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New law pushes treatment for the oft-jailed mentally ill

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A chief challenge in treating serious mental illness is getting patients to recognize they need help, because people who have delusions generally don’t realize they are delusional.

“In many cases, if they knew the voices in their head were only in their head, it would go a long way towards getting treatment,” said Steven P. Katz, a marriage and family therapist in Honolulu and a board member of the National Alliance on Mental Illness Hawaii. “Almost all schizophrenics do not realize they are sick at first.”

A revised Assisted Community Treatment law, Act 231, was designed to tackle that issue in certain severe cases of mental illness, while protecting patient rights. It allows interested parties to petition Family Court to require outpatient mental health treatment for individuals who are so seriously impaired that they don’t recognize they need it.

“It is for people who have been hospitalized and have shown repeatedly they are unable to care for themselves in the community and have been a threat to self or others,” Marya Grambs, executive director of Mental Health of America of Hawaii, said in an interview. “It requires that a psychiatrist evaluate and attest that the person meet stringent criteria. Family members or others who care about the individual may start a petition for mental health treatment.”

The goal is to provide outpatient treatment to seriously mentally ill patients and substance abusers who bounce back and forth from the streets to hospitals and jail. In some cases, injections of long-acting antipsychotic drugs could stabilize someone enough for them to live in the community.

An earlier version of the law was passed in 2013, but the only test case was dismissed from court, after roadblocks obtaining mental health records and objections on the basis of civil rights. In that case a psychiatrist, an attorney and the Institute for Human Services had teamed up to try to get community-based treatment for a woman with a history of mental illness and substance abuse who lay on a Chinatown sidewalk for months in her own waste, through rainfall and hallucinations.

Legislators went back to the drawing board, and the revised bill introduced by state Sens. Suzanne Chun Oakland and Josh Green was signed into law by Gov. David Ige last month.

Diane Haar, the attorney involved in the Chinatown case, was part of a broad group supporting the new law.

“It ensures the individual has access to legal representation, including a public defender if appropriate, rather than possibly having to proceed alone in a court proceeding he or she may not understand,” Haar said. “Also, the court has discretion to appoint a guardian ad litem to protect our most vulnerable citizens, whose mental illness has rendered them incapable of protecting their own best interest but don’t have family or friends who are willing to do so.”

Other changes include revisions in timelines and notice of hearings in hopes of making the process smoother for everyone, including the patient.

Dr. Chad Koyanagi, the psychiatrist involved in the original case, said that bringing such cases to court, devising a treatment plan and ensuring the necessary support requires broad-based commitment.

“There are countless numbers of folks who would benefit from this new law,” he said. “What remains to be seen is how eager the community of providers will be to identify these cases. … Because these cases are so difficult, they need everyone on the same page, not different pages.”

The new law may be invoked on behalf of anyone, regardless of living situation.

“It’s not about where you live; it’s whether you are incapable of making a decision that is in your own best interest,” Grambs said. “This is something that will get them the help that they need. It’s going to ultimately save our system money, and it’s going to save people’s lives.”


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