Issues: Civil Commitment

A growing number of women are finding themselves in custody at MCI Framingham without having been charged with, or convicted of, any crime. They are addicts and alcoholics who have been involuntarily committed for detox and treatment following a civil court determination that they pose a danger to themselves or others because of their addiction and/or alcoholism. The problem is complex and goes beyond current economic concerns, highlighting societal assumptions and prejudices about substance abuse.

Women going to Framingham for detox is nothing new, but the number of women so committed, and the length of time they spend in prison, is increasing. Under Massachusetts General Law chapter 123, section 35, the statute governing civil commitments, men and women can be ordered into treatment, men being committed to MCI Bridgewater, as a matter of course, and women going to MCI Framingham when beds are not available in other detox facilities. The commitment can be for up to 30 days, following a civil procedure that need not involve any criminal charges, although in many cases criminal charges accompany the commitment. The procedure may be initiated by any police officer, physician, spouse, blood relative, guardian, or court official.

The Institute for Health and Recovery (IHR) in Cambridge is the agency charged with placing women once they are committed. IHR Director Norma Finklestein explains that the goal has always been to keep women out of prison, but that in the past, when beds are unavailable elsewhere, women might spend a couple of days there before being placed elsewhere. Within the last six to seven months, however, the number of detox beds available to section 35 commitments has decreased by about 50 percent statewide. This, coupled with other health insurance payer problems, has caused a sharp increase in the number of women going to MCI Framingham under civil commitment.

Nadeene Platt, the section 35 coordinator at IHR, reports that between July 2002 and July 2003 a total of 50 women passed through Framingham before being placed in some other detox facility. As of November 7, 2003, 51 women had been to Framingham following civil commitments since this July. These numbers represent women sent to Framingham on pure civil commitments, with no related criminal charges pending or adjudicated.

Historically, women have not stayed long at the prison following civil commitment, but with the current shortage of detox beds statewide, the stay is increasing. What had been a couple of days, has become week or more. In one recent case, a woman stayed in prison for a full month following a civil commitment, according to Finklestein. And in some cases, staying for more than a day or two will foreclose any chance of getting the woman into another detox, as the private facilities will not take a woman who has already “detoxed.”

The prison is not equipped to handle many of these cases. Women going in on pure civil commitments, without any pending criminal charges, are isolated in the prison’s health care unit, without access to the substance abuse recovery program. The program, “First Step,” is intended for the criminally convicted prison population. Under state law, the prison’s civil and criminal population cannot mix, and the facility is unable to segregate the two populations for purposes of accessing the program. According to Finklestein, some judges understanding this complexity, will revoke bail on small offenses (if available) in order to get the women into Framingham under a “dual status,” and therefore eligible for the First Step program. However, that doesn’t always help, as the First Step program is apparently full, with a waiting list.

In some cases, the public does not understand the shortage of beds and some desperate addicts and alcoholics attempt to use the civil commitment procedure to get around the shortage of available detox beds elsewhere. In a recent case, according to Finklestein, a 68-year old woman, desperate to get into a detox, mistakenly thought that if she subjected herself to civil commitment, she’d be “guaranteed” a bed somewhere by the state. She and her family went through the procedure, and on a Friday, she was taken in handcuffs to the prison, searched, and sat for the weekend, eventually spending four days in prison.

In short, the problem is one of funding. According to a recent Boston Phoenix article, the Bureau of Substance Abuse Services expects detox programs to receive $27.9 million in FY04 ($21 million from Medicaid, and $6.9 million from the DPH), considerably less than the $54.5 million spent on substance-abuse treatment in FY03. Also, because the DPH acts as payer-of-last-resort — funding detox beds for the uninsured — the elimination of MassHealth Basic has made its mission especially difficult, with just $7.2 million currently slated for detox services.

However, cuts in the budget may reflect ideology. Some believe that legislators have chosen to deny medical benefits to an unsympathetic population - drug addicts and alcoholics simply do not elicit the same empathy as other mental health patients. Jane Manchester, Department of Public Health Assistant Regional Manager for the southeast, notes that alcoholics and addicts simply do not have the same advocates as other mental health patients.

Manchester also sees a discrepancy between the way mental health and substance abuse patients are viewed and treated under the controlling statutes, as well as once they are committed. A civil commitment for a mental health patient, without a substance abuse issue, allows lock-up for a maximum of 5 days, versus the 30 days allowed under section 35. Manchester sees this a problematic, as some judges read section 35 as providing a mandatory 30 days, rather than a maximum of 30 days, which may not be appropriate in a given case. Mental health commitments, according to Manchester, also receive a faster follow-up and reassessment than substance abuse commitments, and in many cases, individuals are going into the system under section 35 with underlying mental health problems that could be better served if they were treated as mental health patients. The problem, according to Manchester is one of inconsistent assessment. The DPH hopes that continued education of the public, as well as judges and other officials, will help.

Some are hopeful that the situation will improve as the new “MassHealth Essential” program kicks in, and would-be substance patients regain access to care outside prison. MassHealth Essential replaced MassHealth Basic, which was eliminated in April. However, the new program did not begin until July, and many previous recipients do not know that a new program is available. According to Manchester, many previous recipients have ‘disappeared,’ and although the DPH would like to see them re-enrolled, resources for public education about the new program are short.

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Need For Coherence