Under ACT, a judge can order a person to undergo intensive outpatient mental health treatment while remaining in the community. Usually this treatment comes in the form of intensive case management coupled with a long-acting injection that combats the symptoms of psychosis.
The law targets people with serious mental illness who may be homeless or cycling through the emergency medicine or criminal justice systems.
Many people think the law is broken.
Fewer than 10 people have received outpatient treatment through the program since the law passed in 2013. Most of the successful petitions have been for patients on the verge of release from the Hawaii State Hospital.
Virtually all admissions to the hospital involve patients who were committed to the custody of the Hawaii Department of Health by state courts after getting arrested.
ACT seeks to provide treatment to people with serious mental illness who live in the community. Often they are homeless.
“We’re talking about the most severely mentally ill. The people that you see in the streets that are delusional and hallucinating, they are sometimes naked, they are running in the streets and they are living these horrible, degrading lives,” said Marya Grambs, former executive director of Mental Health America of Hawaii.
“They need treatment and they don’t know they’re sick. They actually don’t know it — that’s part of their sickness. So they are not capable of making a good decision about their own treatment. That’s where the ACT law comes in and that’s why it’s so important.”
Supporters say the law has been difficult to implement because mental health advocates who have taken the lead in petitioning for court-ordered treatment on behalf of people with mental illness don’t have enough funding or resources to fulfill the requirements.
The concept of forcing a person to receive treatment against their will — even when the person is too sick to realize they are suffering for lack of care — is unpopular among many public defenders. The law’s supporters say this makes it more difficult to secure a petition.
Last summer, the Institute for Human Services successfully petitioned to get a person into the program who has been arrested more than 30 times. The nonprofit next took up the fight for outpatient treatment for someone who has been arrested on more than 80 occasions.
But the petition process is lengthy and onerous, and the nonprofit IHS doesn’t have adequate staff or funding to take on more cases.
“It was written with the idea that a family member would initiate it and be able to pay for an attorney,” said Trisha Kajimura, executive director of Mental Health America of Hawaii. “But I think one of the things they are finding in being able to implement it is that organizations like IHS are trying to implement it and they don’t have family members involved necessarily — so who should incur the costs of hiring an attorney?”
To that end, Senate Bill 1124 would allow anyone to petition for a court order to treat a person with mental illness in the community through the ACT law.
It’s due for a vote by the full Senate.
Also alive is Senate Bill 1465, which would require health insurance to cover some expenses related to petitions and hearings required during the process to receive court-ordered treatment under ACT. The bill is scheduled for a vote Thursday by the Senate Ways and Means Committee.
Senate Bill 1465 would encourage mental health professionals to assess patients to see if they are good candidates for ACT upon release from an involuntary emergency psychiatric hospitalization.
John Snook, executive director of the national Treatment Advocacy Center, said Hawaii has a good law in ACT. But the state’s inability to effectively implement it is disappointing, he said.
“What we’re seeing across the nation is how much it is costing the system to not provide care to these people,” Snook said, whose organization gives Hawaii a “C” grade in its analysis of the state’s involuntary psychiatric treatment laws.
“And so communities that you wouldn’t think of — Louisiana, Ohio, Utah, red states, blue states, all over — are starting to use (assisted community treatment programs) and having a lot of success. So I’m really disappointed that Hawaii just hasn’t gotten there yet.”
Grambs said she has partnered with lawmakers and mental health advocates in recent years to figure out why ACT has been so difficult to implement and what legal measures might bolster it.
“I guess the worry is anything that has dollar signs attached to it is very threatened because we have this new budgeting system that is kind of not interested in seeing any money spent,” Grambs said. “Of course, we’re saving millions of dollars by doing this, but that argument doesn’t always work.”
Other bills addressing the needs of people with serious mental illness include House Bill 1221, which seeks to expand the legal grounds law enforcement and hospital workers have to temporarily treat a patient under an involuntary psychiatric hospitalization when certain medication is not taken or necessary mental health treatment is not used.
The current law allows authorities to temporarily hospitalize a person with mental illness against their will only if they are “dangerous to others” or “dangerous to self.”
When a person is deemed to be an imminent danger, the hospital has the right to administer psychiatric treatment against their will for up to 48 hours. Otherwise, they are released.
House Rep. Rida Cabanilla Arakawa said the law would create a legal pathway to force non-violent, non-threatening people with serious mental illness into treatment by expanding the definition of what it means to pose a danger to oneself or others.
The bill, poised for a vote by the full House before it can cross over to the Senate, seeks to fill a void in care that has plagued people in Hawaii with mental illness for the last several decades, Cabanilla Arakawa said.
“What they did in the ‘80s is they disassembled the asylums, put people into case management and they left it to the state,” Cabanilla Arakawa explained. “They said, ‘You don’t have to be crazy anymore if you take your medication.’ But the state did nothing.”
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