Mental Health Advocates Urge Protest Against Forced Treatment Addition to Medicare Bill


An array of national mental health and disability advocacy groups joined together today, urging people to contact their senators in protest of a section of a bill rushed through the House of Representatives by voice vote yesterday. Section 224 of HR4302, up for a vote in the Senate on Monday, would subject people in crisis to forced treatment. “In its rush to fix a problem with Medicare, the House passed a bill including a highly controversial program, involuntary outpatient commitment, with no debate and no roll call vote,” said Raymond Bridge, public policy director of the National Coalition for Mental Health Recovery, “And it seems that the Senate may pass a version of the House bill including this troublesome provision on Monday.” “This legislation would eliminate initiatives that use evidence-based, voluntary, peer-run services and family supports to help people diagnosed with serious mental illnesses to recover,” said Daniel Fisher, M.D., Ph.D. “It would bring America back to the dark ages before de-institutionalization, when people with mental health conditions languished in institutions, sometimes for life.”

Of further interest:
List of phone numbers for DC offices of U.S. Senators
Research on Outpatient Commitment (Psychrights)
Compulsory community and involuntary outpatient treatment for people with severe mental disorders (Cochrane Review)

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Kisely SR, Campbell LA, Preston NJ
Published Online: October 17, 2012

The evidence found in this review suggests that compulsory community treatment may not be an effective alternative to standard care.

We examined the effectiveness of compulsory community treatment for people with severe mental illness through a systematic reviewof all relevant randomised controlled clinical trials. Only two relevant trials were found and these provided little evidence of efficacy on any outcomes such as health service use, social functioning, mental state, quality of life or satisfaction with care. No data were available for cost and unclear presentation of data made it impossible to assess the effect on mental state and most aspects of satisfaction with care. In terms of numbers needed to treat, it would take 85 outpatient commitment orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest.

Press Release From National Coalition for Mental Health Recovery:

For Immediate Release

Mental Health Advocates Decry Forced Treatment Provision in “Doc Fix” Bill

WASHINGTON (3/28/14) – The bill rushed through the House of Representatives by voice vote yesterday to patch Medicare regulations includes a highly controversial provision that has nothing to do with Medicare, and that would subject people in crisis to forced treatment. Studies have shown that such force causes trauma and drives people away from treatment, mental health advocates warned.

“In its rush to fix a problem with Medicare, the House passed a bill including a highly controversial program, involuntary outpatient commitment, with no debate and no roll call vote,” said Raymond Bridge, public policy director of the National Coalition for Mental Health Recovery (NCMHR), a coalition of 32 statewide organizations and others representing individuals with mental illnesses. “And it seems that the Senate may pass a version of the House bill including this troublesome provision on Monday,”Bridge added.

The 123-page Protecting Access to Medicare Act of 2014, H.R. 4302, includes a four-year, $60 million grant program (Sec. 224) to expand involuntary outpatient commitment (IOC) – also called Assisted Outpatient Treatment (AOT) – in states that have laws authorizing IOC. The laws allow courts to mandate someone with a serious mental illness to follow a specific treatment plan, usually requiring medication. The facts show that involuntary outpatient commitment is not effective, involves high costs with minimal returns, is not likely to reduce violence, and that there are more effective alternatives.

Assisted Outpatient Treatment  is central to the controversial Helping Families in Mental Health Crisis Act (H.R. 3717), proposed by Rep. Tim Murphy in December 2013.

“This legislation would eliminate initiatives that use evidence-based, voluntary, peer-run services and family supports to help people diagnosed with serious mental illnesses to recover,” said Daniel Fisher, M.D., Ph.D., a psychiatrist and an NCMHR founder. “It would bring America back to the dark ages before de-institutionalization, when people with mental health conditions languished in institutions, sometimes for life.”

The provisions of H.R. 3717 would exchange low-cost, community-based services with good outcomes for high-cost yet ineffective interventions, according to the NCMHR; the National Disability Rights Network (NDRN), the non-profit membership organization for the federally mandated Protection and Advocacy (P&A) Systems and Client Assistance Programs (CAP) for individuals with disabilities; and the National Council on Independent Living (NCIL), which advances independent living and the rights of people with disabilities through consumer-driven advocacy.

NDRN, NCMHR, and NCIL note that the bill does not represent the mainstream of national thought, practice and research.

“This legislation will have a devastating impact on persons with psychiatric disabilities by stripping SAMHSA [Substance Abuse and Mental Health Services Administration] support for consumer involvement in their recovery,” said Mark Perriello, president and CEO of the American Association of People with Disabilities. “Americans with psychiatric disabilities are our friends, co-workers, neighbors, and sisters and brothers. This legislation tramples their civil rights, and must not move forward as currently written.”

“Force and coercion drive people away from treatment,” said Jean Campbell, Ph.D., one of the nation’s leading mental health researchers. “In 1989, 47% of Californians with mental illnesses who participated in a consumer research project reported that they avoided treatment for fear of involuntary treatment; that increased to 55% for those who had been committed in the past.”

Enlarging the capacity for inpatient commitment “could violate Olmstead v. L.C. (1999), the Supreme Court decision, because it would increase ‘unjustified segregation of persons with disabilities [which] constitutes discrimination in violation of Title II of the Americans with Disabilities Act,’ ” said Kelly Buckland, executive director of NCIL.

Rep. Murphy’s bill is based on a false connection between mental illness and violence, the advocates say. “Study after study shows that no such connection exists. In fact, individuals with mental illnesses are actually 11 times more likely to be victims of violence than the general public,” Dr. Fisher said.

“Rep. Murphy’s bill would eviscerate the rights and privacy protections enshrined in the federally mandated Protection and Advocacy (P&A) System, which is the largest provider of legal advocacy services to people with disabilities in the United States,” said NDRN executive director Curt Decker.

“We all agree that incarceration and homelessness are not the outcomes people diagnosed with serious mental illnesses want or deserve,” Dr. Fisher added. “We urge Congressional leaders to engage in a meaningful dialogue with our mental health communities to learn about our creative innovations that truly support the health and safety of people with mental illnesses and of all Americans.”

Dr. Daniel Fisher, [email protected]877-246-9058, cell: 617-504-0832 (press only)

Raymond Bridge, 703-883-7710[email protected]

More Information From NCMHR:

Repeated studies have shown no evidence that mandating outpatient treatment through a court order is effective; to the limited extent that court-ordered outpatient treatment has shown improved outcomes, these outcomes appear to result from the intensive services that have been made available to participants rather than from the existence of a court order mandating treatment.[1]
Two systematic reviews have been done of studies concerning involuntary outpatient commitment. Both reached the same conclusion: there is no evidence that mandating outpatient treatment is more effective than providing such treatment on a voluntary basis.[2] RAND Health found that there was clear evidence that “alternative community-based mental health treatments can produce good outcomes for people with severe mental illness.”[3]
Common sense, cost concerns, and concerns about forced treatment undermining client-provider relationships and driving individuals away from services dictate that we engage people and offer voluntary treatment before restricting their freedom with coercive interventions.[4]

[1] See Dr. Michael Rowe, Alternatives to Outpatient Commitment, 41 J. Amer. Acad. of Psychiatry and the Law 332 (Sept. 1, 2013), (describing the studies).
[2] M. Susan Ridgely, Randy Borum and John Petrila, RAND Health, The Effectiveness of Involuntary Outpatient Treatment (2001),; Steve R. Kisely, Leslie Anne Campbell, and Neil J. Preston, Compulsory community and involuntary outpatient treatment for people with severe mental disorders, Cochrane Database of Systematic Reviews (Feb. 2012).
[3] Ridgely et al., supra note 2.
[4] No Good Evidence for Outpatient Commitment, Courant (Feb. 5, 2014),–20140204,0,1263487.story.

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected].


  1. 224 e 1, because spending 60 M on force is somehow going to tally up to “cost savings.” Put a provision in there that all forced drugs have to be past patent. That will result in significant cost savings, b/c 224 will magically disappear.

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  2. Medications are poorly managed in and out of hospitals. Too few staff are adequately trained
    to recognize paradoxical reactions to medications and to respond appropriately. The psychiatric system is already overwhelmed with too many patients. This increase in forced drugging will result in a spike in deaths and preventable damages , yielding very poor outcomes for others.

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      • One think mentioned by the NCIL person above… outpatient commitment is a violation of Olmstead. I think the national advocacy has missed this, as the US DOJ has actively been forcing states to get people who are ready to go out of the hospital… they are using the Delaware settlement as a model and there is an agreement with New Hampshire coming up that is supposed to be useful also.

        The thing that they are replacing institutional treatment with in these settlements and recommendations to states in the form of memorandums of agreement to avoid a DOJ lawsuit, is to increase ACT which includes the use of coercion in its fidelity scale. National advocates, thinking the Olmstead battle is already won, have missed that ACT is a staple of the recommended care when people are taken out of institutions.

        Just one aspect, mentioned just about here, is if you mandate drugging in the community (or the hospital) the current research estimates that 40% of the causes of premature death are a result of the medications or their health complications. This essentially means that you are involuntarily subjecting someone to a 4 in 10 chance of early death by forcing them to take psych drugs against their will.

        This is more than an civil rights issue. Evidence based practices are a joke. Simply look at the history of psychiatry… rejecting ice baths, lobotomies, electro shock and any number of other forms of treatment in the past would have been rejecting the “evidence base” of past generations of Doctors who got it absolutely wrong… including the Nazi style eugenics laws that allowed sterilization of the “enfeebled” up until the early 1070″s. (!) I appreciate that Whittaker has tried to show the scientific errors of the current regime, however, the profession and culture as a whole has not made a system that is accountable for what it acts on without any real knowledge. The damages for this are human beings lives… and it should not be lost on people that the absolute refusal to participate in their applied subjective analytics, would have kept a lot of people alive and very much free of the invasion of their biological integrity or human rights.

        In Oregon we have started preliminary meetings to address the force issue with the US DOJ here, we hope someone nationally will bring the issue to someone’s attention in Washington DC


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  3. I’m disappointed by the lack of activity I see on the internet regarding this legislative emergency especially among so called ‘progressives.’ I have been posting and sharing like crazy but was amazed that there isn’t more buzz on this urgent matter .Thanks, Dan for alerting us to this sneaky amendment. So called progressives will be patting themselves on the back for supporting the ‘mentally ill’ if this bill passes ‘as is’ and Republicans will be able to go home and tell their constituents that even though they didn’t have the balls to stand up to the gun lobby and make it harder to get guns, they did something about Sandy Hook–they will round up the crazies and make them take their monthly injection! Scapegoating is old hat. Divide and conquer to keep the masses down.
    On MOnday, I’m clearing the decks and canceling appointments to spend as much time as possible on the phone to halt this legislation and I urge other MIA stakeholders to do the same. After this emergency is over, I urge people to ask: “Why is our movement so reactive and not proactive?” I have some theories but I would like other people’s opinions. Because we spend nearly all of our time chasing after bad.

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  4. @madmom- been thinking and saying the same thing ” maybe it’s time to escape to another country”. How in America can a ” voice vote” in the House when most of its members had left for the day be quietly passed, bringing this horrid MH amendment to the HR 4302 bill which will now expand IOC . How is it even legal an amendment (such as this highly controversial MH program) in the House bill can be squeaked through with NO debate and NO roll call vote???????? And the Senate knowing how clandestinely this MH amendment to the HR 4302 bill was snuck in by the House ” voice vote” , ignored the obvious, voted overwhelmingly by the Democrats( which I happen to be registered as) likely more to quick fix its Medicare reimbursement issues for physicians. So, the ” doc fix” temporary solution, once again, has passed quelling the fires from the American docs outraged each yr Medicare threatens to cut MC reimbursement. Instead of a permanent solution to this ongoing MC reimbursement fee problem which was being negotiated quite well by both parties, in sneaks the HR 4302 bill qnd this very controversial amendment which now will likely have devastating consequences for anyone with serious MH issues. I’m going to call Senators Boxer & Feinstein again, this time to protest their ” yea” vote.

    THIS is American politics, at it’s worst.

    It’s really scary how little democracy means in this country to the elected officials we all voted into office.

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  5. This is what we are up against. On a discussion about this bill on a ‘progressive’ website, an individual on hearing that there was opposition to eliminating federal funding for peer delivered services and other alternatives commented: “the lunatics are running the asylum” the most hateful thing I could imagine–just sent an arrow through my heart. That and the ignorant d*ck head on the street I overheard last year bragging about his Halloween costume that was going to be a deranged escaped ‘lunatic’ carrying a blood stained knife. Do people have no conception of the suffering that people go through when they or their loved ones are institutionalized, incarcerated, segregated, labeled, and forcibly shocked or medicated with life threatening and disabling cocktail of drugs?

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  6. So, let’s just be honest here? What this bill says to me is that Congress doesn’t so much want to cure mental illness, provide better life options, or a better quality of life. If they were concerned with those things, they might have bothered simply reading the statistics on violence and the mentally ill. In fact, if they were really worried that the mentally ill posed a real threat, they might have looked up those numbers on their own for peace of mind. That leaves me with only two other options for the motivation behind this bill. It supports their claims against the “violent” mentally ill while creating the illusion that they are doing something, and congress likes the mentally ill where they don’t have to look at or acknowledge them. It also helps that involuntary commitment is one of the few things that always raises the overall profit for the pharmaceutical companies. ( a more complicated legal aspect is that any time they “criminalize” the mentally ill and make involuntary commitment easier, that later serves to support things like the Adam Walsh Act and the ridiculous claim that sexual predators are mentally ill and must be institutionalized after serving most of their sentence and held until they can be properly treated for that “illness.” See, criminals, by fortune of their criminals acts, are promised certain rights and legal protections like the 8th amendment. Congress quickly discovered that the best way to rob someone of those legal protections was to have them found mentally ill when they argued for the Walsh Act, the problem is that the general public are also happy to ignore our situation if it gives them even the illusion of security. See, no matter how you sugar coat it, involuntary commitment equates to someone being robbed of their freedoms and rights. When this argument first resurfaced, Representatives kept arguing that it should be easier to have a person committed… but what I can’t help but wonder is should ever be “easy” to strip someone of their rights and freedom? In my mind, that should always be something we approach carefully and with real understanding of exactly what that means.

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