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Lawmakers in Ore., Calif. attempt to expand involuntary commitment


When it comes to mental illness, the problem of when to treat people who don't know they need treatment or people who resist treatment is a tough one. For decades now, compelling people into care, something called involuntary commitment, has been deemphasized as an option and considered only as a last resort. The thinking is that the patient should have autonomy and participate in their care. But now Democratic states such as Oregon and California are reconsidering their approaches as mental health, the drug epidemic and also homelessness become increasingly political problems. Joining us now to talk about this more are April Dembosky of member station KQED in San Francisco and Amelia Templeton with Oregon Public Broadcasting. Welcome to both of you.

AMELIA TEMPLETON, BYLINE: Thank you so much.

APRIL DEMBOSKY, BYLINE: Glad to be here.

CHANG: So, April, I want to start with California, a heavily Democratic state that over time has had this strong streak of medical autonomy. Their approach to mental illness is changing now. Governor Gavin Newsom and the legislature are pushing forward with some policies that might be considered tougher to some people. Can you tell us more about what's going on here?

DEMBOSKY: Yeah. The attention to this has really been rooted in homelessness, which is a huge problem in California. Half of the unsheltered population in the country lives here. And even though only a quarter or a third of those folks have a serious mental illness, that is where we're seeing a lot of policy proposals being directed. So this year the state is rolling out something called Care Courts. This is where a family member or a doctor can refer someone who has a psychotic illness to court. And a judge will draw up a care plan that the person is strongly encouraged to accept. Another recent proposal is to expand who qualifies for involuntary commitment. One doctor told me about a patient who's homeless who has both diabetes and schizophrenia, and he keeps cycling in and out of the emergency room because he's not taking his diabetes medication. And that's because he's not taking his antipsychotic medication. So right now doctors' hands are tied with a patient like this...

CHANG: Yeah.

DEMBOSKY: ...Because being unable to take care of your own medical needs is not a reason that doctors can intervene under the current law, and that is something that they want to change.

CHANG: And what's been the reaction so far to these proposals?

DEMBOSKY: Both of them have been hugely controversial. I call it a war of compassion, actually, because both sides want to do the right thing. On one side, you've got disability rights groups saying forcing people into treatment against their will is a violation of their civil rights. You know, locking people up just for being sick - that's not compassionate. But on the other side, you've got families and doctors who say, well, what about people's right to medical care? You know, leaving someone lying on the street, unable to care for themselves - that's not compassionate, either.

CHANG: Right.

DEMBOSKY: So here's how Teresa Pasquini puts it. Her son has schizophrenia, and she says the problem is doctors can only step in after a tragedy has occurred.

TERESA PASQUINI: We will no longer settle for the status quo that has forced too many of our loved ones to die with their rights on.

CHANG: I see the conflict over what values ultimately should predominate when you're talking about severely mentally ill people. And I'm wondering, when you're looking at a value like compassion - in Oregon, Amelia, how does that value play out in this debate?

TEMPLETON: Well, there's absolutely a parallel debate here over what the compassionate approach is and whether we've drawn the line in the right place for civil commitment. But the politics are a bit different. Portland's mayor, who is a moderate Democrat, has talked about loosening the criteria for civil commitment in interviews with national media. And also, it's a talking point he brings up in meetings with downtown businesses that are really upset about homelessness. But in Oregon, it's really just talk. Democrats in the state legislature have not embraced the idea. Republicans have introduced several bills that would expand who could be forced into treatment, but they're very much in the minority. And the bills are widely considered dead on arrival.

CHANG: And why is that? Why is changing civil commitment such a nonstarter in Oregon where, like, in California, they're honestly considering changing it?

TEMPLETON: I think a few things are still different here. First, the power to force a civil commitment in Oregon is very narrow but maybe not quite as narrow as in California. So to take one of April's examples, in Oregon, a person who is not taking diabetes medication due to psychosis - that person could be successfully civilly committed. The legislature made a small change in 2015 that makes those cases a little easier to pursue. But there's real resistance to going further. And the biggest issue by far is treatment capacity for mental illness and substance use disorders. There's just limited political interest in forcing more people into treatment when the system can barely handle the patients it has right now.

CHANG: Wait. Wait. What do you mean by that?

TEMPLETON: Well, Oregon is actually being sued by three of the largest hospital systems in the state over its failure to find placements for civilly committed patients because otherwise, what happens is these patients are getting stuck in hospitals, sometimes for months. The state has two dedicated psychiatric hospitals with about 600 beds total. And over the last decade, more of those beds have been needed for people who are in county jails who are too mentally ill to understand the charges against them.

So the result is that most civilly committed patients are denied a bed at the state hospital. And then there's no community beds, either. Like, sending someone to a nursing home or an adult foster home or a residential treatment facility - those beds were in really short supply already. And then in Oregon, the pandemic just gutted those places. So in Portland, for example, one of the nursing homes that suffered one of the very first devastating COVID outbreaks was a place the state had been relying on to place psychiatric patients. Twenty-eight people died, and it was shut down permanently.

CHANG: Well, April, is this capacity problem, this question of, where do you even send people for treatment - is that a real concern in California, too?

DEMBOSKY: It's a huge concern and a huge problem. Opponents of these measures are pointing out we already don't have enough treatment beds or mental health clinicians for the folks who are voluntarily asking for treatment. And then proponents of the reforms are saying, well, you know, passing these laws will put a spotlight on this, and it will force a fix. So that remains to be seen. But the bigger capacity question here is really one of housing. Advocates will say homelessness is a problem caused by a lack of affordable housing, not mental illness. One doctor told me it's like musical chairs. If you have nine chairs and 10 kids, the kid with a broken leg is going to be the one left without a chair. Well, if you don't have enough housing, it's folks with mental illness who are most likely to have trouble competing in a market of scarcity. UCSF doctor Margot Kushel told me the solution is more housing, not involuntary treatment.

MARGOT KUSHEL: If you try to fix the problem of homelessness by tinkering with the health care system, we're not going to get anywhere.

DEMBOSKY: For the record, the same California lawmakers who are backing these new mental health reforms are also backing ways to increase the housing supply.

TEMPLETON: I mean, we're talking about two states where the rents have risen so much faster than people's incomes. And that is a gap that's worse for people who are living on disability income, which can include people with mental illnesses. Here in Oregon, the new governor, Tina Kotek, says housing is her top priority. And Oregon is trying something really novel. It's the first state in the nation that will use Medicaid money to pay for things like rental assistance. So starting next year, if you're homeless and Medicaid is paying for your substance use treatment or other mental health issue, it might also pay for your housing.

CHANG: That was Amelia Templeton with Oregon Public Broadcasting and April Dembosky with KQED in San Francisco. Both of them are part of NPR's health reporting partnership with Kaiser Health News. Thank you both so much.

TEMPLETON: Thanks so much.

DEMBOSKY: You're welcome.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

April Dembosky is the health reporter for The California Report and KQED News. She covers health policy and public health, and has reported extensively on the economics of health care, the roll-out of the Affordable Care Act in California, mental health and end-of-life issues. Her work is regularly rebroadcast on NPR and has been recognized with awards from the Society for Professional Journalists (for sports reporting), and the Association of Health Care Journalists (for a story about pediatric hospice). Her hour-long radio documentary about home funeralswon the Best New Artist award from the Third Coast International Audio Festival in 2009. April occasionally moonlights on the arts beat, covering music and dance. Her story about the first symphony orchestra at Burning Man won the award for Best Use of Sound from the Public Radio News Directors Inc. Before joining KQED in 2013, April covered technology and Silicon Valley for The Financial Times, and freelanced for Marketplace and The New York Times. She is a graduate of the University of California at Berkeley Graduate School of Journalism and Smith College.
Amelia Templeton