[I]n Vermont, mandatory mental health treatment doesn’t happen only within hospital walls.
But the state’s system for “nonhospitalization” treatment orders has attracted criticism in recent years, with some arguing it is poorly coordinated and ineffective.
The Vermont Senate on Tuesday gave preliminary approval to a bill that could begin to address such concerns. S.203 doesn’t seek to immediately reform orders of nonhospitalization, but it establishes an 11-member committee to examine the program’s “strengths and weaknesses” and recommend changes later this year.
Sen. Dick McCormack, D-Windsor, told his colleagues that he generally dislikes study committees. But in this case, the committee’s makeup is “a very good illustration of the complexity of the issue,” McCormack said.
Orders of nonhospitalization, also known as “assisted outpatient treatment,” are imposed in family court or criminal court. They mandate a care regimen and place an individual in the custody of the state commissioner of mental health.
Failure to follow the order could lead to court-ordered hospitalization.
Nonhospitalization orders are used in most states. A recent report by the Arlington, Va.-based Treatment Advocacy Center said there is “growing recognition” that such programs “can substantially improve outcomes for individuals trapped in the ‘revolving doors’ of the mental health and criminal justice systems” by reducing hospitalization and incarceration rates.
But that same report claimed that, in Vermont, nonhospitalization orders are “largely ineffective” at keeping patients in treatment and out of trouble.
Key problems, the report said, include the lack of a “black robe effect” – the idea that being subject to a court order is a positive motivator for maintaining treatment. The report speculates that Vermont judges don’t interact enough with patients to produce that effect.
The report also said Vermont is “highly unusual” in allowing criminal courts to place a patient under civil commitment.
“There is a strong sense that criminal court-ordered patients are rarely individuals who would have been identified by mental health professionals as (nonhospitalization order)-appropriate, and are especially unlikely to take the (order) seriously,” the document said.
The Rutland-based advocacy group Vermont Psychiatric Survivors is also concerned about nonhospitalization orders.
In legislative testimony earlier this year, Executive Director Wilda White wrote that the orders sometimes are imposed on people who adhere to treatment regimens but “are simply not getting better.” In such cases, the order “feels like a punishment for being ill.”
White also cited “loss of agency and feelings of powerlessness” among patients subject to nonhospitalization orders. And she believes that the orders have “increased visits to the emergency department and have increased distress.”
In introducing S.203 to the Senate on Tuesday, McCormack said the debate touches on issues of civil liberties, mental health and public safety.
“It’s a problem because you’re dealing with someone who’s troubled and out in the world,” McCormack said. “There are enforcement difficulties. There are questions of what do you do when someone is not doing what they were told.”
The bill — which has been approved unanimously by the Senate Health and Welfare Committee and the Senate Appropriations Committee — calls for a committee to “review and understand” existing statutes and patient data.
That committee is also specifically instructed to review each recommendation in the Treatment Advocacy Center’s report, including the possibility of a pilot project that seeks to improve nonhospitalization orders in Vermont.
The committee would include mental health, public safety, judiciary and legal representatives. Vermont Care Partners; the Vermont Association of Hospitals and Health Systems; Vermont Legal Aid’s Mental Health Law Project; and Vermont Psychiatric Survivors also are included.
Additionally, the committee would feature a person who was previously under a nonhospitalization order and a family member of someone who is currently or was previously subject to such an order.
The committee’s report to the Legislature would be due by Nov. 1.
After Tuesday’s approval, the bill requires one more Senate vote before moving to the House.
