Does Assisted Outpatient Treatment violate civil liberties of persons with mental illness? Courts say no, and courts are the arbiters. Courts have decided that since AOT is limited to such a small group (those with a past history of arrest, violence, needless hospitalizations) that AOT is an appropriate use of police power (to protect citizenry) and parens patraie powers (to help those who can't help themselves).
Another way to look at it is that AOT generally does not affect persons with mental illness. Having a mental illness is not enough to qualify someone for AOT. At most, 123,000 people would be eligible for AOT and research shows that even when AOT is funded, only roughly one-third of those eligible will ever be put on it (41,000 individuals). There are 58 million people who had a mental illness diagnosis in past year. Therefore the maximum number of people it will affect, is .07% of individuals with mental illness.
Clearly, not all people with mental illness are being put "at risk". It does not result in the massive depravation of rights claimed by opponents.
The upside is AOT has been proven to work. AOT reduces homelessness, arrest, violence, incarceration over 70% among those enrolled. It is constitutional, does not violate civil liberties; keeps patients public and police safer, is racially neutral, has support from consumers who actually experienced it, and cuts costs to taxpayers in half.
AOT is smart policy to help deliver treatment to a very small group of the most symptomatic.
Unbiased information on serious mental illness (not "mental health") for media and policymakers. Includes info on violence and mental illness, involuntary treatment, involuntary commitment, assisted outpatient treatment, AOT, Not Guilty by Reason of Insanity, NGRI
..and what if the person in question has no mental illness but refuses to meet with psychiatrist for assessment? Reason for refusal to meet with psychiatrist for assessment could be simple, they may have been denied access to call to lawyer or family to check validity of their detention. Outpatient treatment would then be unjustified, if the citizen has no mental illness.
ReplyDeleteGreat Questions
ReplyDelete1. If the person does not have a mental illness, and someone filed a petition saying they do, that person may be punished under the law. "(p) False petition. A person making a false statement or providing false information or false testimony in a petition or hearing under this section shall be subject to criminal prosecution pursuant to article one hundred seventy-five or article two hundred ten of the penal law."
2. The petition has to go to an attorney before any exam takes place and all consumers are entitled to an attorney
"(f) Service. The petitioner shall cause written notice of the petition to be given to the subject of the petition and a copy thereof to be given personally or by mail to the persons listed in section 9.29 of this article, the mental hygiene legal service, the health care agent if any such agent is known to the petitioner, the appropriate program coordinator, and the appropriate director of community services, if such director is not the petitioner.
(g) Right to counsel. The subject of the petition shall have the right to be represented by the mental hygiene legal service, or privately financed counsel, at all stages of a proceeding commenced under this section."
If the person doesn't have a mental ilness, the attorney would make that point and no exam could be scheduled.
You can see the text of legislation at http://kendras-law.org/kendras-law/text-of-kendras-law.html
*** PLEASE NOTE: I AM NOT THE SAME POSTER AS "Anonymous" ABOVE. IT'S JUST THERE'S NO OTHER WAY I CAN SIGN IN ***
ReplyDeleteThe threshold for involuntary treatment in the United States is far, far higher than ours here in British Columbia. We are not entitled to a court hearing before being slated for indefinite assertive community treatment orders. All it takes is the signature of two psychiatrists: one to make the recommendation; and the second to rubber stamp the form.
I still have some concerns, though, with the claims made. First of all, while it may be true that some people are retrospectively grateful (or at least say they are), there are many who are not and these voices are not being heard. Also, one can only claim that AOT reduces violence if you choose to ignore the violence inflicted on the participants. And it's not clear whether your definition of violence is limited to actual convictions or merely the arbitrary assessment of a psych worker. Even in the case of violence convictions, it's not black and white, as it can be as a result of staff getting hurt as they attempt to inject a patient with unwanted medication. Such violence in any other context would be considered justified.
Your program may be racially neutral but it's certainly not socioeconomically neutral. It might be worth investigating why this is so. I am concerned that a "past history of arrest" helps make a person eligible. Unless someone's convicted of a crime, then the arrest for it ought not to be considered. Saving taxpayer money really shouldn't be used as justification. Shooting people when they turn 80 to avoid health care expenses would save taxpayer money but obviously nobody's going to suggest that. And, clearly, AOT is a violation of civil liberties. It's absurd to claim that it's not. The question is whether it's a justified violation.
If voluntary mental health care were both available and effective, most of the need for AOT would dry up. The thing is that we don't have effective services available for those who want it because we're too busy inflicting it on those who don't. Early, effective intervention can keep the train on the tracks long before it deteriorates to the point where people are talking about AOT.
Great questions. Some thoughts.
ReplyDeleteAOT does solve some violence inflicted on people with SMI, specifically suicide. In addition, much of the violence inflicted on people with SMI is a result of the illness. For instance being a substance abuser increases liklihood of victimization and AOT lowers substance abuse. There is a well developed body of literature that shows treatment reduces victimization.
2. AOT offers what some describe as the best services available. As such, many wealthy families try to get relatives who meet the criteria into it. In addition, the AOT system can and does provide treatment to those without means.
3. Families, law enforcement and psychiatric workers are the most likely victims of people with SMI. And 'zero tolerance' policies mean that someone formerly brought to the station house or ER who acts out, will now be incarcerated. It is not in keeping with the facts to suggest that violence in ERs is due to AOT allowing them to inject someone with unwanted medicine. Violence int he workplace is a big issue for psychiatric nurses and was long before AOT
AOT saves money which cna be put back in the system. Arguing that saving money is not a good reason to start a program that helps SMI is not one I share.
AOT is not an alternative to AOT. AOT is a community service. It is a court orde for those, who "as a result of his or her mental illness, unlikely to voluntarily participate in outpatient treatment that would enable him or her to live safely in the community" AOT is limited to those who will not avail themselves of services even when made readily available to them. Some people have hallucinations and delusions and anosognosia. The court order helps them.
Thanks for your quick (and respectful) response. I'm sure you're right that AOT can in some cases reduce suicide. However, psychiatric medication can also cause suicide. That's the reason for the black box warnings on some drugs.
DeleteAgain, you talk about AOT reducing victimization from outside sources but you ignore the victimization at the heart of the program. These people are being injected against their will with powerful, mind-altering substances.
“Some” might describe AOT as the best service available but all that really indicates is that we have very, very poor services.
There's a reason that families, law enforcement and psych workers are the most likely victims of the mentally ill. That's because they are the most likely to label, humiliate and degrade their charges through unwanted treatment. To be honest with you, I popped a psych nurse myself and was convicted of assault. Funny how throwing some into an isolation cell, having male security guards body slam her to the floor and then a nurse injecting with a psychotropic is just business as usual but, yeah, a patient throwing a cup of coffee at a nurse, yes, that's definitely assault. When psych nurses about being hurt, many of say “Boo hoo.”
I didn't mean to suggest that it is only AOT that causes the mentally ill to fight back. I was referring to involuntary treatment wherever it occurs and that has been going on for centuries. “Acting out” is a nebulous term. Do you mean commit a crime? If so, yes, of course they will be incarcerated.
I'd like to tell you that I part company with many of my fellow psychiatric survivors in that I do believe that emergency psychiatric intervention is sometimes justified. Where the problem lies in these long-term soul-destroying programs that foster disability and turn a crisis into a chronic illness. You'd be flabbergasted at the spectacular recovery I made from a very serious mental illness, thanks to my natural skepticism and critical thinking skills. But psychiatry doesn't believe in recovery so I had to do it myself.
Well, I'd agree with you that spending the tax dollars is good idea if I believed that it helped the seriously mentally ill. But it doesn't.
Please understand that while it's certainly true that some people are ill and don't know it, others of us deny that we are ill for a very good reason: Because we aren't! There are two troubles with the leap to diagnose the noncompliant as suffering from anosognosia: The only test for this alleged disorder is disagreeing with your doctor. You can admit that you're ill or you can deny it and your denial will be taken to be proof that you're ill. It's absurd. There is simply no mechanism available for someone like to me to say “Thanks, but no thanks.”
Saying your Supreme Court has declared that AOT is not a violation of civil liberties is a very strange position to fall back on. The issue of medical civil liberties should be dealt with by bioethicists and human rights groups, not judges. I'd also like to point out that your Supreme Court also thinks that executing criminals does not constitute cruel and unusual punishment but that doesn't make it so.
I appreciate your efforts in trying to help the mentally ill. I do wish, though, that the voices of the mentally ill could be heard. What worked for me? What might work for others? What's the very least intrusive treatment we can offer? So, so much we can do.
Wanted to add quickly, in case you're likely to say that my story involves a rare misdiagnosis, it does not. I was enmeshed in the psych system for 10 years, wasting God knows how many tax dollars.
DeleteI went in with situational depression, reacted badly to medication (as many of us do), exhibited mania as a result, was upgraded to bipolar and then later schizophrenic, all of which appears to have been the result of psych meds and related abuse.
Psychiatry is far from a science. When it can demonstrate that people on average are better off with treatment than without, I'll change my mind on the AOT issue.
There's been some research done in the UK recently that suggests that AOT isn't all it's cracked up to be. In fact, one of the earliest proponents of it has come full circle and called it a failure.
ReplyDeleteSome information about research on the UK equivalent of AOT is available here: http://www.communitycare.co.uk/2013/03/26/community-treatment-orders-fail-to-cut-mental-health-hospital-readmissions-major-study-finds/
But all this misses the point which is that if effective, voluntary care and support were available in the first place, there would be very little need for involuntary treatment. When someone's actively psychotic or suicidal, then hospitalization is probably the only humane option. However, once stabilized, the patient has to be heard. Many of us when told "You WILL do this or we will MAKE you do this because we SAID so" just respond by digging in our heels, even if it means making decisions against our best interest.
There's a real art to fostering cooperation and trust with the mentally ill and unfortunately very few professionals have it. In general, though, treating people kindly and respectfully works wonders.
The Lancet study by Burns et al. at Oxford is a different kind of study. First, it randomized all patients who were “considered suitable for supervised outpatient care,” not just selected patients. Second, it did not compare the same patient with him/herself as in the before-and-after studies of AOT, but rather compared one group on CTOs with another group not on CTOs (section 17). What this study tells us is that CTOs are not needed for most patients. This is consistent with what we have been saying: AOT is only needed for a small number (e.g. one percent) of individuals with serious mental illnesses, a highly select and problematic group. We thus agree with the Lancet results that there is no reason to use AOT widely.
DeleteOther observations:
· How different are CTOs and AOTs? CTOs, for example, do not allow for involuntary medication.
· In the past, European patients have been more medication compliant than American patients, i.e., they do what the doctor tells them. I suspect this is still the case.
· Since this was an open study, clinicians knew who was on CTOs and who was not. Did clinicians opposed to using CTOs, of which there are many, make a special effort to supervise the patients not on CTOs so that CTOs would appear to be less effective?
· The 13 sickest patients in this study were never discharged from the hospital and thus were not counted.
· 23% (100 of 442) of the patients initially deemed to be eligible to participate in this study refused to take part (91 patients) or “lacked capacity” (9 patients), as noted by Jeffrey Geller. Were these the ones for whom CTOs would have made a difference, e.g., paranoid schizophrenia with anosognosia and non-compliance?
· The authors acknowledge in the Discussion that an additional unknown number of patients who could have been eligible for the study were not included if “patients’ families had expressed strong preferences.” This preference was most likely in favor of CTOs, thus making it impossible to randomize them? These may well have been the patients who were most likely to benefit from CTOs but they were not included in the study.
· Among the 124 patients actually put on CTOs, in half the CTO was not renewed after the first 6 months. In the North Carolina study of AOT, the effect on decreased hospital admissions did not become evident until after 6 months.
· The authors of this study appear to be biased against AOT (and presumably CTOs). For example, they cite the 1999 Swartz et al. study twice as having shown no difference “in the primary outcome measure of readmission rates.” This is not true. The Swartz et al. study was purposefully planned to continue for one year and reported that “subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmission and 20 fewer hospital days than control subjects.”
· The effectiveness of AOT has been shown not only for decreasing rehospitalizations (6 studies), but also for decreasing homelessness (1 study); arrests (2 studies); incarceration (1 study); violent behavior (2 studies); and it saves money (2 studies).
· Bottom line: The Lancet study says nothing about the effectiveness of AOT for highly selected patients. It does confirm TAC’s position that AOT should not be indiscriminately used for large number of patients. And it confirms the importance of generating as much research as possible to demonstrate its effectiveness.
PART 1
ReplyDeleteBetter voluntary care would cut down the need for AOT, but not eliminate the need. Hinkely was self directing his care when he decided the best way to get a date with Jodi Foster was to shoot President Reagan.
American studies show AOT works. See
http://mentalillnesspolicy.org/kendras-law/research/kendras-law-studies.html
http://mentalillnesspolicy.org/states/california/llresultsin2counties.html
and
http://mentalillnesspolicy.org/aot/outpatient-commitment-research.html
Community Treatment Orders (CTO) in England don't involve a judge and are therefore not comparable to AOT. The CTO program in England really just compared short term coercion with longer term coercion, and found no difference. They didn't compare coerced care with non coerced care.
Thank you for the info on CTOs. I was absolutely not aware they did not involve forced medication. It makes me wonder what the "treatment" part of CTO is, then. Can you really force a person into psychotherapy?
DeleteAnyway, I've already said that AOT is way less intrusive and much more fair than what we call ACT up here. The chance to speak before a judge would dispel most of my fears about the program IF the judge genuinely gave weight to the patient's testimony. I would hope an effective legal advocate would be available to ensure that. Also, I'd like to know more about what constitutes "violence." Does merely an alleged offence count?
Please don't pull out a John Hinckley as representing the average seriously mentally ill person. That's an absurd characterization of an entire segment of our population. If the Treatment Advocacy Center was really interested in saving lives, they'd dump their research and devote their careers to getting people out of single occupancy vehicles and into public transit. It's not X number of saved lives that Fuller Torrey is after. It's the fame and glory of being named as the one who saved us from all those horrible, smelly, dangerous schizophrenics.
Funny you mention Kendra's Law given that Kendra's killer, Andrew Goldstein, had been unsuccessfully seeking voluntary care before this tragedy! How many others had been turned away from care before getting so out of control? It certainly happened to me.
Seriously, I do believe you that AOT "works" in the sense that people cause less trouble. However, that's true for just about anybody you put on antipsychotics. Targeting people on the basis of their mental status is just as abhorrent as targeting on the basis of race. In fact, race is a better indicator of violence then mental illness is but no sane person is suggesting structuring policy that way.
And the ultimate problem remains which is that a psychiatric diagnosis is merely a fluid and arbitrary judgement. Without an objective test to confirm or deny, we run the risk of forcing the wrong people into treatment. Remember the old legal saying "Better that 1,000 guilty men go free ...."? It also applies here.
Even you acknowledge that improved voluntary care would reduce the need for AOT. If the ultimate goal is good care and safety, wouldn't it make more sense just to concentrate on that? Neither of us nor anybody else knows how much the need for AOT could be reduced by good care until we provide good care!
Came across this as I was researching the claim of racial neutrality:
DeleteRacial Characteristics From NYC Census
NYC Pop. Census Kendra NYC Commitment
African Am. 15.9% 36%
Latino(a) 17.6% 38%
Asian 12.7% 3%
White 65.7% 23%
If it's accurate, it's troubling.
Sorry that the formatting didn't work out. The two extremes in the table are that African Americans represent only 15.9% of the population but are 36% of those committed under Kendra's Law. Whites, by contrast, comprise 65.7% of the general population but are only 23% of those committed under Kendra's Law.
DeleteI am also wondering if the legal threshold for AOT is the same as for involuntary hospitalization. Up here, they are ostensibly the same but in practice it's pretty easy to get someone to "consent" to community treatment. You just have to threaten them with hospitalization and they'll sign whatever you want.
DeleteOne issue that hasn't been addressed (I don't think) is that if the numbers of people being coerced under AOT/ACT, etc. reach the tipping point, there will not be enough beds to hospitalize them should they fail to comply. In BC, we are likely at this point already. It's a situation begging for civil disobedience (everybody deny their care team access at the same time) and the results could be chaotic.
This is just bad policy for so many reasons. Perhaps I shouldn't even be discussing it with you. If you had seen me when I was so ill, you likely would have pegged me as an AOT candidate. That's the real problem. The seriously mentally ill are not given a chance to recover. Had I believed what I was told, I would have agreed that I was neurologically defective and that the best I could hope for was to rent an inexpensive apartment somewhere and collect welfare. This is not an exaggeration! That's actually what they told me. The system trains people to become chronically disabled. Meanwhile, I'm an A+ student and have every reason to believe I'll have the career that I want, the home that I want, the friends that I want, the life that I want. The psychiatric system would have robbed me of all that. I wonder how many people weren't so lucky as me.
I'll bow out now before I overstay my welcome. May I say, though, how refreshing it is to actually discuss these issues in a fair and civilized fashion? The extremists are there on both sides and they add absolutely nothing to the discussion. From the wackos on my side, I know of people who think it should be illegal to intervene in a suicide. From the wackos on yours, I know of others (NRA members, mostly) who think the seriously mentally ill should be institutionalized for life, no matter the circumstances. So, thanks again.
ReplyDeleteSorry, one last thought ... it's probably true that atypical antipsychotics reduce dysfunctional and/or violent behaviour. That is why they're used as chemical restraints on psych wards and in nursing homes. However, in terms of the numbers of people chronically disabled by mental illness, it is clear that conventional treatment worsens outcomes in the long term. I know lots of people (including myself) who have declined their psychiatric labels and associated treatment and whose lives have improved immeasurably as a result. Housing First strategies are far more promising than AOT.
ReplyDeleteI have some questions regarding my son and his treatment. Is there a way or are you willing to answer some questions for me? If so how can I get in touch with you?
DeleteI am not a doctor, not a lawyer, and have no staff. So the best thing to do is to review the information at http://mentalillnesspolicy.org which may have the answers to your questions. I wish I could be more helpful, but that really is the best info out there. Good luck with your son.
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ReplyDeleteMental health is important when it comes to taking care of health. Health and mental state are both connected to each other. If your mind is free of emotional and mental obstacles then you can live a healthy life.
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