Team Care Is a Better Way for the Mentally Ill

On July 12, 1976, Edward Charles Allaway carried a rifle into the library at Cal State Fullerton and opened fire on his co-workers because he believed that they had taunted him about some pornography he thought was being made on campus. He shot nine people, seven of whom died.

Allaway was diagnosed with paranoid schizophrenia and declared not guilty by reason of insanity. Now the state psychiatric hospital where he has been for 25 years would like to set him free, claiming that he is healed and no longer a threat. Predictably, there has been a public outcry.

Psychiatric illness terrifies us, for good reasons. People in Allaway’s condition have wildly irrational thoughts. They may believe that others are mocking or baiting them and strike back violently. They may decide to punish someone for impure thoughts or for causing them to have impure thoughts. And because their thinking seems radically alien, we feel helpless in the face of their illness, and often we feel an intense desire to do anything that will control the uncontrollable.

The California Assembly is considering legislation to tighten the grip on mental illness with a device called “involuntary outpatient commitment.” An amendment to the Lanterman-Petris-Short Act would enable a judge to require that a patient report for and accept psychiatric treatment.

This seems like a good idea; more patients could be followed and managed by making their management mandatory. The problem is that involuntary outpatient commitment doesn’t seem to work:

* As a recent Rand health study conducted at the request of the California Senate pointed out, there is no empirical evidence that a court order is necessary to get patients into treatment when they want it or that it gets them to stay in treatment when they don’t. The schizophrenic man who pushed Kendra Webdale off the New York City subway platform in 1999 didn’t need involuntary commitment. He had asked for help repeatedly. He was failed by a system with inadequate resources that had repeatedly turned him away.

* The bureaucracy created by legally mandated treatment will drain more money from those already inadequate resources for inpatient hospitalization and outpatient care. This is one of the reasons why many patients hate the idea of involuntary outpatient commitment. They fear that it will give the state an excuse to reduce the funding for inpatient psychiatric care even further. The community mental health movement began with great idealism when the federal government mandated community-based outpatient care and provided the initial funding. States took the money, closed many of the hospitals and did not continue funding the outpatient programs when the federal money dried up. Suddenly, urban streets were full of patients who were homeless as well as chronically mentally ill.

* The proposal infantilizes clients, most of whom are not violent, and reinforces the stigma of inhumanity. The position paper from the California Network of Mental Health Clients says clearly that the people whom this approach was intended to help are against it. As a client once told me bitterly, “If you had a heart attack right here, they’d call the ambulance. If I get sick, they’d call the police, and the police would haul me off in handcuffs.”

Instead, the Legislature should consider investing in a system that has been shown to have results across the country: Program of Assertive Community Treatment, or PACT. This establishes patients and staff as collaborators. A team of social workers, nurses, psychiatrists and other specialists keeps track of a relatively small number of patients, following them in their homes or neighborhoods. The team helps with housing, medication and vocational rehabilitation. Team members search the patients out rather than waiting for the patients to come to them.

There is excellent evidence that PACT works and that it provides for clients at least some of the social community, intervention and continuous care that they need. And because PACT significantly reduces the rate of hospitalization, it is cost-effective.

We are all afraid of madness. But involuntary outpatient commitment treats our fears, not our problem.