Parents praise new Iowa mental health commitment law; critics fear loss of civil rights

IOWA CITY, Ia. — Leslie Carpenter hopes Iowa families like hers, who have loved ones with severe mental illness, will no longer have to wait for a life-threatening crisis before authorities order treatment.

Carpenter, whose adult son has been repeatedly hospitalized for schizoaffective disorder, helped lead a successful effort this spring to change Iowa's mental health commitment law.

The change is designed to bring prompt, court-ordered treatment to people such as Carpenter's son, who goes off his medication and falls back into dangerous delusions after he's released from the hospital.

“If somebody had a heart attack, we wouldn’t wait until 99 percent of their heart was dead — we would get them care at the beginning of the problem, not at the end of the problem,” Carpenter said. “If somebody is deteriorating with their mental health, it’s really scary to sit there and hope you’re going to catch them at just the right moment before they hurt themselves, or before they even, God forbid, hurt somebody else.”

Others worry the change is a step backward to the old days when it was easy to lock up people with mental illness, taking away their civil rights.

“The standard for me to get help in this state is the same standard for me to lose my civil liberties,” said Phil Steffensmeier, a mental health advocate from Iowa City who has bipolar disorder.

The law change is subtle but important, proponents say.

Under current Iowa law, mental health commitment orders may be imposed only if a person poses an immediate threat to themselves or others. The law was used to involuntarily commit Iowans more than 5,200 times last year.

Legislators added a new option in the 2018 legislative session that allows judges and magistrates to order treatment for people who in the past have become dangerously ill because they failed to comply with doctors’ recommendations.

Those patients will no longer have to pose an immediate threat before being ordered into treatment.

The new law takes effect July 1. With the change, Iowa joins 24 other states — including most of its neighbors.

Supporters say the change shouldn't lead to a surge of commitments to Iowa's psychiatric hospitals, which already are crammed with patients.

Instead, they say, the new commitment option should lead to more court orders for outpatient treatment — before people with serious mental illness become so ill they need hospitalization.

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Critics worry about patients' civil rights

Critics say the new law could violate patients’ civil rights.

They worry it could start a return to the days when Americans were being locked up simply for being eccentric.

American Civil Liberties Union of Iowa leaders said the change in the state commitment law is “a step backward.”

“Civil commitment for mental illness obviously is a significant deprivation of a person’s liberty, and any expansion of the reasons that someone could bring court proceedings against a person who doesn’t want to be institutionalized is concerning,” Daniel Zeno, the group’s policy director, wrote in an email to the Register.

Phil Steffensmeier, a mental health advocate from Iowa City, has mixed feelings about the change.

“There’s such a delicate boundary to walk, and I’m not sure we know yet how to walk it,” he said.

Steffensmeier, 37, was voluntarily hospitalized five times for treatment of his bipolar disorder when he was in his teens and 20s.

He has never faced an involuntary commitment, but he understands such orders can be necessary.

“It is definitely not something to be taken lightly,” he said. “At the same time, I can’t look around at my fellow sufferers and say nobody needs that help.”

Steffensmeier is an activist with the National Alliance on Mental Illness, which supports the law change. He regularly speaks in public about the need for improvements to Iowa’s tattered mental health system.

The main problem in Iowa is a lack of resources for people who recognize they need treatment, he said.

Many people with mental troubles would voluntarily seek treatment, but they are forced to wait until they spiral so far out of control that they pose a danger to themselves or others, he said. They’re then locked up for a few days or weeks in a hospital or jail — and released.

Parents led fight for law change

Proponents of the new commitment law say it aims to break that cycle.

They want judges and magistrates to have more power to order outpatient treatment to keep patients from plummeting back into life-threatening crises.

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Leslie Carpenter and her husband, Scott, traveled to the Statehouse this spring to urge legislators to approve the change.

Their state senator, Democrat Joe Bolkcom, introduced the proposal as a separate bill. The idea was incorporated as a little-noticed section of a sweeping mental health reform bill, which was approved unanimously by the Legislature and signed into law by Gov. Kim Reynolds.

People with common mental health issues, such as moderate depression or anxiety, would not face commitment.

Instead, the law change is aimed at people like the Carpenters' son, whose illness has caused him to be terrified of water, bed linens and believe food was poison. He doesn’t stay in treatment long enough for his brain to heal to the point that he can understand he is mentally ill, they said.

“His brain fools him into believing the medications that help him are actually poison,” Leslie Carpenter said.

The young man loses touch with reality, becomes a danger, and is locked up, his parents said. Then he gets out, stops cooperating with treatment and plunges back into psychosis.

The Register is not naming the Carpenters’ son, because he could not be reached to give his permission.

Swinging pendulum on commitments

It used to be much easier to have someone committed to a hospital or institution for purported mental problems.

In the 1940s and '50s, Iowa's mental hospitals were crammed with thousands of patients. Some were locked up for years under court orders procured by family members or local authorities.

Reports of horrific conditions at mental institutions led to reforms in the 1960s. Commitment laws were tightened across the nation to protect the rights of people to remain free unless they represented a danger to themselves or others.

Iowa now has about 800 inpatient psychiatric beds in private and state hospitals. Most patients stay in those units for a few days or weeks before being released.

The shift away from routine commitments to mental institutions was supposed to be accompanied by a major expansion of community mental health services.

Critics contend the country never lived up to that end of the bargain, leaving many Americans adrift with untreated mental issues. But civil liberties advocates say the shortage of community options should not be an excuse to impose more court-ordered treatment.

Commitment orders are made in proceedings at which patients are represented by court-appointed lawyers. A magistrate or judge hears from medical experts, and patients have an opportunity to give their side.

In Polk County, most of those hearings take place in a courtroom at Broadlawns Medical Center.

Des Moines lawyer Katharine Massier, who often represents patients in such cases, said she’s uneasy about the commitment law change.

Massier said the new wording is vague and doesn’t take into account why patients might not have complied with previous treatment recommendations. She noted that many psychiatric medications have debilitating side effects, including sleepiness, heavy perspiration, dizziness and involuntary muscle movement or stiffness.

Patients who stop taking troublesome drugs shouldn’t necessarily face a court-ordered commitment, she said.

She added that judges and magistrates will need to ensure the new commitment option isn't used by families as a way to control patients who happen to disagree with a doctor's recommended treatment but don't pose a danger.

Several Iowa court officials who are involved in commitments told the Register they weren’t aware of the law change.

National mental health advocate Betsy Johnson, who supported the change, said judges, magistrates and other court officials will need to be educated about it.

Johnson, a policy expert for the Treatment Advocacy Center, worked with the Carpenter family to lobby Iowa legislators on the issue.

She said in an interview that the goal is to give judges and magistrates more leeway to order people with serious mental illnesses to comply with outpatient treatment, including medication.

Such treatment can keep them stable and out of jails and hospitals, she said. Patients who didn't comply with an outpatient order could then be committed to inpatient treatment.

The broad reform bill that included the commitment law change also calls for numerous improvements to Iowa’s mental health system. Among those are new “access centers,” residential treatment programs and other alternatives for people who need mental health help but don’t need hospitalization.

Johnson would like to see the new commitment law tried out in “mental health courts,” which handle people who are accused of minor crimes stemming from mental illnesses.

Iowa now has four such courts, in Pottawattamie, Scott, Wapello and Woodbury counties. Johnson hopes Iowa will add more such programs to channel people into expanding treatment options instead of into jail.

Johnson said she understands why civil-liberties proponents have concerns about the change. She acknowledged that court-ordered outpatient treatment is a restriction on a patient’s rights.

However, she said, “it’s far less restrictive than hospitalization or jail.”

Commitment law change

A sweeping mental health reform bill passed unanimously by Iowa legislators includes language that could make it easier for families or acquaintances to obtain involuntary commitment orders for people with mental illness before they become imminent dangers to themselves or others.

Under current Iowa law, a judge or magistrate may order an involuntary commitment if a person with mental illness meets any of these three criteria:

Is likely to injure himself or others if allowed to remain at liberty without treatment.

Is likely to inflict serious emotional injury on family members or others who lack reasonable opportunity to avoid contact with the mentally ill person if he or she remains at liberty without treatment.

Is unable to satisfy the person’s needs for nourishment, clothing, essential medical care or shelter so that it is likely that he or she will suffer physical injury, physical debilitation or death.

Legislators added a fourth criterion under a law to take effect July 1. The new language says an involuntary mental health commitment may be made for a person who:

Has a history of lack of compliance with treatment and any of the following apply: 1) Lack of compliance has been a significant factor in the need for emergency hospitalization. 2) Lack of compliance has resulted in one or more serious physical injuries to oneself or others or an attempt to physically injure oneself or others.

How to seek a commitment order

Mental health commitment orders are often sought by patients' family members, but they also can be requested by others who know a person and are concerned about their well-being.

The first step is to contact the county clerk of court office. In Polk County, the clerk's office number is 515-286-3666.

At least two people who know the person must sign notarized affidavits about the person's mental condition and the risks their problem poses. A magistrate or judge will then determine whether to have the person brought in for a court-ordered evaluation and possible commitment for treatment.

Once an evaluation order is signed, sheriff's deputies generally pick up the person and bring them to a hospital. If doctors believe the person needs extensive treatment, a formal commitment hearing is held within five days. A magistrate or judge listens to medical experts and the patient, who is represented by a lawyer. Then the magistrate or judge decides whether to sign a commitment order.

Similar rules govern commitment orders for drug-abuse treatment.

About Tony Leys

Tony Leys has been a Des Moines Register staff member since 1988. He grew up in the Milwaukee area and graduated from the University of Wisconsin-Madison. He spent 10 years as a Register assignment editor before returning to reporting in 2000. Since then, he has mostly covered health care issues, including Iowa’s mental health system. He serves on the national board of the Association of Health Care Journalists. As a Register reporter, he has traveled to Afghanistan, Guatemala, Haiti, Mali and Uganda.