FACT SHEET

Baker Act reform

Florida's mental health law, the Baker Act, makes it difficult for mental health professionals and families to
help people who refuse treatment for severe mental illnesses. Florida is one of only nine states that does not
allow court-ordered outpatient treatment for people with untreated severe mental illnesses. As inpatient beds
continue to dwindle and hospitals continue to close, this often means that people who are in crisis end up in
the streets or in jails instead of in treatment.

The Baker Act was created 30 years ago when we knew less about mental illnesses. Today we know that half
of those with untreated severe mental illnesses have some impaired awareness of their illness – their brain
disease actually affects their ability to understand that they are ill. The Florida Sheriffs Association is leading
the effort to reform the Baker Act to keep those who are too ill to know they need help from getting trapped in
the revolving door of short-term hospitalizations, incarcerations, victimization, and violence.

The consequences of non-treatment are horrific. More than 15,000 Floridians with untreated mental illness
are homeless. Between 7,511 and 10,798 inmates with severe mental illnesses are in Florida’s jails – more
than three times as many people as are being treated in Florida’s state psychiatric hospitals. And nationally,
people with untreated severe mental illnesses are 10 to 15 times more likely to commit suicide than the general
population – and severe and persistent mental illness is estimated to be a factor in 10 to 15 percent of violence.

Recidivist costs are escalating and draining resources. The Baker Act reform focuses on ensuring
treatment for the small, but significant group of people with severe mental illnesses who have multiple
involuntary admissions for psychiatric treatment or a history of violence. In Florida in 2002, one individual
alone accounted for 41 Baker Act examinations at an approximate cost of $81,000 – not including court costs,
law enforcement resources, or long-term treatment. The number of Baker Act examinations for recidivists
increased 50% between 2000 and 2002. There were 540 individuals with eight or more Baker Act emergency
examinations in one 24 month period (2000 to 2001), averaging at least one every three months. These
recidivists use a disproportionately high share of mental health, criminal justice and court resources.

Law enforcement officers are not mental health professionals. Even though treating severe mental
illnesses should be a medical issue, law enforcement officers rather than mental health professionals are
increasingly becoming the first point of contact for people needing treatment. Last year, law enforcement
handled more Baker Acts than burglaries. More than 100 times a day, law enforcement officers initiate the
Baker Act for people with severe mental illnesses. In nearly one-third of Florida counties in 2001, mental
health professionals did not initiate a single Baker Act petition. Nationally, conservative estimates show that
people with mental illnesses are killed in police altercations at a rate four times greater than the general
population. It is expensive and dangerous to send a law enforcement officer – even one with specialized
training – to manage a severe mental health crisis.

Court-ordered outpatient treatment works. A New York report on Kendra’s Law showed that for people
placed in assisted outpatient treatment: 77% fewer were hospitalized, 85% fewer experienced homelessness,
83% fewer were arrested, and 85% fewer were incarcerated. A Duke University study showed that long-term
assisted outpatient treatment: reduced the risk of arrest by 74%, hospitalization by up to 74%, victimization by
50%, and risk of violence by up to 50%. Court-ordered outpatient treatment can make existing services more
effective.

For more on Baker Act reform, including supportive editorials from Florida papers like The Miami Herald, The St. Petersburg
Times, and The Orlando Sentinel, visit [Link]. (10/03)

[Link]
 BAKER ACT REFORM
Experiences from Other States
41 states, but not Florida, have enacted laws that allow court-ordered outpatient treatment for people with a
severe mental illness who do not recognize their own need for treatment. Court-ordered outpatient treatment
improves treatment effectiveness and preserves individual liberties. Empirical data and anecdotal evidence
from other states’ officials demonstrate the success of such programs.
• New York’s Kendra’s Law went into effect November 1999, and has proven to be beneficial. Of those
individuals placed in six months of court-ordered outpatient treatment through December 3, 2002, 77%
fewer were hospitalized, 85% fewer experienced homelessness, 83% fewer were arrested, and 85%
fewer were incarcerated.
• A Duke University study showed that court-ordered outpatient treatment is effective: long-term
assisted outpatient treatment reduced the risk of arrest by 74%, hospitalization by up to 74%,
victimization by 50%, and risk of violence by up to 50%.
• William Martin, who was involved with implementation as “[W]e are dealing with these
the General Counsel for New York City’s Department of cases one way or another.
Health and Mental Hygiene, called Kendra’s Law, “a That is, if we do not handle the
tremendous asset in New York for ensuring that individuals cases on the civil docket for
with severe mental illnesses who were previously non- court-ordered treatment, we
compliant are able to get the sustained treatment they need.” will have to deal with them on
• Wisconsin Circuit Court judge Ralph M. Ramirez described the criminal docket when
court-ordered outpatient treatment as a “win-win-win crimes are committed, often as
situation.” Judge Ramirez explained that court-ordered a result of the untreated
outpatient treatment serves as a means of ensuring that symptoms of their illness.”
individuals with a severe mental illness who need treatment - Wisconsin Circuit Court judge
but who otherwise refuse it: Ralph M. Ramirez
1) are not arrested by law enforcement, which reduces the risk of injury and protects public
safety;
2) are not institutionalized in jails or hospitals, which saves money; and
3) are treated as patients in their communities, which preserves their dignity.
• Judge Randy T. Rogers, a Butler, Ohio, judge who has many cases involving people with a severe
mental illness, called court-ordered outpatient treatment, “an effective tool to help sustain a group of
individuals in the community with persistent impairment in decision-making who would otherwise
continue to revolve through the doors of hospitals and jails.”
• Fritz Mielke, assistant corporation counsel for Waukesha County, Wisconsin, explained that his county
consistently uses court-ordered outpatient treatment and has seen a “net result of enhanced
compliance” and “a great reduction in recidivism.”

For more on Baker Act reform, including supportive editorials from Florida papers like The Miami Herald, The St. Petersburg
Times, and The Orlando Sentinel, visit [Link]. (10/03)

[Link]
 BAKER ACT REFORM
Supporters believe reform can save lives
The Florida Sheriffs Association is leading the effort to reform the Baker Act to keep those who are too ill to
know they need help from getting trapped in the revolving door of short-term hospitalizations, incarcerations,
victimization, and violence. The Sheriffs’ efforts have received support from many constituencies, including
the editorial boards of some of Florida’s biggest newspapers, others in law enforcement, family members and
advocates, and professional organizations.

Editorial boards:

The Miami Herald says “Reform the Baker Act: Give judges, counselors more leeway”:
“The well-targeted proposal focuses on a small group of the mentally ill – about 7,500 – who already
are cycling in and out of the system, at great expense to state taxpayers, but getting little help. The
proposal could break that ineffective cycle .… Lawmakers should update the Baker Act legislation in
this coming session. It is a humane and sensible response that supports better protection of the public's
safety.” –Feb. 12, 2003

The Orlando Sentinel says “Judges should be allowed to order treatment for disturbed behavior”:
“The Florida Sheriff's Association proposes a modest reform aimed at the population that costs the
criminal-justice system the most -- those with serious mental illness who have been repeatedly arrested
or subject to the Baker Act. The measure deserves approval in the upcoming legislative session …. The
sheriffs show political savvy in not seeking additional funding to implement the law in this financially
austere year. They argue, convincingly, that the measure could end up saving money in the criminal
justice system. In addition, the measure doesn't require that additional services be provided. Judges
would not be able to order treatment if services in an area were inadequate or unavailable.”
–Jan. 19, 2003

The St. Petersburg Times says “Reform the Baker Act”:

“[I]t makes sense to reform the law now. It would give judges one more option in dealing with repeat
Baker Act cases, and if the process works, there will be even more motivation for lawmakers to expand
mental health services …. A recent study in a state with such a law found that people with a history of
mental illness and a police record have a 74-percent reduced risk of arrest when they stick to a long-
term care plan. That means fewer chances for harm, and it is reason enough for the Legislature to act.”
– Nov. 26, 2002

Law enforcement

Sheriff Donald Eslinger:

“There is a serious downside to not adopting the Baker Act reforms proposed by the Florida Sheriff's
Association: continued arrests, homelessness, victimization, violence and suicide by people who,
because of their mental illness, do not recognize their own need for treatment …. In 2000 an estimated
7,500 individuals were ``Baker Acted'' two or more times, accounting for about one-third of all adult
cases. This is the same group that accounts for an ever-increasing workload for mental health
professionals, law enforcement and both criminal and civil court judges now. The proposal is designed
to ensure more effective treatment for this population.” – “Effective Treatment,” The Tampa Tribune,
Feb. 24, 2003

[Link]
Florida Police Chiefs:
“The Florida Police Chiefs Association strongly supports legislation which will revise and strengthen
the Florida Mental Health Act (Baker Act) to allow for court ordered community treatment to
individuals who refuse to accept needed treatment for a severe mental illness.” – Florida Police Chiefs’
Resolution 2002-2

Florida Sheriff Ken Jenne on John Beraglia, who died in the Broward County jail:
"Here is a man who has been arrested more than 120 times for petty crimes, a man who was psychotic,
a man whose acting out posed a clear threat to those around him. A mental institution would have been
a far better place for John than a jail. ... The truth is, the urban jails of America have become the
asylums of [today], and they ought not to have these people in them." – Sun-Sentinel of Fort
Lauderdale, Oct. 28, 2001

Family members and advocates

Rachel Diaz, Miami, family member and executive director of NAMI Miami:
“Florida law ignores excellent possibilities of effective treatment with new medicines and places the
civil right to refuse treatment above the humanitarian right of the state to mandate psychiatric care.
Ordering medical care gives the mentally ill a chance for a better life not available any other way.
When these individuals are treated, they benefit and so do the families and the community; and the state
saves money.” – “Reform Baker Act to help the mentally ill,” The Miami Herald, Jan. 3, 2003

Rhonda Atkins, Sarasota, family member:

“For years I have watched [my daughter] cycle in and out of treatment, powerless to help her because
of Florida law, which requires her to be "dangerous" before the court can order her to treatment. Then
she can only get help on an inpatient basis …. All the police training in the world won't solve the
problem of people who need help denied them by their own state laws.” – “Law Needs Repair,” The St.
Petersburg Times, Nov. 17, 2002

Professional groups

Florida Council for Behavioral Healthcare:

“The legislation proposed by the Sheriff’s Association goes far beyond helping protect law enforcement
officers and reducing the high costs of treating people with mental illnesses in Florida’s county jails. It
also offers a more humane and less coercive way to provide treatment and support services to people
who have been severely disabled by a mental illness. At present, the system is often unable to help
these people until after they have harmed themselves or others. This is a tragedy for the individuals
involved, as well as for those harmed by behavior related to a mental illness. It is especially tragic when
we know that provision of earlier treatment services can not only reduce an individual’s recovery
period but also prevent future psychotic breaks.” – Letter of support, March 6, 2003

Florida Coalition for the Homeless:

“[A]ssisted outpatient treatment for mentally ill homeless people would increase compliance with prescribed
treatment and thus ensure greater success in securing and sustaining access to adequate housing as an
alternative to jail and the streets …. therefore, be it resolved that the Florida Coalition for the Homeless
seeks to improve the quality of life for the public and homeless persons with severe mental illnesses by
supporting the Florida Sheriffs’ Association’s proposed Baker Act reform to include an earlier intervention
standard and assisted outpatient treatment for Baker Act recidivists.” – Resolution of support, Dec. 4, 2002

For more on Baker Act reform, visit [Link]. (10/03)

[Link]
 BAKER ACT REFORM
Consequences reduced, but not in Florida
The Florida Sheriffs Association is leading the effort to reform the Baker Act to keep those with untreated
severe mental illnesses who are too ill to know they need help from getting trapped in the revolving door of
short-term hospitalizations, incarcerations, victimization, and violence.

You only have to pick up a Florida newspaper to confirm that Baker Act reform is long overdue. Newspaper
accounts provide ample evidence of the tragedies resulting from Florida's outdated law. So far in 2003, other
states have been using assisted outpatient treatment to reduce hospitalization, homelessness, arrests,
incarceration, harmful behavior and victimization. But in Florida, people with severe mental illnesses are still
subject to a bad law. The result is, unfortunately, all-too predictable.

Hospitalization Reduced - But Not in Florida:

IN NEW YORK Need for hospitalization reduced by 77 percent (Kendra's Law report).

IN NORTH CAROLINA Need for hospitalization reduced by 57 percent - 72 percent (Duke Studies).

IN FLORIDA Alan Houseman had been hospitalized under the Baker Act thirteen times. His
disproportionate use of emergency psychiatric services ended when he was shot and killed in an altercation
with a Tampa police officer after stopping medication. (The Associated Press, March 10, 2003, Tampa
Tribune, March 10 and 11, 2003.)

Homelessness Reduced - But Not in Florida

IN NEW YORK Homelessness reduced by 85 percent (Kendra's Law report).

IN FLORIDA Robert Stephen Mills III, 19, was homeless after moving out of his mother's house because he
would not take medication for his bipolar disorder. Miami-Dade police shot and killed him after he lunged
at them with a shard of glass. His mother tried to ''Baker Act'' her son at least twice last year, but each time
the courts sent him home. (Miami Herald, February 10, 2003.)

Arrests Reduced - But Not in Florida

IN NEW YORK Arrests reduced by 83 percent (Kendra's Law report).

IN NORTH CAROLINA Arrests reduced by 74 percent (Duke Studies).

IN FLORIDA A man was arrested after walking into a Jacksonville bank and demanding $50,000 to get
something to eat. He told police he had schizophrenia, but stopped taking medication. After he was
arrested he sank to his knees and said "I'm Jesus and my people should take care of me." (Florida Times
Union, April 16, 2002.)

Incarceration Reduced - But Not in Florida

IN NEW YORK Arrests reduced by 83 percent (Kendra's Law report).

IN FLORIDA Ryan Thomas Green, 19, remains in Escambia County Jail on charges of first-degree murder
and attempted first-degree murder because his trial has been delayed pending psychological evaluations.

[Link]
 He is accused of going on a 30-minute shooting spree in a stolen car, killing a 59-year-old retired
Pensacola police officer and critically injuring a 26-year-old house painter. He was diagnosed with
schizoid tendencies and bipolar disorder, and had quit taking his medications in December. (Pensacola
News Journal, February 26 and April 2, 2003.)

Violence Reduced - But Not in Florida

IN NEW YORK Harm to others reduced by 44 percent (Kendra's Law report).

IN NORTH CAROLINA Violence reduced by 50 percent (Duke Studies).

IN FLORIDA J.C. Conyers, 40, who had been diagnosed with schizophrenia, was shot and killed by an
Orange County deputy after he attacked two deputies with a pitchfork-like tool. He had been arrested at
least 21 times and convicted several times for crimes including aggravated battery, driving with a
suspended license and dealing in stolen property. His brother explained that he had his biggest problems
when he didn't take his medication. (Orlando Sentinel, May 29, 2003.)

Victimization Reduced - But Not in Florida

IN NORTH CAROLINA Victimization reduced by 50 percent (Duke Studies).

IN FLORIDA David Bruce Wells is charged with second-degree murder in the beating death of his mother,
Colleen Francis Wells. Both David and his mother, the victim, were diagnosed with schizophrenia and
were known to stop taking medication. David Wells had been previously involuntarily committed and had
an extensive criminal history. (Florida Today, April 1, 2003.)

The results of implementing assisted outpatient treatment are clear - and so is the fact that the list of
Florida tragedies will continue to grow without Baker Act reform.

The full report on Kendra's Law is available at [Link]

For more on Baker Act reform, visit [Link]. (10/03)

[Link]
 BRIEFING PAPER FROM THE TREATMENT ADVOCACY CENTER
Impaired awareness of illness (anosognosia):
A major problem for individuals with
schizophrenia and bipolar disorder
SUMMARY: Impaired awareness of illness (anosognosia) is a major problem because it is the single
largest reason why individuals with schizophrenia and bipolar disorder do not take their medications. It
is caused by damage to specific parts of the brain, especially the right hemisphere. It affects
approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar
disorder. When taking medications, awareness of illness improves in some patients.

***

What is impaired awareness of illness?

Impaired awareness of illness means that the person does not recognize that he/she is sick. The person
believes that their delusions are real (e.g. the woman across the street really is being paid by the CIA to
spy on him/her) and that their hallucinations are real (e.g. the voices really are instructions being sent by
the President). Impaired awareness of illness is the same thing as lack of insight. The term used by
neurologists for impaired awareness of illness is anosognosia, which comes from the Greek word for
disease (nosos) and knowledge (gnosis). It literally means "to not know a disease."

How big a problem is it?

Many studies of individuals with schizophrenia report that approximately half of them have moderate or
severe impairment in their awareness of illness. Studies of bipolar disorder suggest that approximately
40 percent of individuals with this disease also have impaired awareness of illness. This is especially
true if the person with bipolar disorder also has delusions and/or hallucinations.
Amador XF et. al. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives of General
Psychiatry 51:826-836, 1994.

Fennig S et. al. Insight in first-admission psychotic patients. Schizophrenia Research 22:257-263, 1996.

Is this a new problem? I've never heard of it before.

Impaired awareness of illness in individuals with psychiatric disorders has been known for hundreds of
years. In 1604 in his play "The Honest Whore", playwright Thomas Dekker has a character say: "That
proves you mad because you know it not." Among neurologists unawareness of illness is well known
since it also occurs in some individuals with strokes, brain tumors, Alzheimer's disease, and
Huntington's disease. The term anosognosia was first used by a French neurologist in 1914. However in
psychiatry impaired awareness of illness has only become widely discussed since the late 1980s.
Prigatono GP and Schacter DL. eds. Awareness of Deficit After Brain Injury. New York: Oxford University Press, 1991.

Is impaired awareness of illness the same thing as denial of illness?

No. Denial is a psychological mechanism which we all use, more or less. Impaired awareness of illness,
on the other hand, has a biological basis and is caused by damage to the brain, especially the right
brain hemisphere. The specific brain areas which appear to be most involved are the frontal lobe and
part of the parietal lobe.

[Link]
 Flashman LA. Specific frontal lobe subregions correlated with unawareness of illness in schizophrenia. Journal of
Neuropsychiatry and Clinical Neuroscience 13:255-257, 2001.

Amador XF and David AS eds. Insight and Psychosis. New York: Oxford University Press, 1998. A revised edition of this book
is scheduled for publication in 2004.

Can a person be partially aware of their illness?

Yes. Impaired awareness of illness is a relative, not an absolute problem. Some individuals may also
fluctuate over time in their awareness, being more aware when they are in remission but losing the
awareness when they relapse.

Are there ways to improve a person's awareness of their illness?

Studies suggest that approximately one-third of individuals with schizophrenia improve in awareness of
their illness when they take antipsychotic medication. Studies also suggest that a larger percentage of
individuals with bipolar disorder improve on medication.
Jorgensen P. Recovery and insight in schizophrenia. Acta Psychiatrica Scandinavica 92:436-440, 1995.

Why is impaired awareness of illness important in schizophrenia and bipolar disorder?

Impaired awareness of illness is the single biggest reason why individuals with schizophrenia and
bipolar disorder do not take medication. They do not believe they are sick, so why should they? Without
medication, the person's symptoms become worse. This often makes them more vulnerable to being
victimized and committing suicide. It also often leads to rehospitalization, homelessness, being
incarcerated in jail or prison, and violent acts against others because of the untreated symptoms, as
described in other Briefing Papers.
Lin IF. Insight and adherence to medication in chronic schizophrenia. Journal of Clinical Psychiatry 40:430-432, 1979.

Lacro J et al. Prevalence and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review
of recent literature. Journal of Clinical Psychiatry 63:892-909, 2002.

McEvoy JP et. al. Insight and clinical outcome of schizophrenia patients. Journal of Nervous and Mental Disorder 177:48-51,
1989.

Impaired awareness of illness is a strange thing. It is difficult to understand how a person who is sick
would not know it.

Impaired awareness of illness is very difficult for other people to comprehend. To other people, a
person's psychiatric symptoms seem so obvious that its hard to believe the person is not aware he/she
is ill. Oliver Sacks, in his book The Man Who Mistook His Wife for a Hat, noted this problem:
It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to
know their own problems...And it is singularly difficult, for even the most sensitive observer, to
picture the inner state, the 'situation' of such patients, for this is almost unimaginably remote
from anything he himself has ever known.

[Link]