Consumer Organization and Networking Technical Assistance Center

Contents: Testimony Regarding the Results of the Research Study of the New York City Involuntary Outpatient Commitment Pilot Program   PSYCHO KILLER'S BID FOR RELEASE STIRS ANXIETIES By DOUGLAS MONTERO   Objection and Alternatives to Involuntary Outpatient Commitment Initiatives     Testimony Regarding the Results of the Research Studyof the New York City Involuntary Outpatient Commitment Pilot Program December 16, 1998 Harvey Rosenthal, Executive Director New York Association of Psychiatric Rehabilitation Services This testimony represents the collective position of an organization that has joined thousands of consumers and hundreds of progressive community-based mental health service providers in a powerful coalition dedicated to improving services and social conditions for people with psychiatric disabilities. NYAPRS works to promote an environment in which: individuals have widespread access to a broad range of quality recovery-centered psychiatric rehabilitation and self-help services the rights and stated needs of people with psychiatric disabilities are considered central to public policy and service development the goal and expectation of recovery is afforded to every individual

This testimony is based on direct feedback from consumers and providers, collected over the past few years in NYAPRS-led forums, focus groups, meetings and conferences held regularly across the state. It features considerable input from people diagnosed with major mental illnesses who are overcoming numerous personal, systemic and social challenges to achieve a life in recovery.

First, we believe that the results of the Research Study on the Bellevue Involuntary Outpatient Commitment Pilot need to be examined in the context of other recent notable findings in this area:

• People with these diagnoses can and do recover, especially when given access to rehabilitation-based services. Thirty-plus year follow-up studies of individuals residing on back wards of a Vermont State psychiatric hospital showed very successful community adaptation (more productive, fewer symptoms and better overall functioning) when offered accompanying social, residential and work-based rehabilitation services. Harding et al, British Journal of Psychiatry, 1995

• A growing array of community-based rehabilitation and peer-operated services are very effective in helping even "hard-to-serve" groups manage their disability and engage in productive and independent lives, according to studies conducted by Fountain House, the Center for Psychiatric Rehabilitation, Matrix Research Institute, the Mental Health Empowerment Project and may others including:

a NYS Office of Mental Health 1993 study that demonstrated that over 70% of self-help groups report their members stay out of the hospital, hold a job and are living more independently and assuming more responsibility.

• Yet, fewer than half of those diagnosed with major mental illnesses are currently gaining access to a proper array of community care that includes these approaches, according to a national study funded by the Agency for Health Care Policy and Research and the National Institute of Mental Health in March of 1998.

• Instead, consumers have been relegated to relying on more traditional mental health services they have frequently experienced as negative if not harmful, as described in:

A 1994 study by the NYS Commission on Quality of Care for the Mentally Disabled showed that the use of restraint and seclusion in the state’s psychiatric hospitals had doubled over the past decade and been associated with over 100 patient deaths. An accompanying survey of over 1,000 former inpatients demonstrated that almost one third reported that they had experienced serious concerns for their safety and well being and that their basic dignity and privacy were routinely violated.

In turning to the findings of the research conducted by Policy Research Associates on the Bellevue IOC Pilot program, we were struck by the are struck by the following observations:

• Force had no effect on improving outcomes.

There was no justification for the introduction of a coercive program of involuntary outpatient commitment.

• If the program does indeed support improved client outcomes, it appears due to the efforts of the program’s Coordinating Team in the "mobilization, coordination and follow up" of an "enhanced" package of services that were delivered in a climate of "ongoing and flexible negotiations."

Due perhaps to the "tenacious follow up" and the "heightened sense of accountability extended by the Coordinating Team", the program largely served to make available to its participants a more adequate array of community-based services delivered by more responsive and accountable service providers.

• In keeping with the findings of the MacArthur Foundation study, none of the participants was involved in any acts of violence.

Discussion of the Study Findings

• The study generally confirms the common experience of most consumers that the delivery of adequate, appropriate and accessible services continues to be compromised by a system that is under-resourced, uncoordinated, inflexible and unresponsive:

"providers..often found themselves exasperated by a chaotic system"

• Program participants were afforded the special advantage of longer and more appropriate hospital discharge planning procedures.

"OCP patients..(were able to) stay in the hospital longer than other ‘non-OCP’ patients, in order for the package of outpatient services to be put together."

• Providers felt impelled to provide more attention to OCP clients.

Providers "cited the enhanced priority conferred on these clients (who were) participating in the program", along with the "heightened sense of accountability extended by the Coordinating Team"

Discussion of the Issue of Forced Community Treatment

• OPC is a false substitute for good services, and potentially covers up the need for and diverts badly needed funding away from the proliferation of responsive, effective and respectful community-based services. Involuntary outpatient commitment, and other forms of force, do not yield better results in assuring treatment outcomes.

• Programs that work well with "treatment resistant" people are based on choice, not force.

• Force breeds resistance: Even the threat of forced treatment causes people to avoid services altogether. Coercion results in feelings of fear, anger and repugnance towards mental health services and paradoxically promotes the very resistance it is designed to address.

• "The key problem in community mental health care has always been funding. The relative success of coerced community treatment as compared with voluntary community treatment cannot be adequately assessed until an appropriate range of services is available. (Stefan)

• Burden to taxpayers: OPC involves high costs in policing people to make sure that they are in participating in mandated services.

• "What outpatient commitment is far more likely to achieve is the disruption or destruction of trust, the precluding of adult responsibility, and the creation of an adversarial relationship which is in and of itself dangerous - one that actually encourages defiance. Do not underestimate the degree of alienation, desperation and rage created by the use of force." Laura Ziegler

• "Even now many people won’t seek treatment for their mental illness because of the stigma attached to it. This bill would have a chilling effect on those who are struggling with the decision to seek help. People would no longer feel safe to tell their treaters anything because of the fear - fear that their choices would be taken away from them" Yvettte Sangster.

• "How can you enforce order and save the professional relationship? (provider response to Research Study)

• OPC will serve to obviate and/or destroy the creation of trusting, therapeutic alliance with treatment providers that is essential to positive client outcomes (per Dr Daniel Fisher)

• Arbitrary nature of inflicting forced treatment on this population: "Why can someone check out of the hospital with arrhythmia (and therefore be presumably ‘dangerous to self’), but not with schizophrenia?" Dr. Thomas Szasz

• "Involuntary treatment for treatment of mental disability is unquestionably the most severe action a government can impose upon an individual, short of a criminal charge and conviction. Indeed, in many respects, civil commitment has been compared to a criminal sentence in that both deprive the individual of his or her liberty, usually involve forced residence in an impersonal institution, subject the persons to indignities of many sorts as well as to the general control of the variety of persons who run the institution. And, in the case of forced treatment, a person can well be subjected to extremely distasteful side effects, dangers of short term and long term related disabilities and conditions, and the possibility of drug errors which may result in serious harm, including death in some instances."

Paul Stavis, Counsel, NYS Commission on Quality of Care

• OPC makes an entire class of people subject to involuntary detention and forced treatment based on a presumed eligibility status, resulting in a blanket violation of individuals’ civil rights.

• The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.: "Indeed, this Commission believes that serious efforts by health care institutions to ensure that patients have one identifiable and reliable source of information concerning their care would do far more to remedy the current ills of the health care system than would legal prescriptions with which compliance can neither be assured nor enforced."

• Forced treatment initiatives like OPC have been disproportionately aimed at people of color.

• OPC criminalizes the unwillingness to enroll in services they (and many others) perceive as inadequate, unresponsive and in some cases harmful.

• IOC draws badly needed resources away from a community-based system of services that is woefully underdeveloped in many critical areas.

• Coercive treatment damages self-esteem, sense of self-determination and integrity.

• Coercion serves to re-trigger psychological wounds associated with past experience of violence and abuse.

• Some providers in the study agreed that "In reality, sometimes people are non-compliant for good reasons" (citing "what do you do about people who take their medication but they get terrible side-effects, or when medications don’t work?).

• IOC amounts to a misguided tinkering with a deficient system that imposes coercion as a substitute for an adequate, accessible and appropriate array of effective community-based services and supports.

• Resisting services which have proved to be disempowering, demeaning if not harmful to many can hardly be seen as an irrational act denoting incompetence but a choice individuals have a right and a need to make. Fix the services rather than force them on people.

Recommendations

• City and State government should renew their commitment to dramatically expand the availability of effective, person-centered rehabilitation and recovery-based services via:

enhanced funding streams

continued full funding of Community Reinvestment program

full enforcement of initiatives within the soon-to-be-implemented Special Needs Plan program that guarantee broad consumer choice from a full array of services (including rehabilitation and self-help) that must demonstrate proficiency in helping consumers achieve recovery-centered outcomes.

adequate rate structures within the SNP program to assure enhancement of existing services

full funding of New York/New York II program

passage of full mental health parity legislation

Offer an adequate range of service options, which people want and identify as responsive to their needs and that promotes wellness, healing, independence and personal responsibility.

Provide adequate discharge planning from inpatient stays.

Provide adequate crisis prevention and management services, especially the highly promising and innovative peer-operated crisis support, diversion and respite services.

Help people develop and file advanced directives to go into effect in the event of a crisis.

Testimony Regarding the Results of the Research Study

of the New York City Involuntary Outpatient Commitment Pilot Program

December 16, 1998 

Offered by Harvey Rosenthal, Executive Director

New York Association of Psychiatric Rehabilitation Services

with support from: 

Association for Community Living

Brooklyn Peer Advocacy Project

Clubhouse of Suffolk

Community Access

Community Living Associates

Hands Across Long Island

Howie the Harp Advocacy Center

INCUBE, Inc.

Institute for Community Living

Mental Health Empowerment Project

Mental Patients Liberation Alliance

NAMI-FACT

National Empowerment Center

Restoration Society

Skylight Center

Urban Justice Center

Venture House

PSYCHO KILLER'S BID FOR RELEASE STIRS ANXIETIES By DOUGLAS MONTERO

FLANKED by two mental patients, Juan Gonzalez stood silently against the wall
inside the Bronx Psychiatric Center.
The eyes of the man who used a sword to slice two people to death and injure
nine others on the Staten Island Ferry in 1986 looked normal.
    So normal, it was nerve-wracking.
    Saying the wrong thing, I thought, could prompt this man to pull out an
imaginary 2-foot- long sword like the one he used 12 years ago and start
hacking away like somebody in a Kung Fu flick.
    "I can't talk to you. You're going to have to talk to my lawyer," said
Gonzalez, a healthy-looking, 55-year-old man with a pudgy face.
    That's a pretty normal - and smart - thing to say.
    What may be unsettling to New Yorkers is that tomorrow, Gonzalez and lawyers
for the state attorney general's office will meet in a Bronx courtroom to
determine if he will start the journey to becoming a free man.
    A Bronx jury decided in July that Gonzalez, a schizophrenic who was found not
guilty by reason of insanity for the deadly rampage, should be released.
    But Supreme Court Justice Michael DeMarco overturned the jury's decision.
    "Sometimes you just have to do what is in the best interest of justice," he
said, ordering a retrial.
    On Monday, the state will say whether it will continue fighting or agree to
allow Gonzalez to take unsupervised furloughs. If he's good, Gonzalez will
subsequently be a free man.
    The meeting will come seven days after the death of Edward delPino, 67, the
retired city cop who used a gun to stop Gonzalez before the killer could
plunge the ornamental sword into another victim.
    DelPino, who saved countless lives on July 7, 1986, was buried Monday on
Staten Island.
    He can't talk now, but his son, Detective Mark delPino of Brooklyn's 70th
Precinct, can.
    "How could you rehabilitate someone who goes on a ferry and starts slashing
anyone he sees?" says the younger delPino. "If he wasn't stopped, he would've
had the run of that boat ... killing hundreds."
    DelPino doesn't buy the position that medication has cured Gonzalez of his
maniacal tendencies, arguing that they've merely been temporarily suppressed.
    "They might as well hand him a sword on his way out," he said.
    Gonzalez didn't want to tell me how normal he is. His lawyer, Michael Genkin
of the Mental Hygiene Legal Service, did.
    "I don't know anyone who could dispute that he is a model patient," said
Genkin, who emphasized that any release for his client would include strict
monitoring requirements.
    The court-imposed requirements could include living in a supervised residence,
mandatory drug testing and treatment. I wouldn't mind an electronic ankle
bracelet to track his every move.
    It is hard to say if Gonzalez should be freed.
    He may appear normal today, but if he runs away and stops taking his
medication, he could be a time bomb.
    Andrew Goldstein, 29, of Queens stopped taking his schizophrenic medication
before he fatally pushed aspiring screenwriter Kendra Webdale, 32, in front of
a subway train last month.
    Let's hope the doctors and lawyers make the right decision after they stop
shuffling all those papers - because Eddie delPino isn't around to protect us
anymore.

Objection and Alternatives to Involuntary Outpatient Commitment
Initiatives

March 22, 1999
TO: Senator Thomas W. Libous
FROM: Harvey Rosenthal Jody Silver, Chair
Executive Director Rights and Protections Task Force
  As promised, we present here some general discussion and background materials related to our numerous objections and concerns regarding involuntary outpatient commitment initiatives and our recommendations as to how best to effectively and appropriately serve those individuals who, having fallen through the cracks of our service system, are most at risk of coming to or causing harm.

Background and Discussion of Issue

1. Our inadequately funded and structured mental health service systems
remain the primary cause of "treatment failures."  Authorities on all sides of this issue all agree that the fundamental root cause of the problem of such "at-risk" individuals who have fallen "beyond the pale" of help is the lack of adequate, appropriate, accountable and engaging community mental health services in communities across the state and the country.
  We point, in particular, to our routine failure to provide adequate hospital discharge planning when such individuals attempt the crucial process of reintegration into typically scarce and fragmented community service systems.
2. Our outmoded approaches discourage and drive people away from the help they seek.   Despite Dr. Courtenay Harding's internationally acclaimed 25-year study demonstrating that even the most "severely and persistently mentally ill" individuals could attain a full recovery if offered an approach that fostered "self-sufficiency, rehabilitation, and community integration", most community mental health systems continue to offer focus demoralizing futures to recipients, based mostly on "maintenance, stabilization with medications, and entitlements"that merely "promote and extend chronicity." As a result, our mental health systems often numb and/or despair its clients by relying excessively on high dosages of medicine, abysmally low expectations and little room for hope and smoke-filled treatment centers with all too few opportunities to play a meaningful or productive role.  Such a system all too frequently drives people either down...or in the serious instances under discussion here, drives them away.
3. Our service systems fail to engage and properly serve over half of those in need.   A recent National Institute of Mental Health's Patient Outcomes Research Team (PORT) study found that fewer than half of patients under treatment for schizophrenia were receiving appropriate treatment.  "Medication alone is not enough," stated Principal Investigator Dr. Anthony Lehman. He points out that most patients are not receiving "the benefit of the most effective approach (which) integrates (medicines) with psychosocial (rehabilitative) treatments."
Hence, many individuals, including Andrew Goldstein, are not evading services but often crying out for adequate, attentive and active care that is simply not there.
4. Far too often, "treatment resistance" is often an appropriate response to system failures or abuses rather than the symptoms of a mental illness. Recently, our newspapers have been filled with stories detailing the reasons why many avoid our mental health service settings: The Boston Globe series showing widespread patient abuse due to risky drug testing.
    The Hartford Courant series on the numbers of residents of psychiatric facilities who either died or were seriously injured by seclusion and restraint procedures (leading to the recent discussions on reforming such standards by the Joint Commission on the Accreditation of Healthcare Organizations).
    The City Limits magazine exposee revealing continued deplorable conditions in today's NYC psychiatric hospitals.
    The New York Post has run almost daily articles exposing unsafe and unethical psychiatric drug testing practices in New York State facilities.  The New York State Commission on Quality of Care for the Mentally Disabled has found that "the use of restraint and seclusion in state psychiatric centers has almost doubled over the past decade (1984-1993) and has been associated with over 100 patients deaths over that period." 62 percent of (former inpatients) who had been restrained or secluded reported unnecessary force, psychological abuse, ridicule or threats by staff. 29 percent alleged they were physically abused, with 26 percent reporting injuries, and 10 percent reported they were sexually abused; 47 percent of respondents said staff placed them in restraint or seclusion without first trying to calm them down or resolve their problem.

Objections to Involuntary Outpatient Commitment Initiatives:
   Forced Service Interventions Don't Work.
   The research study of the Bellevue Hospital Involuntary Outpatient
Commitment Pilot Program found that coordinated, compassionate community mental health care helps to successfully engage and serve "hard to serve" groups, not forced treatment interventions.
   Forced Service Interventions Actually Drive People Further Away.
   The very threat of forced treatment causes people to avoid services
altogether. Coercion typically results in feelings of fear, anger and repugnance towards services. Coercion frequently results in the re-triggering of psychological problems associated with past experiences with violence and abuse.
    A California Department of Mental Health survey showing that 55% of former patients reported an avoidance of traditional mental health services because of their experiences of being involuntarily committed (Campbell and Schraiber).
    Forced Service Interventions Damage the Trust Necessary for the Development of the Therapeutic Relationship, Turning Professionals into Police.
    Forced Service Interventions Are Costly, Diverting Precious Resources
From Services That Work.
    Involuntary Outpatient Commitment amounts to a form of preventive
detention that psychiatrists admit does not work. The APA Statement on Prediction of Dangerousness, says that "psychiatrists have no special knowledge or ability with which to predict dangerous behavior. Studies have shown that even with patients in which there is a history of violent acts, predictions of future violence will be wrong for two out of every three patients." There are just too many variables in the biopsychosocial nature of mental illnesses.
    Forced Service Interventions are Discriminatory, If Not Unlawful.
    "The (Spitzer) bill threatens the liberty of all persons who have been psychiatrically hospitalized within thirty-six months, regardless of whether the hospitalization was for dangerousness, regardless of whether the hospitalization was voluntary or involuntary, and regardless of whether the hospitalization was caused by refusal of treatment. Thus the bill will create a strong disincentive to seeking psychiatric hospitalization. The bill disregards completely the constitutionally protected liberty interest of all persons in controlling their medical care.  In sum, the outpatient committed person loses all voice in what medication he takes, and can be summarily forced to take whatever medication the outpatient psychiatrist orders, without an opportunity to be heard by the court or even to be heard by the outpatient psychiatrist.  The bill creates a psychiatric dictatorship which violates due process under the New York and United States Constitutions."
Cliff Zucker, Executive Director, Disability Advocates, Inc.

Public Calls for Forced Service Interventions are Frequently Based on Inaccurate Stigmatized Views of People with Psychiatric Disabilities Despite sensationalized views of people with psychiatric disabilities as typically dangerous, research shows that not only are they no more dangerous than the general public, such individuals are more often than not the victims of violence (from a recent Duke University study as reported by the ABC website.
   Editorial Boards, Consumer, Family and Provider Advocates and Governmental Bodies All Agree in Their Opposition to IOC!
"Those mentally ill people who do not pose a threat to anyone, whether or
not they take their medication, should not be forced to take it. Encouraged,
yes, but not forced. They, too, have rights, and may even be correct to suspect that "doctor does not always know best."
Daily Gazette (Schenectady)
    "While we cannot prevent every tragedy, we know how to guard against catastrophes like this one. We know that integrated, assertive, coordinated community-based treatment works. We know that discharging someone from a hospital without a discharge plan to a lonely empty basement apartment with little professional support, onsite services or crisis intervention does not work. We know that newer drugs, albeit more expensive in the short run, have fewer side-effects that discourage people from complying with their medication than the older ones, like the Haldol that Andrew Goldstein was taking." "Not only is it more humane to provide appropriate community services to people with mental illnesses, it is less expensive too."  Compare the following:
  -$10,000 for a year's supported housing services

  -$33,000 for a year's stay in a community residence with crisis intervention capabilities
  -$69,246 for a year's stay in a New York City Jail with mental health services
  -$120,000 for a year's stay in a state psychiatric center Philip Saperia, Executive Director, Coalition of Voluntary Mental Health Agencies
     "The actual explanation for the revolving door phenomenon...involves a system of interlocking deficiencies that make it more possible for all parties to shift the blame to each other. The politically most palatable response is..to point at the recalcitrant, treatment-resistant patient. But let us look at the way the current mental health system stacks the odds against survival in the community and in favor of reinstitutionalization and then reassess the part played by the patient in pushing the revolving door. There is no sense in making it ever easier to pull people into mental health services that do not have the capability to treat the people already committed to them. The only way to prevent institutionalization truly is to ensure that all the pieces of an adequate existence in the community are truly available.."
Susan Stefan, JD   Professor, University of Miami Law School
     "Promoting the image of walking time bombs surely deepens fear and mistrust
by a public already made fearful by violent media stereotypes. What's needed
is a reasoned appraisal of the pros and cons of forced treatment, based on reliable information. Vitally important to the policy-making process are the findings of new studies, the results of high-quality voluntary programs vs. coercive treatment and the views of consumers/survivors."  Jean Arnold, family member and Chair of the National Stigma Clearinghouse
     "When you treat us like criminals, with punishment instead of support, you destroy the hope of mental health. When you don't make a distinction between mental illness and criminal acts, you make laws that rob us of our freedom. We, like you, want to be safe from harm and free to work on issues of mutual concern. When we have to fight for adequate treatment, or you make us beg for the housing and community services that we need, we have little time left, for our most important job, getting better." "We are receptive and responsive when treatment programs meet our needs a we are involved in the process of defining and decision making. We are receptive and responsive when treatment programs meet our needs a we are involved in the process of defining and decision making. "
     Client Committee of the Queens Mental Health Council "What outpatient commitment is far more likely to achieve is the disruption or destruction of trust, the precluding of adult responsibility, and the creation of an adversarial relationship which is in and of itself dangerous - one that actually encourages defiance. Do not underestimate the degree of alienation, desperation and rage created by the use of force."   Laura Ziegler
     "Involuntary treatment for treatment of mental disability is unquestionably the most severe action a government can impose upon an individual, short of a criminal charge and conviction. Indeed, in many respects, civil commitment has been compared to a criminal sentence in that both deprive the individual of his or her liberty, usually involve forced residence in an impersonal institution, subject the persons to indignities of many sorts as well as to the general control of the variety of persons who run the institution. And, in the case of forced treatment, a person can well be subjected to extremely distasteful side effects, dangers of short term and long term related disabilities and conditions, and the possibility of drug errors which may result in serious harm, including death in some instances."
Paul Stavis, Former Counsel, NYS Commission on Quality of Care
     The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.:  "Indeed, this Commission believes that serious efforts by health care institutions to ensure that patients have one identifiable and reliable source of information concerning their care would do far more to remedy the current ills of the health care system than would legal prescriptions with which compliance can neither be assured nor enforced."
     "Even now many people won't seek treatment for their mental illness because
of the stigma attached to it. This bill would have a chilling effect on those who are struggling with the decision to seek help. People would no longer feel safe to tell their treaters anything because of the fear - fear that their choices would be taken away from them" Yvettte Sangster
     "Creative services, delivered in an appropriate setting, and tailored to
the wishes of the client is the opposite of what occurs today....It is a sad testament to New York's mental health system .... that it was nobody's job to occasionally pick up the phone and call Andrew Goldstein to see how he was feeling; to buy him a cup of coffee; to take him to a movie; or to visit him in his home.  We don't need 'treatment police.'   We need a system that rewards caring professionals and peers for working side-by-side with mental health consumers as respectful, supportive partners in the recovery process."
Steve Coe, Executive Director, Community Access and member, NYAPRS Advisory
Board

     "Do no let involuntary outpatient commitment impose force and steal
personal civil rights as a substitute for adequate, well-coordinated, flexible, responsive and accessible community-based services." Jack Guastaferro, Executive Director, Restoration Society and NYAPRS President
Recommendations for Alternatives to Involuntary Outpatient Commitment
1. NYAPRS strongly supports plans to widely implement the use of both
advance directives and health care proxies.  Advance directives are legal documents individuals with psychiatric disabilities can use to indicate their
preferred desires for appropriate mental health care in the event that they become incapable of making decisions regarding their treatment needs.  A health care proxy is an individual that person can appoint to make mental health treatment-related decisions for them during a time they can no longer make them for themselves.
    During times of crisis when people with psychiatric disabilities cannot
make clear their preferred treatment choices, their appointed health care proxy
can act on their behalf to see that the instructions contained in the advance directive are followed.  Copies of the advance directive can be distributed to all participating or potential mental health care providers to ensure that such directives drive treatment decisions during times of crisis.  It is important to point out that individuals' present objections to treatment can always override the instructions contained in the advance directive.  This underscores the importance of the trusted relationship with the health care proxy (who could potentially be a friend, family member or a mental health provider).  Such a relationship can provide the trust and sense of security necessary to the successful implementation of the services contained in the advance directive.
    In this way, we believe the widespread familiarity and use of linked advance directives and health care proxies can play crucially important roles in preventing the needless disconnection from critical services and supports on the part of people who are experiencing an acute episode of their mental illness.
    Currently, the Office of Mental Health is underwriting a statewide program
of education around the nature and use of advance directives and health care proxies for consumers and providers in the state-operated service sector.
    NYAPRS urges the Legislature to see that such training is widely available
to all those who work in or are served by the state's community based mental health services.  We further recommend that  the Legislature direct the Office of Mental Health to require that all of the state's public mental health care providers ensure that all recipients are provided with the option of using these measures to ensure that plans to serve them in future times of difficulty fully incorporate their wishes and are based on approaches that offer services and possibly medications that have worked well in the past.
     State funds allocated for these purposes could be distributed by the
Office of Mental Health using the RFP process to contract with appropriate
entities to make presentations and to widely distribute such materials both during these presentations and via mailings and on a special website.
2. NYAPRS also strongly supports the targeting of extra service dollars to ensure enhanced coordination of existing and additional new services designed to engage a small group of individuals with psychiatric disabilities who meet the defined criteria for being at high risk for coming to or causing harm. This recommendation arises from the pivotal finding of the research study recently conducted of the Bellevue Hospital Involuntary Outpatient Commitment pilot, which demonstrated  that such enhanced, coordinated, mobilized and accountable extra care proved effective in helping formerly non-responsive individuals to sustain effective engagements with community services that reduced their potential for relapse and re-hospitalization.
    We strongly recommend the inclusion of a broad range of newer, recovery-based service models that are demonstrating highly effective results in engaging formerly non-responsive individuals that include, but are not limited to:
1. peer-run hospital diversion programs
2. peer-run warm lines for peer support
3. peer-run crisis respite services
4. peer bridger programs
5. peer-run drop in centers
6. Double Trouble in Recovery programs
7. clubhouse programs
8. social club rehabilitation centers
9. intensive case management programs
10. peer-assisted assertive community treatment programs
11. crisis residential programs
12. specialized housing and support programs for those with co-occurring
psychiatric and substance abuse disorders who are currently, or at risk for, homelessness.
    We recommend that state funds be made available to help fund specialized individual care coordinators who effectively engage such identified groups of at-risk individuals and make available, in a highly coordinated and accountable fashion, a range of the aforementioned services.   We suggest that extra funds be made available to providers of these services who agree to serve this identified group of individuals to both underwrite their additional expenses and to provides incentives for their participation in serving this group of individuals