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COLUMN ONE : Treatment Against Their Will : More states are making it easier to force the mentally ill into hospitals. Some doctors, families and even patients back such changes, noting the delicate balance between civil rights and 'the human right to live.'


NEW YORK — The temperature had climbed above 90 degrees, but Tressa, a slender 20-year-old woman sitting on a park bench outside the Staten Island Ferry Terminal, was wearing five layers of clothing. The holes in her jeans were stuffed with cardboard. Her shoes were wrapped in silver duct tape.

She had occupied the same bench every day, all day, for the last five months. A psychiatrist and a nurse, members of an outreach organization called Project Help, were trying one last time to persuade her to enter the Bellevue Hospital Center psychiatric ward voluntarily.

Eyes wide with fear, Tressa refused, as she had for five months. "There's a time and place for everything," she told them. "Even though I'm just sitting here, I certainly hope I'm not drifting from reality. I have a strong belief in God. He has always let me know when the right moment comes."

Within hours, Tressa became part of a quiet but significant change in the way American society is dealing with the mentally ill, especially those who are indigent and resist treatment. Invoking special authority recently granted to health professionals, a Project Help psychiatrist took Tressa to Bellevue, despite her pleas to be left alone in the tiny triangle park where she felt safe.

For more than three decades beginning in the 1950s, government policy, medical opinion and the law lined up together to enforce strict limits on the conditions under which such involuntary commitments could occur. But today, the situation is changing:

Under pressure from the public, from relatives of mental patients and from the medical community, the strict prohibitions against involuntary commitment are being reconsidered and several states have already relaxed their standards for involuntary treatment. This has made it easier to commit mental patients--especially the indigent--whether they agree or not.

"The pendulum is starting to swing back," said E. Fuller Torrey, a clinical and research psychiatrist based in Washington who is a leading voice in support of involuntary treatment. "None of us are saying it should go back to where it was in the 1920s or '30s. But we're definitely going back in the direction where you will be able to get people in the hospital who need treatment."

Most jurisdictions still permit involuntary commitment only for people with severe mental illnesses--schizophrenia, manic-depression and major depression--and only when they pose a danger to themselves or others--the standard set in the 1950s during the movement away from involuntary commitments.

Recently, however, some states--including, Arizona, Hawaii, Oklahoma, Delaware, South Carolina and Iowa--have modified those criteria, allowing courts to order involuntary commitment based on other factors, including psychiatric history and potential emotional injury to a family. In effect, the new rules permit authorities to act where the need for treatment is very clear and individuals are unable to make a decision for themselves.

In part, the change is being driven by neighborhood groups and citizens who are frightened by--or fed up with--the growing numbers of homeless mentally ill people in their communities. The balance between the rights of society and the rights of individuals is out of kilter, these groups contend.

Moreover, relatives and friends of mentally ill people who refuse treatment are banding together to pressure lawmakers. Consigning such people to live on the streets, eat out of trash cans and suffer without care or medication--all in the name of protecting their civil liberties--is perverse, they argue.

"In the name of civil rights they are denying people like my son the human right to live," said a 70-year-old engineer whose 40-year-old son has suffered from schizophrenia for 17 years and has lived for years on the streets of New York because he denies that he is sick and refuses to take medicine. "When my son is psychotic, he's an animal. He can't decide what is best for him," his father says.

Families tell of being unable to get treatment for their loved ones, no matter how clearly psychotic, until they have crossed the line into violent behavior. Slicing one's scalp, pulling one's hair out or hurting another person are among the examples cited by relatives. Desperate to get help, family members say, they sometimes lie to authorities, claiming that violent acts have already occurred.

Adding to the pressure from neighbors and families is the fact that doctors have new tools for alleviating the problems of serious mental illness.

"This comes at a time when we have a new generation of anti-psychotic drugs that are more effective and have fewer side effects," said Robert Levy, the Project Help psychiatrist who decided to treat Tressa. "It's much more humane to give these people treatment."

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