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In a series of special reports and personal profiles, VPR News explores mental health issues in Vermont.Reports: The Acute Care System; Community Mental Health; Corrections; Involuntary MedicationProfiles: Vermont Mother; Paige Corologos; Anne Donahue; Marla SimpsonThis project was made possible by the VPR Journalism Fund. Learn more about the series State Of Mind.

State Of Mind: The Fight Over Involuntary Medication

Flickr: benchilada 2467405983
Ad for Abilify on the side of a pay phone (unknown location)

VPR's special series, "State of Mind," on Vermont's mental health system, concludes with the controversial issue of involuntary medication, or what opponents call forced drugging.

A discussion and potential fight loom in the state legislature this winter over changing the process for when a doctor may administer anti-psychotic medication to a patient refusing treatment in a psychiatric hospital.

The Experience of Involuntary Medication

Marla Simpson lives in Randolph and struggles with bipolar disorder. She has testified in front of the legislature and works for a support hotline.

Speaking calmly and confidently, she shares her perspective on the issue.

"I am fully against forced drugging. It is terrifying. It leaves psychological scars. It's an act of violence. I've experienced it probably 20 times since 1997. And every time I experience it, it is terrifying. I feel like I'm going to die."

When Tropical Storm Irene hit Vermont, Simpson was one of the patients being treated at the Vermont State Hospital. She had been taken there against her will after being found walking naked down the road.

"So my crime," she says, "which wasn't really a crime, was public nudity. And it was right before Hurricane Irene hit and I felt like some apocalypse was coming and that was mid-July of 2011. And so I was off to meet the mother ship. And that's why I was walking down the street with my cat."

Simpson was picked up by the police and taken to the hospital. When the facility was evacuated, she was transferred to the Brattleboro Retreat, where she remained until she was deemed stable enough to be released.

The Involuntary Process

When people are hospitalized involuntarily in Vermont, there is one process they go through to be committed. There's another process to determine whether or not they can be forcibly administered medication. Both of these take place in a court, in front of a judge.

The commitment process typically takes about 30 days from the day the patient is admitted to a psychiatric hospital.

Only after that happens can a second process can be initiated by the hospital to allow doctors to forcibly administer drug treatment.

That second hearing can take another 30 to 60 days. Governor Peter Shumlin wants to make the process quicker.

"Most people who deliver mental health in Vermont will tell you that when they have a really critically ill person and they're unable to give the treatment that they are trained to give because the patient's refusing it and you have to wait and go to a judge and go through this long process that it definitely not only extends recovery for the patient who desperately needs the treatment they deserve, but it also means a much more difficult treatment until they are able to get what they need."

The Brattleboro Retreat takes in some of the sickest patients in Vermont. Often they have been admitted against their wills. Fritz Engstrom, the Retreat's medical director, says it's not just un-medicated patients who suffer.

"You're typically talking about people who are harmful to themselves or others. So it could be someone trying to gouge out their own eyes and one of these times they're going to be successful. Or, the harm to others; we've had lots of staff be injured. And we're talking about serious injuries such as concussion or broken leg. And we're talking about other patients being terrified. It makes them worse.

"So it's terrible for other patients, it's terrible for the individual involved, and it's terrible for the staff."

Engstrom would like to see the legislature take action to shorten the time between admission and treatment.

Some family members who have watched their loved ones struggle for months in acute psychosis would like to see the process streamlined too.

We talked to a mother who didn't want us to use her name because her adult son has severe schizophrenia. Revealing her identity could jeopardize her relationship with him. Her son refuses to take anti-psychotics because he doesn't believe he has a disorder.

He's been hospitalized about 17 times in the last ten years after becoming violent, breaking the law, or going into a catatonic stupor.

Speaking in rapid-fire staccato, this mother says her son was 20 when he first went to the State Hospital. It took months to get him stabilized. But in the meantime he was administered emergency medication to sedate him when he got out of hand. (Emergency medication is allowed without a court order.)

"So what happened was, when he would get out of control, get violent, become a danger to self or others, they would put him in restraints, strap him down, all extremities, then shoot him up with what were so-called emergency medications. As if the whole thing was not an emergency. This happens over and over and over again. He's getting sicker and sicker, more and more psychotic but yet he's still denied treatment because it is his civil liberty. If it is not his choice to be treated, he doesn't have to be treated against his will unless it goes through more court proceedings."

Not Everyone Agrees

It can be anguishing for family members and caregivers to watch a patient get sicker and sicker, but not everyone believes forcing medication on psychiatric patients more quickly will solve their problems. They say the current system exists to protect people at their most vulnerable.

Marla Simpson has been hospitalized many times because of her bipolar disorder.

"If there is a crisis, I think the person should still have choices in their own treatment. Once someone has been labeled involuntary, you're at the mercy of the system."

Simpson says she takes medication voluntarily most of the time, but when she's hospitalized against her will she feels like she loses all control over her own body. When she's medicated involuntarily, it's often with higher doses of drugs than she takes on her own, and she loses a sense of time.

The drugs in question are usually anti-psychotics with names like Abilify, Risperidone, and Haldol. And they're often administered by injection.

"There's no communication at all," Simpson laments. "And that's why it feels so violating and that's part of my mistrust in psych wards of psychiatrists in general because of the lack of communication."

That lack of trust is a huge hurdle to overcome in helping someone get well. Jack McCullough runs the Mental Health Law Project for Vermont Legal Aid. He and his team represent patients going through the court processes of involuntary commitment and medication.

"As soon as you introduce force into the equation," he asserts, "you make it very much harder for the person to have a trusting relationship with not only the psychiatrist in the hospital, but with the entire mental health system. Because we're training people to understand that the mental health system is not there as something to help them, but as a system that's going to do things to them. And that in the long run is destructive to any kind of therapeutic alliance. It makes people less likely to ask for help when they need it and more likely to avoid the system that they would see has treated them very badly in the past."

Legislative Action Looms

It's a very small number of people who are forced by a court order to take involuntary psychiatric medication. About 40 or 45 a year in Vermont.

But, in a system that is already straining to accommodate all the patients who need acute care, just one person taking up a bed for 60 or 90 days before getting medical treatment means that others are waiting in emergency rooms.

That's one reason why Governor Shumlin wants the wait time to be significantly shortened. He's asked the legislature to take up the issue and one of the lawmakers committed to doing just that is Northfield Representative Anne Donahue. She sits on the House Human Services Committee and the Mental Health Oversight Committee.

"It's definitely going to come up. But I'm not sure where it's going to go."

Donahue has tried to address this issue in the past, with little success. But she says the crisis we're facing with the strain on emergency rooms and hospitals trying to treat severely mentally ill patients virtually guarantees a discussion in Montpelier this year.

One of the questions on the table will be whether involuntary commitment and involuntary medication can be decided at the same time, rather than in two separate court hearings.

Mental Health Law Project Director Jack McCullough says he doesn't want to see the process sped up at all. And he's particularly concerned about combining the commitment and medication hearings.

"Under the proposals we've heard about," he warns, "where the involuntary medication case and the involuntary hospitalization case happen at the same time, we would see a dramatic increase in the number of involuntary medication cases that were filed because the state would want to take advantage of that and get the involuntary medication order right away."

McCullough says most of his clients voluntarily accept medication, often after being involuntarily admitted. The extra days give patients and doctors more time to come to a mutual agreement.

Representative Donahue is sympathetic.

"How many additional people will be caught in that net when, with a little more time, they may have decided this is appropriate for them to take medications with a little bit more support?"

But Donahue says there's another process that needs speeding up.

"I think we are egregious in a way we violate rights in Vermont in that it takes a month before you first see a judge. Now if you're arrested or if you have your child taken away from you—major invasions of your rights by the state—you don't have to ask for a hearing. It's automatic that within a couple of days a judge is going to review, on a preliminary basis, whether that was appropriate. Doesn't happen in mental health."

Donahue says she'd like to see an initial hearing taken up within 7 days, to make sure the state has standing to detain a person.

Beyond that, Donahue thinks a more wholesale change is needed. She'd like to see decision-making more closely parallel what happens in other medical situations where a patient is unable to make decisions. Someone else—not a judge—makes decisions on their behalf.

"And often informally that's a family member," she explains. "If there isn't someone appropriate it may become a guardian, if someone has written an advance directive it's their agent. But they're always speaking on behalf of what that person would have wanted if they were competent. And right now we don't do that for a person with a mental illness. We automatically say: if they're objecting and they don't have capacity, then we have to go through a court process and a judge makes the decision, based on a petition from the doctor. So we treat it completely differently."

Jack McCullough warns that however this issue is addressed, we need to keep in mind that these patients are real people with real emotions.

"As significant an intrusion as it is to just confine someone to a mental hospital for mental health treatment, it's an even greater intrusion to involuntarily medicate them. And it needs to be taken very very seriously."

What's best for one patient is not always the best for another. So the issue of involuntary medication, or forced drugging, is one that will likely raise a lot of questions, and more concern, when the legislature reconvenes in January.

This article has been revised to reflect the following correction.

Anne Donahue's call for  an initial hearing within 7 days for patients admitted to psychiatric hospitals involuntarily was mistakenly categorized as a commitment hearing. Representative Donahue does not advocate for speeding up a full commitment hearing, but for making an initial assessment on the state's right to hold a person against his or her will.

Jane Lindholm is the host, executive producer and creator of But Why: A Podcast For Curious Kids. In addition to her work on our international kids show, she produces special projects for Vermont Public. Until March 2021, she was host and editor of the award-winning Vermont Public program Vermont Edition.
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