commitment standards. “I see this as heading down a slippery slope of losing our rights,” said Charlie Rodican, 51, of New York, who has been treated for mental illness through most of his adult life but has been stable for several years. “I think people have a right to choose whether they should be treated.”

Some mentally ill people and civil libertarians are banding together to speak out against broadening standards for involuntary treatment. They repeat horror stories of patients being abused by insensitive orderlies and argue that the risks of treating people against their will outweigh the benefits.

Dorothy Purnell, for one, does not see it that way. A 43-year-old former homeless crack addict who suffers from schizophrenia, Purnell was diagnosed as mentally ill as a child in Savannah, Ga., but for more than three decades denied she was sick.

“My shoes used to talk to me,” Purnell said in an interview, referring to the first time her parents committed her when she was a child. “That’s when they involuntarily committed me. I was mad at them for putting me into the hospital, because I felt like it was fine that my shoes were talking to me.”

She refused to take medication unless she was hospitalized--and she hated hospitals. She ended up living on the streets of New York--smoking crack, sleeping in subway cars or train stations and eating out of garbage bins. Several times, the police took her to emergency rooms, but because she was not violent they had no legal grounds to treat her against her will.

“I thought, I’m not going there with crazy people because I’m not crazy,” she recalled. On one cold night three years ago, Purnell took refuge in a shelter. A social worker was unusually attentive and, for the first time in many years, Purnell took medication.

“She would watch me take it,” Purnell said. “I had to open my mouth to show I had swallowed it. It was involuntary treatment, but a good kind of involuntary because it helped to stabilize me and it was done with kindness.”

Now that she is stable, Purnell wishes the laws had been different.

“I would like for someone to have committed me to the hospital, because I was not able to care for myself,” Purnell said. “Intervention would have helped a lot. There are a lot of people out there who have problems with reality who could be helped through involuntary intervention.”

For the first time in decades, she is in close contact with her family. She has discovered grandchildren she did not know. And she is attending college on a scholarship. She just started a job as a counselor at a halfway house associated with the program that helped her.

Specialists estimate that 30% to 40% of the people living on the streets or in homeless shelters suffer from severe mental illness. Most get no medication or treatment, in large part because--like Purnell--they are afraid of hospitals or insist that they are not sick.

One sign of the increasing public determination to do something about the problem was a decision this summer by the New York state Legislature to expand the state’s authority to compel mentally ill people with a history of hospitalization to take medication or attend counseling on an outpatient basis. If the patients refuse, they can be recommitted.

Civil libertarians, conceding that public views had changed so much that they could not defeat the proposals, opted not to fight. Instead they helped draft the legislative language.

“It’s inconceivable that five years ago it would have passed,” Torrey said. “The fact that they passed that law without opposition from the American Civil Liberties Union is a significant indication of how far things have come.”

Robert Levy, who for a long time was the New York Civil Liberties Union’s expert on the issue, contended that the new law is not a sign of a trend but a reaction to a specific, highly publicized case involving a homeless, schizophrenic crack addict named Larry Hogue who menaced an Upper West Side Manhattan street for years.

Hogue had a long history of involuntary commitments. He was often picked up by police. Sometimes he was released in days, sometimes within months. When discharged, he would stop taking his medication, start smoking crack and return to setting fires, grabbing passing schoolchildren and hurling himself into traffic.

In one especially horrendous episode, he pushed a teen-ager in front of a truck. Fortunately, the driver swerved the vehicle in time, avoiding a tragedy.

The cycle stopped when he was involuntarily committed for a longer term to a state hospital on the grounds that he was likely to abuse crack and become dangerous.

“Sometimes exceptional cases tend to drive legislation,” Levy said. “I think there’s a great tension between the forces of liberty and the forces of benevolence. For the last seven or eight years there has been a lot of pressure to cut back on the constitutional liberties that had been recognized in the 1970s and 1980s,” he said.

Advocates of greater freedom to impose involuntary commitment see the issue not as a matter of civil liberties but of effective medical treatment and balanced social policy.

“The Hogue court finding as a precedent was a very important one,” conceded Zebulon Taintor, a professor at New York University, a practicing psychiatrist and the president of the U.S. branch of the World Assn. for Psychosocial Rehabilitation. But he added: “Involuntary treatment is often a necessary first step to getting people involved in treatment.”

Besides, he said, “we think untreated mental illness gives all mental illness a bad name.”

Families of mentally ill homeless have argued that they should be trusted to advise authorities when someone is psychotic and needs treatment.

Every time the family of Victoria Jacobs Madeira sought involuntary treatment for her, authorities in California said that the Anaheim woman showed no signs of endangering herself or others, because she was finding food and shelter--even though she got her food from Dumpsters and she and her then-11-year-old son lived in a parking lot. Like many people with mental illness, Madeira did not recognize her illness and refused treatment.

One day in 1990, Madeira dressed her son in girl’s clothes and makeup, took a taxi 75 miles to her parents’ home and stabbed and shot her 78-year-old mother.

“She did not fit the criteria (for treatment) until she murdered my mother-in-law,” said Carla Jacobs, who is crusading to change the commitment laws in California. “Waiting for danger is too late.”

Jacobs said that her sister-in-law’s case illustrates the absurdity of the claim that the law protects individuals’ constitutionally enshrined liberty.

“The laws give civil rights to the psychosis rather than human rights to the person,” she said.

After being arrested, Madeira bounced from a mental hospital to jail, where she refused medication and was found incompetent to stand trial, then back to the hospital. She finally was committed to a state mental hospital.

California’s 1967 Lanterman-Petris-Short Act, which prevents involuntary commitment of those not deemed to be dangerous to themselves, was a pioneering step in the nationwide transformation of mental health laws during the period in which it was passed, and all attempts to change it failed.

But Jacobs said that he believes public opinion is changing. She and other advocates plan to launch another attack on the law during the next session of the California Legislature.

Still, even those who advocate more flexibility in commitment laws acknowledge that it is a difficult issue, that there can be a downside to involuntary treatment and that no single strategy is best for all cases.

Liz Ramsey, the mother of a 31-year-old mentally ill woman, lobbied strongly and successfully for broadening the standard in Arizona and used the new criterion of “persistently and acutely disabled” to get treatment for her daughter at what she believes was a critical moment:

“She had not done anything to me. She had said she wanted to kill me with a knife. But she did not have a knife, so that was not enough to show she was dangerous. But we were able to show by her previous records that she had been helped by being in the hospital and receiving treatment, so they hospitalized her.”

But she understands clearly the perils of forcing treatment.

“Broadening the standard to those who are persistently and acutely disabled is as far a step as we can go to take away someone’s civil rights,” she said. “Taking someone’s civil rights away creates a trauma that the person will never get over.”

Her daughter’s words still echo in her memory: “You have taken away my life, Mom.”

On balance, however, Ramsey said that she believes she and her daughter are better off now. “The way it was, she said, “you had to have someone hurt themselves or someone else” before you could get help.