Mental Illness in Hawaii I
Price of Paradise · Hawaii Public Radio · aired 1996-04-21
Guests: Fran Smith (Executive Director, Oahu Alliance for the Mentally Ill); David Rammler (attorney, Protection and Advocacy Agency of Hawaii); Stephen B. Kemble (physician)
Duration: 01:04:35

[00:00:00] Speaker 1: decision but no treatment.

[00:00:02] Speaker 2: Exactly. And I'd be interested in some comments from the the people in the studio about that.

[00:00:08] Steve Kimball: Okay, Steve Kimball.

[00:00:09] Steve Kimball: Yes, actually, I agree with you, this is an aspect to it that many people may not realize, which is that once the decision is made by the courts that some kind of coercive intervention is necessary, it often is not done in its decisively enough way to move toward constructive addressing of the problem. An example, this is a glaring example I had when I was doing a lot of inpatient work at the same hospital, Dr. Bussey, a few years back, was a patient who was severe, chronic schizophrenic, whose family had arranged for him to get a guardian, from the public guardian's office, who was going to make the decisions about treatment. So that, you know, everyone agreed he was severely disabled and incompetent to make his own decisions, except that the public guardian's office felt that the decision to hospitalize the patient was tantamount to incarceration and they were not willing to do that without going to a court hearing.

[00:01:03] Steve Kimball: So we had the bizarre situation of the patient wanted to be in the hospital, the patient's family wanted him to be in the hospital, the hospital wanted him to be in the hospital, but nobody, neither the patient nor the guardian, nor the family was able or willing to sign a voluntary order, and we had to go to court to get a voluntary admission to the hospital. That's absurd.

[00:01:23] Speaker 1: You know, David, I gotta tell you, I talked to somebody else getting ready for this show and it was a family member of someone who was mentally ill and and he didn't have anything kind to say about the attorney who had been appointed to to defend the rights of the mentally ill person. I I think there are a lot of people out there who feel that sometimes the attorney will go overboard in terms of demanding um the kind of process that will be very time consuming and then very expensive for for society and and for the the family. Um I'm sure you confront this regularly. What's your reaction to to those folks?

[00:01:58] David Rammler: Well, I think that the process and the court system has its limitations as it's now funded and staffed, in dealing with these problems. But it's not that I set a hearing date three weeks hence, I don't know, if there was a hearing date tomorrow or in two days, so long as we had sufficient time to prepare, then that's not the issue. I mean, the the process grind slowly, not necessarily and solely because of the lawyers involved, but if a patient, And that has to do with resources, I assume. Right, and and it has to do with backlogs in in court systems and and I'm sure that that they would all like more resources. Um, you know, just like Fran Smith would like more resources and I happen to agree with her, you know, um.

[00:02:41] David Rammler: But it's not always the lawyer's fault. On the other hand, if a patient says to me or a client says to me, I don't want this thing to happen, do whatever you can do to stop it, you know, then it's my moral and legal obligation to do that.

[00:03:00] Speaker 1: Am I still on the line?

[00:03:01] David Rammler: You are.

[00:03:02] David Rammler: Yeah, I I guess there there, at least one state has figured out a uh a method of dealing with this, and this is the state of Utah. And there they they basically combine the finding of of uh of uh commitability with the finding of competence or incompetence so that, um, at the same hearing, both issues are adjudicated, so that you can at least, if the person is committed to the hospital, um, you can also begin treatment at that point in time. And, and, um, in the interest of, of, um, of, um, uh, patient rights, I would almost think that if you can't treat the person, then maybe you shouldn't hospitalize them, and maybe they should be treated if they're doing dangerous things in the criminal system instead of the, the, um, psychiatric system.

[00:04:48] Speaker 1: Georgia, sounds like an awfully good idea. There there must be something I'm missing. Uh, David Ramler, why wouldn't we put those together?

[00:05:07] David Rammler: Well, that I'm not sure why we wouldn't in some in some ways. My question actually in this is whether that involves the appointment of a guardian at that single hearing, because that seems to be the secondary stage which, which then takes some time. And once you decide that someone is not capable of making proper decisions about their own health care, then you must appoint someone to do that for them in most situations. That guardian needs some time to prepare to help make that decision. Well, the the question is whether in Utah, the guardian is appointed at the same hearing. I mean, and, and, um, unfortunately, I don't, I just have the the the the case name, but I don't know how they actually appoint the guardian, um, because that, that, that's where we often get stuck here in Hawaii, is trying to find someone who will take on that responsibility. The the court seem to have decided that family members are not neutral enough and clearly, um, I can understand why the court might think that the physician who's petitioning for for commitment is not neutral enough, either. So we're we're left in this void of trying to find someone to do that.

[00:06:17] Speaker 1: And I think there are a lot of people out there that that don't want to get involved in a situation involving somebody who is or may be mentally ill.

[00:06:24] Steve Kimball: I think it disturbs a lot of people, but you know, we my organization deals with people with various kinds of disabilities and, and I think our society has real problems with lots of disabilities. I mean, people don't like to to look at other people who have obvious physical disabilities or obvious speech impediments or, I mean it's it's a thing that our society is hope hopefully coming to grips with, um.

[00:07:11] Speaker 1: Okay. George, thank you for your call. We really appreciate your input. Um, I want to remind listeners that this is the Price of Paradise radio show. We call it Pop Radio. We're talking about mental illness this morning. In the studio is David Ramler, an attorney with Protection and Advocacy Agency of Hawaii and Stephen Kimball, who is a physician on the faculty at the John A. Burns School of Medicine. If you'd like to ask a question or make a brief comment, just call us at 955-8821, neighbor Islanders dial 1800-955-8821. If you tuned in a little bit late and you'd like to catch the show in its entirety, it'll be replayed this evening beginning at 8 o'clock on KIFO 1380 AM. Uh, well we have Randy Hack back on the line. Randy is a a consumer of mental health services who has personally experienced involuntary uh treatment. Randy, currently is the executive director of United Self Help. Uh, Randy, are you there?

[00:08:28] Randall Roth: Yes, I am.

[00:08:29] Speaker 1: I assume you've got some additional thoughts.

[00:08:31] Randall Roth: Well, I, uh, what David had said earlier, uh, about advanced directives, um, when somebody gets involved with the criminal justice system in conjunction with their mental illness, things have often times been going on for quite some time, and there is an existing law in Hawaii which provides for an advanced psychiatric treatment directive, uh, and uh, in case someone needs hospitalization, the person would prepare this in advance and have it witnessed and would specify what types of treatment to use. Also, there are other advanced directives which will help prevent these kinds of situations, such as a medic alert bracelet or a emergency health information card which we at United Self Help produce and we do this free of charge.

[00:09:54] Speaker 1: You know, all of that sounds like incredibly good ideas to me. I'm curious, uh, Randy and and then I'll ask uh, Stephen our our psychiatrist, do many people avail themselves of that sort of thing? Because especially someone with a history of of mental illness, it strikes me as as a very intelligent thing for them to at least consider doing, if not doing. Do you know, Randy, do a lot of people avail themselves of that sort of thing?

[00:10:53] Randall Roth: We've produced over 900 emergency health information cards for people with mental illness, uh, Medic Alert bracelets are available nationwide.

[00:11:16] Speaker 1: But these the the advanced directive where we can uh get around this slow process, even even the defenders of the process are concerned that it that it is slow, that the that the courts don't have the kind of resources that in a perfect world we would have, to to kind of shortcut that whole process. That kind of advanced directive, are are there a lot of people using those?

[00:12:16] Randall Roth: There are very few, it's underutilized and we have the forms that were produced by an attorney at Protection and Advocacy. Uh, if anybody is interested in setting one up, please call United Self Help. Uh, we we go ahead. We have them available and it specifies in advance what needs to be done if I or any other mental ill person becomes incapacitated and ununable to have good judgment.

[00:13:03] Speaker 1: That strikes me as an awfully good way to go about this. Stephen Kimball?

[00:13:07] Steve Kimball: Yeah, I I would support that. Um, of course, there are some mental illnesses which are unremitting where the judgment never comes back, and that wouldn't work in those cases, but many mental illnesses are off and on things where a person may may be quite capable of making decisions for themselves and cooperating in their treatment much of the time, and it's only during acute episodes of illness that their judgment is impaired to the point where someone would need to step in and an advanced directive would be very useful for that purpose. I seem to recall there was a law about this that came a few years ago that did not make it through the legislature, but I can't recall the details of of what went wrong with that. Are you aware of that, David?

[00:13:46] David Rammler: Well, advanced directives do exist. There was a law, uh, proposed last year, I believe, to allow the appointment, an verbal appointment of someone uh in a crisis situation that the as if the patient is is can can agree that they don't uh that they can't make the decisions, but it requires that the that the physician determine that the person is incapable of appreciating the various consequences and the risks and and benefits of any particular treatment, but does appreciate the fact that that's that they need treatment and that something must be done um and can say, um, listen doctor, I want my brother John, um, you know, do whatever he says, right? I I can't quite understand what you're saying, but I trust him.

[00:14:35] David Rammler: And um that's correct, that that is not currently the law. It it is the law in some states, it has a lot of problems and um it's which are beyond the scope of this of this discussion probably. Yeah, yeah. Okay, uh, Randy, appreciate uh, you know, your your additional input. I've got some people on the line I'm going to go to them if you want to hang on the line and and talk to some more later that'd be great. Thank you.

[00:14:55] Speaker 1: Let's go to David in Honolulu. Good morning, David.

[00:14:56] David: Good morning.

[00:14:58] Speaker 1: What do you have for us today?

[00:15:00] David: Well, I'm an inpatient uh, nurse on a psychiatric unit, and I find your discussion very interesting. I don't know if I'm going to clarify or confuse the discussion. Um, one of the reactions I have is that it's clearly a ethical dilemma, whether it's okay to force people to take medication against their will. And I'm in a front-line position where I'm involved with having to administer medications and sometimes uh not administer medications to people who most people would clearly think need medication.

[00:16:11] David: And in many cases, it seems like lawyers are advocating for patient's rights without necessarily advocating for patient's best interest. And there's also no real mechanism to have a patient take medication once they leave the hospital. Many patients that get discharged from my facility get discharged to the streets and everyone knows that they're not going to follow up with medication once they leave the hospital and so very often we see them back in a very short period of time.

[00:17:13] Speaker 1: You know, David, a minute ago, when you're talking about uh the rights of the individual versus the best interest of the individual, David Ramler had a reaction in the studio and I just want to hear his thoughts. I think I I saw them. Uh, David, want you comment on that brief? Well, it's absolutely true that legally, my job is to act in the in the uh in the patient to protect the patient's rights to do what the patient wants me to do, not to act in the patient's best interest. And that's a clear legal distinction that I that I think you put your finger on, that that's not understood very well beyond the those of us who deal with it.

[00:18:48] Speaker 1: So, so listeners really understand this, your job is not to do what's in the best interests of your client, your job is to protect their legal rights.

[00:18:56] David Rammler: That's correct.

[00:18:57] Speaker 1: And and that's a different, at least sometimes, that's a difference.

[00:18:59] David Rammler: Yeah. As if if a patient has a view which which someone else says that's not in your best interest. I mean, you know, anyone who's raised children can can remember a situation and probably thousands of them where where, you know, this this other human being and you had different ideas about what was in that person's best interest.

[00:19:16] Speaker 1: Mm-hmm. And I think Stephen, you said something to that effect in your article this morning.

[00:19:19] Steve Kimball: Yes, I did. Um, I I also would like to say that I think when these dilemmas where uh forced treatment is is involved, uh when they have the best outcome usually is when the judges or the attorneys have decided to bend that rule a bit and act in behalf of the patient's best interest, even though that's not really what they're supposed to do according to their legal charge.

[00:20:40] Speaker 1: As a psychiatrist, do you see that sometimes that the courts even though they're supposed to be going strictly by the books watching out for, you know, the the legal issues, that sometimes as you put it they they they bend a bit and they're really watching out for that individual?

[00:21:44] Steve Kimball: It varies a lot. Sometimes they do and sometimes they don't, but I It varies by judge or by the day of that judge? Uh, could be both.

[00:22:01] Speaker 1: Uh-huh.

[00:22:01] Steve Kimball: Strongly by the judge, to some extent by the day.

[00:22:04] Speaker 1: Yeah, okay. David, any additional thoughts?

[00:22:06] David: Well, um in this day of dwindling resources, right now, all patients who have quest funding from the state of Hawaii are allowed uh a total of 30 inpatient days a year. Um, there have to be mechanisms to rethink this whole process to help society deal with this enormous problem. And psychiatric patients are usually considered to be not very important and at the bottom of society's barrel until they cause trouble.

[00:22:35] Speaker 1: Yeah. Three days is not very long to get well. 30 days.

[00:22:38] David: 30 days. 30 days is still not very long. If you don't medicate them, It can it can go away fast.

[00:22:45] Speaker 1: Yeah, it can take that long to find out whether or not you can medicate them, I guess. David, thank you for your call. We're going to go to Craig from Honolulu. Good morning, Craig.

[00:22:53] Craig: Good morning. Good morning.

[00:22:55] Speaker 1: Good morning. You're on the air.

[00:22:56] Craig: I just want to make a comment. Um, I do uh I'm a consumer myself, I have schizophrenia and I do um work in the community at schools and various uh places for the Mental Health Association giving uh talks on mental illness. And I just wonder um, how much, what kind of role education could play in this if if people grew up knowing a little bit more about mental illness, if it happened to them, if they would be more um I think I might have been um more willing to comply with doctor's orders than I was in the past.

[00:23:11] Speaker 1: Mm-hmm. How do people react to you when they find out that that you have been mentally ill, that you're schizophrenic?

[00:23:37] Craig: Um, I think people have a preconceived notion of how I should act or how I how I should appear. I'm not in a straight jacket all the time walking around, and I'm not necessarily behaving in a way that that people might be alarmed at and and I think it's it's good for them to see that mentally ill people can you can't always tell by looking at someone. Um, I've been on medication since 1987 and uh I had to go through a lot of denial to get to that place where I was able to realize that, hey, I have a problem, and I need to do something about it. I need to take the medication, I need to see my doctor, and this is my responsibility.

[00:24:19] Speaker 1: Okay. Um, Craig, I appreciate your your thoughts. Dave Ramler has a comment.

[00:24:24] David Rammler: Well, I have a actually a question for Steve and and that is in your experience um, this whole question of denial, you know, that we were just hearing about, um, do you have any thoughts on whether people who ultimately come to that decision, you know, from a from a personal rights and a personal dignity perspective can follow through with treatment later on because they have come through that recognition and whether there's any really negative impact on long-term treatment potential if people are forcibly medicated and they develop presumably, uh some antagonism or antipathy toward uh treatment providers?

[00:25:04] Steve Kimball: Well, um, I I have certainly had people that I've worked with personally who have been through that process of starting out, refusing to acknowledge their illness, ending up getting in trouble, having things done to them involuntarily, but have come around to say, I really have an illness, and I I need to take responsibility for taking care of and have been willing to work with me. Let me know when there's early signs of relapse so we can intervene intervene voluntarily before it gets out of hand. And that's very gratifying when it occurs, but it's a process that often takes years.

[00:26:00] Speaker 1: And along the lines of what Craig was saying, I I assume that that education of of of the entire population, not just those with symptoms, could be very helpful.

[00:26:08] Steve Kimball: Yes.

[00:26:09] Speaker 1: Okay. Craig, we really appreciate your call.

[00:26:11] Craig: No problem. Thanks for um bringing up the subject. This is very interesting.

[00:26:14] Speaker 1: You bet. Uh, we have from Maui, Allison. Good morning, Allison.

[00:26:18] Allison: Oh, hi. Um, I'm glad to get on. I'm speaking from the perspective of a person who's the daughter of a severely uh manic depressive uh woman who's very highly educated and in 1990 was uh with my sister who's an internist in San Francisco was um we tried to get her into hospitalization during a particularly bad manic episode. And um she was in for uh the minimum number. I think it was 48 hours. That's probably right. in California, and um she got out and promptly sued everyone in the family. And I've not seen her now in almost six years. Um, I'm 43. Um, she's had this basically

[00:19:00] Speaker 1: her life, will not get medication and will not get help. She has a doctorate. She was a vice president of a major company in the Bay Area, and I would I would have preferred to have had cancer myself or all of us would have preferred that compared to the um, disaster that has been reaped upon our family.

[00:19:22] Speaker 2: Have have you tried to to force treatment upon her?

[00:19:25] Speaker 1: Well, she was we tried to get her in. We found the best female psychiatrist in the Bay Area. She sued that woman. I mean because she, I mean that a lot of them spend their time in court. Um, I came to find out suing, and she has plenty of money to do it.

[00:19:43] Speaker 2: Mhm.

[00:19:44] Speaker 1: Um, she'll carry on a lawsuit for years, even if she loses. She doesn't care.

[00:19:49] Speaker 2: So everyone who has has tried to help her has ended up getting sued and and presumably backing off.

[00:19:54] Speaker 1: Yeah, and I blame the uh, and now she's in a, um, a prolonged depressive cycle, and she is in the room uh with a, uh, husband of a friend of hers who died. And she owns four homes, a huge home in Woodside. She refuses to come out of her room, and this woman man that she lives with, is very happy to meet her uh physical needs because, you know, he's bought off by her as well.

[00:20:18] Speaker 2: Mhm.

[00:20:19] Speaker 1: So and I really condemn the lawyers for them going along with this.

[00:20:23] Speaker 2: So in your opinion-

[00:20:24] Speaker 1: You know, we we're all independently wealthy. We don't want any of her money. We just would like to have our mother back.

[00:20:29] Speaker 2: So in your opinion, she she's obviously ill, but evidently doesn't pose an imminent danger to herself or to others.

[00:20:36] Speaker 1: Well, in at one point she did. She was carrying guns because she became paranoid on top of the manic depression depression. And uh, you know, because she had been jumped as she said by my sister and my father, they got a divorce, a very messy one, and um, it it's um, just destroyed our family, and the lawyers continue um out of their greed. I'm sorry to say it, but it's out of their greed that they um go along with this. They know she's out of it. They know she's I mean she bought a plane one year, uh, got rid of the plane, she'll buy cars for um anybody who comes along and and plays her game for a while and then she'll sue them and get them out of her life.

[00:21:16] Speaker 2: Alison, stay on the line and and I I really appreciate your sharing all of this with us. I want to get our psychiatrist, Steve Campbell's reaction and and then, uh, the attorney with Protection and Advocacy, David Ramler. Steve?

[00:21:27] Speaker 3: Well, I think this kind of case is exactly what uh, the kind of case that highlights the dilemma we're talking about where uh, if you strictly defend patient the patient's rights to have what she says she wants, uh, it ends up in a disaster, and the only um, way that there could be a better outcome to this is if um, the even the legal system were to take more responsibility for her best interest instead of her rights. Uh, otherwise we end up in these disasters here and there.

[00:21:55] Speaker 2: David, is that what we're back to is the difference between best interests of of the client versus the legal rights of the client?

[00:22:02] Speaker 4: I mean, I think that's probably right. The the 48 hours that um Alison's mother spent in the hospital, were court-ordered for evaluation to determine whether she was in need of treatment and further care. Um, and um, but probably applying a standard like imminent danger as opposed to a standard like obviously ill.

[00:22:20] Speaker 3: Yes. Yes, the the the medical team would then go back to the court and have to and have to tell the court whether they thought this person was imminently dangerous.

[00:22:28] Speaker 4: And um,

[00:22:28] Speaker 1: Yeah, legally and they're not going to stay. She's very articulate. She um could convince anyone of any that her state is perfectly normal.

[00:22:38] Speaker 2: Well, I it it is true. I mean, because that that many people who have severe who who suffer seriously from serious mental illness have um are very lucid most of the time and you can carry on conversations and and it can take, I mean, I've I've been in, particularly when I worked for long-term in in a hospital, uh, because now I only see people in in sort of shorter episodes, but when I worked in a hospital it was clear that there were many people there who for weeks you would think uh were just perfect perfectly normal, you know, I mean, and carried on normal lives within the context of the hospital, uh, but who suffered serious mental illness. That's absolutely true. The problem is what, you know, society, to to say that that our society has the right to intervene in that person's life and to order them to do something, is is a concept that our society has guarded jealously uh from the inception of of what we know you know as human rights in in our Anglo-Saxon legal system and and um this is this kind of case is an invitation to abandon that social basic philosophy that I think we have to resist.

[00:23:21] Speaker 2: So back to the slippery slope.

[00:23:23] Speaker 3: Yeah.

[00:23:23] Speaker 1: Well, and then there we are. We're all alienated as a family and um, you know, we as her daughters have stuck together, but we have not seen her in years.

[00:23:32] Speaker 2: Alison, let me let me ask uh uh Stephen Campbell um what you would suggest. What what can Alison and and her family do?

[00:24:00] Speaker 1: We tried lithium, I mean, she was she did that. Oh no, I get a reaction besides, I'm not manic depressive. Well, that there I was a manic depressive.

[00:24:06] Speaker 3: Now there there are certain people who uh, who you cannot do anything about under the current constraints. I I think that, you know, that as a society, we have a dilemma that whichever wherever you draw the line of the point at which we can become coercive, there are risks to it. If we draw the line closer to uh, protecting patients rights, it's this kind of case that's the risk and there's going to be a certain number of those which ended in disasters because we've chosen to draw the line uh, toward protecting people's rights.

[00:24:37] Speaker 1: Well that's how we feel. We've done as much as we can, and we've had to let go, and that is been a more pain, I cannot tell you how many pain uh a family goes through to have to let go because we just we don't have the kind of money to mount um defenses, I mean, and be summoned all the way in Hawaii and be sent back to California.

[00:24:58] Speaker 3: I was just going to say that uh it's also true that if we draw the line further toward making sure that people who need help get treatment, it opens the door for more abuses of, you know, if if you have a doctor or nursing staff who aren't going to take the trouble and just to find out what's going on and just want to make things as easy as possible for themselves by clamping down on anybody who raises their voice. Uh you know, you can get disasters on the other side there too. There is there isn't any solution that's going to work for every single situation.

[00:25:28] Speaker 2: It's a horrible dilemma.

[00:25:29] Speaker 1: Oh, and I really appreciate your show. I've really tried to think about it for a long time, but

[00:25:34] Speaker 2: Alison, I I know that was difficult for you to to share. I really appreciate your calling in this morning. We're we're running out of time. I'm going to have to move on, but thank you very much for your call.

[00:25:42] Speaker 1: Oh, thank you very much.

[00:25:44] Speaker 2: We're down to just the last minute or so in 30 seconds, uh, David Ramler, any closing comments?

[00:25:52] Speaker 4: It's a terrible dilemma. I think that Steve is absolutely right that, you know, we've made a decision on where to draw the line. There are benefits and detriments to that, but there will always be a line that has to be drawn somewhere. Um, and we're we're slowly working our way through the positive and negative aspects of the line we've drawn. But I don't see a change in in the near future. I think that the courts have pretty much settled on this line because it's um, it's something that you can, it's a pretty cold, hard line, you know, that's justifiable.

[00:26:20] Speaker 2: So the system is not perfect, but it seems to be working as well or better than any alternative that that we really have access to.

[00:26:28] Speaker 4: Yes.

[00:26:30] Speaker 3: Well, um, I think that the line is the line is probably fairly close to where it should be. Um, as I said before, I think in practice, sometimes the line is bent a little and maybe there needs to be a little room for that, even if we don't officially acknowledge it, uh, which helps to minimize the disasters. Uh but it it's always going to be an extremely painful dilemma, um, painful for the patients, family members and the doctors and nurses involved in taking care of them. It's painful for everyone. and these situations are are are not something that have easy answers.

[00:27:05] Speaker 2: Okay. Well, I want to thank all of my guests this morning in the studio. I had David Ramler, an attorney with Protection and Advocacy Agency of Hawaii, a nonprofit organization that serves as advocate for the rights of persons with disabilities, and Stephen Campbell, a physician who holds a joint academic appointment in medicine and psychiatry at the University of Hawaii John A. Burns School of Medicine. That's probably a patient calling him right now. By phone, we had John Bryant, a family court judge whose responsibilities include uh holding hearings on involuntary mental health commitments. Fran Smith, the executive director of the Oahu Alliance for the Mentally Ill and Randolph Hack, the executive director of United Self-Help and himself a consumer of mental ill or mental health services. Our producer is Susie Roth, our director of operations is Jeff Alardi. Next week will be the second installment of our two programs on on mental illness. We're going to focus on street people and uh the the issues that they raise so far as society is concerned. We've got a real good show. I hope you'll listen to us. You've been listening to Pop Radio. I'm Randy Roth. Aloha.

[00:38:00] Stephen B. Kemble: and if you let them follow their arguments, you'll you'll end up with disastrous consequences. And if you intervene, you'll get vigorous protests. So that would be an example of an illness where you can run into this dilemma where someone appears to be fairly rational, but really isn't.

[00:38:15] David Rammler: Well, I know all of this can be extremely hard not just on on the person directly involved with the illness, but but the family members of that person. We have on the phone Fran Smith, and if you've seen the paper this morning, you've seen an article written by Fran. She's the executive director of the Oahu Alliance for the Mentally Ill. It's a grassroots self-help organization dedicated to improving the lives of mentally ill individuals and their families. It's an affiliate of the National Alliance for the Mentally Ill and it sponsors programs of advocacy, education and support.

[00:38:48] David Rammler: Before coming to Ohami, that's the Oahu Alliance for the Mentally Ill, Fran was an advocate in Hawaii, and, following that was following an extensive and successful career on on Capital Hill. Uh, Fran, I believe you're there on line three.

[00:39:03] Fran Smith: I'm on the line.

[00:39:04] David Rammler: Good morning. Uh Fran, have you had an opportunity to hear Stephen and David this morning?

[00:39:09] Fran Smith: Yes, I have.

[00:39:10] David Rammler: Uh especially from the point of view of of family members who are very, very concerned about the well-being of of this person who who may very well be mentally ill. Um any thoughts to share?

[00:39:22] Fran Smith: Well, um the principal thought I have is that um we really ought to focus our um energy and effort on developing and making readily available the kinds of services uh that people who are mentally ill need not only to um recover from their illness and to stay in recovery, prevent relapse, but to get into recovery in the first place.

[00:39:55] Fran Smith: And um often um a mentally ill person on the street like the um type of person that um I think was described in Steve's article in this morning's paper, may not be um lacking treatment because of a refusal to get it, but a lack of awareness that treatment is available and that it can make a difference. Um better outreach, and then better what's called assertive case management where people who are in um recovery and getting uh treatment can um learn to um understand their illness so that before the illness affects their judgment they can pursue treatment. Um it poses a challenge, but it's a challenge that we really ought to um meet.

[00:40:53] David Rammler: Well, Stephen Kemble is is here. I noticed nodding nodding that that he agrees. Um, uh are are we talking about something that that requires more resources? Is is that the key here that the state has to come up with more resources or or is it uh something that can be done without additional resources?

[00:41:10] Stephen B. Kemble: I think there is definitely a need for more resources. And there are a lot of people who uh could benefit from treatment voluntarily who aren't able to get access to adequate treatment because of limited resources. And with the cutbacks in government funding, both federal and state, that's only getting worse.

[00:41:26] David Rammler: Fran, um from the family's point of view, because I've I've heard a number of stories, um the impression I have is that quite often family members will know that someone is mentally ill, they will will desperately want that person to get treatment, but they they won't be able to talk that person into getting it and and going through the court system can take some time and it's my impression that there are a lot of family members out there who feel that that that something about the current system isn't working just right.

[00:42:00] Fran Smith: Um I'm not sure they look at it from that perspective so much as that um the current system doesn't answer their question and their question is what are they supposed to do? Um and I think um that's what we hear from family members most is what am I supposed to do? How can I um how can I help my son or daughter or sister or brother? How can I get them into treatment?

[00:42:29] David Rammler: And presumably to call an organization like yours would be a great place to start, wouldn't it?

[00:42:34] Fran Smith: Oh sure. We're always happy to receive calls and what we try to do when we hear from people is put them in touch with um the uh places and individuals who provide professional services to meet the demand and also in touch with other family members who have had the same experiences and can share um steps they've taken or if nothing else provide them a shoulder to cry on.

[00:43:03] David Rammler: I would think that would be extremely helpful.

[00:43:05] Fran Smith: Yeah, it is really important.

[00:43:07] David Rammler: Fran, we we appreciate you sharing those thoughts and and the article in the paper this morning, I thought was was extremely good. If if you want to um hang with us and and give us some additional thoughts toward the end of the hour, that'd be great. Uh if you've got some things that you've got to uh to take off to attend to, well that's fine too.

[00:43:23] Fran Smith: What I'll do is listen to you and call back if there are some additional thoughts.

[00:43:27] David Rammler: That's great. Thanks a lot, Fran.

[00:43:28] Fran Smith: Thank you.

[00:43:29] David Rammler: We also have on the line Randolph Hack. Uh Randolph Hack has been the executive director of an organization called United Self Help since May of 1995. Uh he's a consumer of mental health services who has personally experienced involuntary psychiatric treatment. He's had extensive history of psychiatric hospitalization over the past 30 years, only in the past 12 years has he been able to re-enter the workforce. Uh Randy, are you there?

[00:43:56] Randall Roth: Yes, I am.

[00:43:57] David Rammler: Good morning.

[00:43:57] Randall Roth: Good morning.

[00:43:58] David Rammler: Do you have any thoughts to share about the topic generally or about anything that you've been listening to this morning?

[00:44:03] Randall Roth: Well, I think it needs to be stressed that involuntary treatment involves the use of force. And uh in our society, the use of force is generally reserved for the police and the military. But, in this case, the use of force is in association with psychiatric procedures against a person who has a mental illness. And we have to be very, very careful to make sure that a person's human rights and constitutional rights are protected in any forcible psychiatric procedure.

[00:44:53] David Rammler: Randy, hol- hold on just a second. I think Dave Ramler has a a thought on that to share.

[00:44:58] David Rammler: Um I'm just thinking that uh while I agree with Steve that there are situations where people don't appreciate their their condition. Um I think Randy's point must be clearly understood by by your listening audience, and that is that today in psychiatric institutions and uh care facilities, it is not uncommon that staff will physically restrain either with their hands or by strapping someone down with straps a a patient, in order to inject them with medication that the doctor has ordered. I think that that's probably a terrifying experience and Randy can speak to that but people need to know that that's not just the dark ages. I mean it still happens when you have an involuntary medication or treatment situation.

[00:45:43] Randall Roth: So, we're talking here about the use of force, and uh in two instances in history, I can point to where state-sponsored psychiatry has uh been abused uh that is in the Nazi uh period in Germany and the Soviet Union, where uh the lives of psychiatric patients were forcibly ended. So so uh we have to be very, very careful with this type of thing. And as one who's experienced a forcible psychiatric procedure being held down and injected with medication, I can assure you it is not a pleasant experience.

[00:46:35] David Rammler: Okay. You know, David, I I know, and I don't remember if it ended up in the paper this morning or if it was in your first draft, but I read something you wrote about it's not just in Germany and the Soviet Union, that that there are some instances in this country. I think you mentioned the CIA or whatever.

[00:47:02] David Rammler: And the United States Army, both well documented, and you know, in the post World War II era in our lifetimes, the both the United States Army and the CIA have done drug testing and have exposed unknowing people um to to not not just treatment in terms of drug experiments, but also I mean the whole the army tests with uh nuclear radiation in the Southwest in in the late 40s um and early 50s. You know, there there are there are people who think there is a greater good to be gained by not informing people of what they're being exposed to, and or by treating them against their will. And and I think that the courts um about 20 years ago, 15 years ago, there was a very heavy emphasis in the courts on medical opinion to deal with this situation and the doctors were given a great deal of latitude. Um about 15 years ago or so, a series of court decisions came down both in Hawaii and in uh the federal courts and across the country which injected judges and legal, rational fact finding back into these decisions in a very forceful way. And I think um that while it has to be a balance, that the balance is shifting in in the direction of objective third-party decisions at least in terms of trying to gather facts and and make some some more rational decision and and some decision which is a step removed from that patient doctor or patient family relationship.

[00:48:18] David Rammler: And you're talking about the legal setting. You're talking about the courtroom. Right. Okay. Uh Steve Kemble?

[00:48:21] Stephen B. Kemble: I I want to make a couple of comments. One is that there is a distinction between involuntary hospitalization and involuntary treatment. And they're they're not always identical. In fact, there are many cases where people are involuntarily hospitalized but they're not allowed to be involuntarily treated. So they can't leave the unit, but they can't be forcibly medicated without their consent.

[00:48:40] David Rammler: I agree.

[00:48:41] Randall Roth: Um I had something to say about that.

[00:48:42] David Rammler: Go ahead, go ahead and then we'll come back to Steve.

[00:48:45] Randall Roth: Uh involuntary treatment, being locked up against your will, is uh also I consider a use of force. Uh in other words you're losing your freedom, uh is can be just as devastating as I use your free losing your freedom and and sometimes losing even your clothing, having to wear uh pajamas or whatever on the unit can be just as devastating as being uh held down and injected with medication.

[00:49:20] Stephen B. Kemble: Yeah, well, the other thing that I wanted to say is that I really do acknowledge how devastating and humiliating it can be to have something done to a person against their will. And um it in order to minimize that, there's always a certain percentage of cases where that's necessary. When someone is really violent, really out of control, uh other people's safety is endangered. Uh there are situations where coercion really is necessary and there's no way around that small group. But there's a wide range in between of people for who are getting upset uh maybe getting speaking loudly or yelling or or acting in a way that looks somewhat intimidating where taking the extra effort to talk to the person, to negotiate with that person could avert a coercive outcome but for whatever reason the doctors and nurses involved don't take the trouble to do that and it ends up being a coercive situation unnecessarily and that does happen every day and I I it would be my concern as much as anyone else's in this show that those situations be minimized. Mhm Uh but I do think there is that certain percentage where there's no way around uh something coercive needs to be done because otherwise the consequences would be disastrous. Hopefully even in those circumstances, uh you know, under the best circumstances, the doctors and nurses involved would take the trouble to treat the patient like a human being, explain why this is necessary, continue to talk to the person after the forceful intervention has been made and steer things toward a constructive um outcome in the end and those are the situations that may come out well. If that is not done, it usually ends up being a destructive occurrence. Okay.

[00:51:01] David Rammler: Randy, we really appreciate your participation this morning. Um you might do what Fran's doing. Uh listen to the show and and if you've got some additional thoughts to share, give us a call, tell Suzy, our our producer that it's you and we'll get you on again.

[00:51:13] Randall Roth: Thank you.

[00:51:14] David Rammler: Thank you. Uh finally in terms of of the uh the people that we've arranged to um uh be with us this morning by phone, we have uh John Bryant uh who is the lead judge of the family court special division. Uh responsibilities include hearings on involuntary mental health commitments. He's been with the family court since October of 91. From 1983 to 1991, he was a prosecutor for both the uh city and county of Honolulu and the state of Hawaii. Uh Judge Bryant, good morning.

[00:51:43] John Bryant: Good morning.

[00:51:45] David Rammler: Uh you've been listening to the show, I'm sure you've got a a few thoughts to share about either the topic in general or comments that have been made. Uh what do you think?

[00:51:54] John Bryant: Well, I uh I appreciate the viewpoints of everyone. I think they're very well presented, including the the articles in the paper this morning. Uh Randy, one thing I'd like to probably clarify from my point of view is the uh issue as to uh commitment involuntary mental health commitment for both persons that are either obviously ill or gravely disabled. And you hear a lot of criticism that family court judges aren't applying those standards and and uh Steve, I'm one of those judges that ignore those two standards, believing them to be unconstitutional. Mhm. The fact of the matter is, they are unconstitutional. Uh 20 years ago, Judge King, federal district court judge here in Honolulu, said, you cannot commit involuntarily a person just because that person is uh mentally ill. You have to have a corresponding dangerousness uh finding with the finding of mental illness. Uh that was 20 years ago. As late as two years ago, the United States Supreme Court said that in civil commitments, you have to have a person who is both mentally ill and imminently dangerous. So for us to uh uh involuntarily commit a person because they're obviously ill or gravely disabled is uh I think it's a violation of our oath.

[00:53:13] David Rammler: So so you're bound by not just the the statute which gives these these other standards, but you're bound by the case law and if the case law says the parts of the statute are unconstitutional then then you're you you can't apply those standards.

[00:53:26] John Bryant: That's right. That's right. Uh if we don't have a finding of imminence dangerousness to self or others, we cannot and will not involuntary commit a person and you know my my personal opinion is frankly irrelevant to that analysis and finding, but you know for what it's worth, I'm I'm happy that it's difficult to involuntarily commit a person. I I think that uh uh Randy's comments earlier and along with David's indicate just the massive curtailment of liberty that a person uh suffers when they're uh uh against their will sent to a a mental hospital and uh against their will treated.

[00:54:02] David Rammler: And just so our listeners understand, uh this case law is saying even if a person is quote obviously ill, or quote gravely disabled, if they don't pose an an imminent threat to themselves or to others, then according to the case law, uh these folks uh cannot be forcibly treated.

[00:54:20] John Bryant: That's right. And you know, obviously ill is not even detained in the statutes and and that raises all kinds of interesting questions as to, you know, who's going to be saying who is uh obviously ill. Uh cigar smokers uh may be obviously ill under this standard. Uh you know, that may be an extreme example but uh to me it's a slippery slope. Uh the state's interest has to be paramount and the only way it can be paramount is when you when you have a a finding of dangerousness. When someone is going to hurt themselves or others uh that is when we can commit.

[00:54:54] David Rammler: Okay. Well, John, I I really appreciate your being with us this morning. Um uh will you be able to listen to the rest of the show and and perhaps call in if if anything is said that you think needs to be clarified?

[00:55:05] John Bryant: Well, I've got a number of house chores this morning, but I'll keep an ear out for the radio. If I have anything I think is is important and necessary to to comment on, I'll give you a call back.

[00:55:14] David Rammler: Well, we sure appreciate your participating this morning and and I know um uh the decisions that you make from the bench in this area are have to be excruciatingly difficult and and we appreciate the the job you're doing.

[00:55:24] John Bryant: Thanks a lot.

[00:55:25] David Rammler: Thank you.

[00:55:26] David Rammler: I want to remind listeners that this is the Price of Paradise radio show. My name is Randy Roth, and I have uh guests in the studio David Ramler, who's an attorney with Protection and Advocacy Agency of Hawaii, a nonprofit organization that serves as advocate for the rights of persons with disabilities. And Stephen Kemble, a physician who holds a joint academic appointment in medicine and psychiatry at the UH John A Burns Burns School of Medicine. Uh he also is in the private practice of of adult psychiatry. We've had on the phone, uh John Bryant who is the lead judge in the Family Court Special Division that makes decisions in in this area having to do with uh commitment and and guardiorship. Fran Smith, who's the executive director of the Oahu Alliance for the mentally ill, and Randy Hack, the executive director of United Self-Help and himself a consumer of of mental health services. Our topic is is mental health, mental illness. and uh we would invite your questions and in any brief comments that you'd like to make. Our number is 955-8821 and with that I'll go back to Steve Kemble. Any thoughts on uh what Judge Bryant or any of the others were saying?

[00:56:34] Stephen B. Kemble: Yes, I want to share uh uh uh an example um of a a patient that I dealt with. I'm going to change some of the details, but um this is a person uh with schizophrenia, uh the the one that I was alluding to at the beginning of my article in the paper this morning, who was told during a hospitalization that she had the right to review treatment, and after that did. And um engaged in bizarre behavior for

[00:57:00] Speaker 1: a year. The person had a family, and this is obviously very distressing to the family. And, um, eventually did something that could be construed loosely as dangerous. Uh, doing something that could have burnt the house down, and ended up being hospitalized again. And although she was certainly not suicidal or violent, her behavior was so bizarre that, um, it was highly disruptive. And the way the situation ended up getting resolved when it came to a commitment hearing, is the judge, after listening to all the evidence, told the patient she had to listen to her doctor and take the medication. And after that she did, and she has been compliant with treatment ever since.

[00:57:42] Speaker 1: And this is a situation that doesn't really meet the legal criteria, but where taking a paternalistic attitude and telling the patient what to do was very useful. It didn't involve tying her down or anything like that, but it did involve, um, telling her that she couldn't just do what she wanted to do, even though, legally, that shouldn't have happened.

[00:58:03] Speaker 2: So it's it's somewhere in between the two extremes. Okay, David Ramler?

[00:58:07] Speaker 1: Well, I mean I think that's right. It is somewhere in between the two extremes, but, you know, our our concern is uh what the judge called a slippery slope, and that is that societies, um throughout history have evidenced again and again their ability to to lose sight of the underlying morality of this question, uh in, in uh reaction to the emergency or exigencies of the of the current problem.

[00:58:33] Speaker 2: Okay. Well, we have a caller on the line and I happen to know him, George Bussey, who himself is a psychiatrist from Kyloo. Good morning, George.

[00:58:41] George Bussey: Good morning, Randy.

[00:58:42] Speaker 2: I guess you've been listening to the show.

[00:58:43] George Bussey: Yes, indeed. I I saw the articles in the paper this morning and got done with my morning run in time to come back and catch the whole show.

[00:58:50] Speaker 2: Well, I'm I'm curious, which direction are are you pulled? Uh, we we have in the studio a psychiatrist and an attorney, and you happen to be both a psychiatrist and attorney. You must feel a little bit of a conflict.

[00:59:02] George Bussey: Well, I a a little bit. I think the the question that I wanted to pose to the to the two folks in the studio and anybody who wants to, you know, call in, who's been talking, is the uh, the, um, the split between the process of of committing someone because they're dangerous and then the finding of incompetence to consent to treatment.

[00:59:26] George Bussey: Because one of the the problems I experienced when I was practicing a lot of inpatient psychiatry is that you could uh have a patient who was was seriously mentally ill and suicidal, or homicidal, or you know, threatening to burn down the house or something like that, clearly indicating a severe illness, also in plain denial of the fact that their behavior was bizarre, or abnormal, or or or dangerous.

[00:59:54] George Bussey: And yet the the legal process was such that they would clearly meet the criteria for a commitment, but then you might have to sit around for two or three weeks um waiting for another hearing to make a determination about competency, and then further time to wait for the appointment of some kind of guardian, or to figure out who was going to make treatment decisions for this person.

[01:00:16] Speaker 2: The wheel of justice is turning slowly.

[01:00:18] George Bussey: And, and, and all that time, the patient is remaining disturbed, uh, frightened by their illness, often experiencing many of the things that, uh, the Protection and Advocacy, uh, and United Self-Help people were talking about: I.e., physical restraint and seclusion because as a, as a psychiatrist, I would not be allowed to medicate them and treat the underlying illness.