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Mental health reform may founder on forced drugging

MONTPELIER, Vt. --A move to have regional hospitals care for more acutely mentally ill patients could be derailed over the question of how much power the facilities should have to medicate patients against their will.

The debate over "involuntary medication" or "forced drugging" -- the terms of art used by proponents and opponents, respectively -- has flared up several times in the Vermont Legislature and courts in recent decades.

Now it has reared its head again as lawmakers begin to consider the findings of a report issued earlier this week on how to replace Vermont's troubled, century-old state hospital in Waterbury.

The report by a team of three consultants hired by the Legislature called for replacing the Waterbury facility with one designed to care for the long-term mentally ill, while gearing up community hospitals around the state to handle acute cases -- those in mental health crises.

One big issue, though, is how those community hospitals should handle a patient deemed by doctors to be in need of one or more of the powerful psychiatric drugs on the market, when the patient doesn't want to be medicated.

Many patients are helped by the drugs, according to some of those testifying at a legislative hearing on Friday. Others maintain the trauma already brought on by their psychosis was worsened by being forced to take the medications.

And there are civil liberties concerns. "It's a very serious intrusion on someone's liberty and autonomy" to be forced to ingest mind-altering chemicals, said Jack McCullough, an attorney and director of the Mental Health Law Project at Vermont Legal Aid.

Xenia Williams, 59, of Barre Town, a self-described "psychiatric survivor" who has done three stints at the Waterbury state hospital, said she was "held down and shot up" with Thorozine, a powerful anti-psychotic drug, while being treated at a mental health facility in Massachusetts.

"It made me sleep for 20 hours and I felt like I had cement in my brain," she said. "It was horrible. It was like being raped both in your body and in your mind."

The state Department of Mental Health currently has a policy that drugs can be administered against a patient's will only in Waterbury, and not in the psychiatric wards operated by some of Vermont's community hospitals.

Forced medication occurs only after at least two court hearings -- one in which the person is committed to in-patient psychiatric care, and a second in which a judge signs off on the state's request that the patient be drugged against his or her will.

If more people in psychiatric crisis are sent to the community hospitals, those facilities are widely expected to assume the role of administering the medications. But the hospitals have expressed strong reservations about waiting for the two-step judicial process, which can take more than three months, before they administer the drugs.

Vermont began its current debate over the future of the state hospital more than three years ago. Early in that process, the Vermont Association of Hospitals and Health Systems outlined its position on forced medication in a statement shared with lawmakers.

"If a patient is treated involuntarily, it should not require two separate judicial actions to initiate treatment and medication," the association said. "There should be one judicial action to determine treatment and if necessary, medication administration. Courts must make commitment determinations within 48 hours with adjudications at the facility."

Association Vice President Jill Olson said Friday the group had since backed away from that position and had not settled on a new one. But she called the forced medication issue "the area where we're least likely to come to consensus" with other participants in the debate.

She added that the hospitals have even more fundamental issues with the push for regionalization of mental health, among them what she said would be the need for renovating spaces and adding staff to deal with more seriously mentally ill patients.

Ken Libertoff, executive director of the Vermont Association for Mental Health, agreed that resolving the involuntary medication issue is the biggest stumbling block to bringing the envisioned reforms to fruition.

"We as a state would be foolish to let a whole potential plan fail for an inability to solve a hard issue," Libertoff said. "And this is a hard issue." 

Copyright 2007 The New York Times Company