Assisted Outpatient Treatment
Reschackling Road Tripping Back to the Asylum:
Restraints On Us All
Judi Chamberlin, Confessions of a Non-Compliant Patient
“I tried hard to be a good patient. I saw what happened to bad patients: they were the ones in the seclusion rooms, the ones who got sent to the worst wards, the ones who had been in the hospital for years, or who had come back again and again. I was determined not to be like them. So I gritted my teeth and told the staff what they wanted to hear. I told them I appreciated their help. I told them I was glad to be in the safe environment of the hospital. I said that I knew I was sick, and that I wanted to get better. In short, I lied. I didn’t cry and scream and tell them that I hated them and their hospital and their drugs and their diagnoses, even though that was what I was really feeling. I’d learned where that kind of thing got me – that’s how I ended up in the state hospital in the first place. I’d been a bad patient, and this was where it had gotten me. My diagnosis was chronic schizophrenia, my prognosis was that I’d spend my life going in and out of hospitals.
I’d been so outraged during my first few hospitalizations, in the psychiatric ward of a large general hospital, and in a couple of supposedly prestigious private psychiatric hospitals. I hated the regimentation, the requirement that I take drugs that slowed my body and my mind, the lack of fresh air and exercise, the way we were followed everywhere. So I complained, I protested, I even tried running away. And where had it gotten me? Behind the thick walls and barred windows and locked doors of a “hospital” that was far more of a prison that the ones I’d been trying to escape from. The implicit message was clear: this was what happened to bad patients.
I learned to hide my feelings, especially negative ones. The very first day in the state hospital, I received a valuable piece of advice. Feeling frightened, abandoned, and alone, I started to cry in the day room. Another patient came and sat beside me, leaned over and whispered, “Don’t do that. They’ll think you’re depressed.” So I learned to cry only at night, in my bed, under the covers without making a sound.
My only aim during my two-month stay in the state hospital (probably the longest two months of my life) was to get out. If that meant being a good patient, if that meant playing the game, telling them what they wanted to hear, then so be it. At the same time, I was consumed with the clear conviction that there was something fundamentally wrong here. Who were these people that had taken such total control of our lives? Why were they the experts on what we should do, how we should live? Why was the ugliness, and even the brutality, of what was happening to us overlooked and ignored? Why had the world turned its back on us?
So I became a good patient outwardly, while inside I nurtured a secret rebellion that was no less real for being hidden. I used to imagine a future in which an army of former patients marched on the hospital, emptied it of patients and staff, and then burned all the buildings to the ground. In my fantasy, we joined hands and danced around this bonfire of oppression. You see, in my heart I was already a very, very bad patient!”
You may ask yourself as you read through the available literature, what is so wrong with being integrated into the community as opposed to being in a dedicated facility of some type. The intentions of the Murphy Bill are vacuous or at the very least, grossly grandiose. It starts in the vein of community integration but implementation will take us back to forced and involuntary shackles and asylums.
There are currently, as of this writing, 45 US States which practice Assisted Outpatient Treatment (AOT). The US Supreme Court identifies involuntary civil commitment to a psychiatric facility as a, “… massive curtailment of liberty” meanwhile emphasizing “involuntary commitment to a mental hospital, like involuntary confinement of an individual for any reason is a deprivation of liberty which the State cannot accomplish without due process of law.” The US Supreme Court can not find for, “… constitutional basis for confining such persons involuntarily if they are dangerous to no one and can live safely in freedom.” The Court holds that “the mere presence of mental illness does not disqualify a person from preferring his home to the comforts of an institution.” Assisted outpatient treatment refers to a program of services where public community based mental health treatment is delivered under a civil court order to an individual who meets criteria established by the state where the order is issued.
Criteria for assisted outpatient treatment differ by state but almost universally is for individuals who have a demonstrated difficulty adhering to prescribed mental illness treatment on a voluntary basis and, as a result, have experienced recurring negative outcomes (e.g., multiple hospitalizations, violent acts, or suicide attempts). Called by a variety of names depending on regional location references [AOT, involuntary outpatient commitment, mandatory outpatient treatment, and others] the process is most often used in conjunction with discharge from involuntary hospitalization but in some jurisdictions may also be ordered pre-emptively, prior to crisis intervention. Individuals ordered to receive AOT are, by definition, already known to public mental health systems. Because of their unique treatment patterns, individuals typically have a history of utilizing high-cost resources, often in multiple systems.
Health Management Associates, One Michigan Avenue, Building 120 N. Washington Square, #705 Lansing, MI 48933 Telephone: (517) 482-9236 www.healthmanagement.com
Mental Health America believes that involuntary treatment should only occur as a “last resort” and ought to be limited to individuals experiencing and stated imminent self or other harm and to “circumstances when no less restrictive alternative will respond adequately to the risk.” MHA opposes Assistive Outpatient Treatment (read Involuntary Commitment) intrinsically.
The Bazelon Center opposes involuntary inpatient civil commitment except for in response to an emergency, where it must be based on the usual standard for crisis presenting imminent danger to self or others, and when “… there is no less restrictive alternative.”
A MASSIVE CURTAILMENT OF LIBERTY in the land of the free.
The National Association of Rights Protection and Advocacy espouse that inpatient and outpatient civil commitment is a grievous injustice to the American people carried out by biased and broken legal systems in less informed regions where the mental health stigma and fear of “the other” prevails and an aggressive, progressive change in policy is desperately needed to meet the means of a misunderstood and misrepresented population of disabled citizens. When the justice system intervenes and a person’s civil liberties, such as whether or not to be medicated with psychoactive pharmaceuticals, citizens are subjected to the limitations of the confining, often irrelevant, subject matter in past court cases. Mental health reform will be forced to slow to the pace of the ever changing shape of the law, not patient care and medical needs.
Dr. Lauren Tenney in her foundational article on racialized aspects of the Asylum and Psychiatric Systems, dating back to the 19th century, in Psychiatric Slave No More:
Parallels to a Black Liberation Psychology (2008) broadly but precisely reported Elizabeth Parsons Ware Packard of the 19thcentury draws distinctions between Slave owner and the Asylum system:
“The insane are permitted to be treated and regarded as having no rights that any one is bound to respect — not even so much as the slaves are, for they have the rights of their master’s selfish interests to shield their own rights. But the rights of the insane are not even shielded by the principle of selfishness. What does the keeper of this class care for the rights of the menials beneath him? Nothing. His salary is secured by law whether there be few or many under the roof which shelters him. Unlike the slaveholder, he can torment and abuse unto death, and his interests are not impaired by this wreck of human faculties.” (p. 62) In fact, in Women of the Asylum (Geller Harris, 1994) several authors note comparisons to slavery. Davis (1855) writes, “Such patients were used as servants in the bad halls . . . the patients do all that part of labor which the attendants feel above doing” (p. 54). Elizabeth Stone writes, the asylum is “a system of slavery, and any crime can be done there and covered up under the garb of derangement and no one interferes” (p. 39).
Not withstanding, the Substance Abuse and Mental Health Administration (SAMHSA) is fast-tracking AOT to evidence based status. On April 18, 2016 SAMHSA issued a call for the RFA intended to solicit applicants who will develop and implement AOT programs.
This 4-year pilot program is intended to implement and evaluate new AOT programs and identify evidence-based practices in order to reduce the incidence and duration of psychiatric hospitalization, homelessness, incarcerations, and interactions with the criminal justice system while improving the health and social outcomes of individuals with a serious mental illness (SMI). This program is designed to work with families and courts, to allow these individuals to obtain treatment while continuing to live in the community and their homes.
Funding Mechanism: Grant
Anticipated Total Available Funding: $13,250,000
Anticipated Number of Awards: Up to 15 awards
Anticipated Award Amount: Up to $1 million per year
Length of Project: Up to four years
This pilot program was established by the Protecting Access to Medicare Act of 2014 (PAMA), Section 224, that was enacted into law on April 1, 2014. Within the Act, AOT is defined as “medically prescribed mental health treatment that a patient receives while living in a community under the terms of a law authorizing a state or local court to order such treatment.”
The Assisted Outpatient Treatment (AOT) initiative – otherwise known as Involuntary Outpatient Commitment – is a program carried out by OMH to meet the requirements of Kendra’s Law which requires people to comply with pharmacological management while in the community at the threat of institutionalization for non-compliance (Tenney 2008). In a 2005 report from The New York Lawyers for the Public Interest. entitled, “Implementation of ‘Kendra’s Law’ is Severely Biased” racial discrimination in the psychiatric system is addressed, noting that Blacks made up 16% of the general population, but 24% of those with a label of “Serious and Persistently Mentally Ill” (Tenney 2008).
Grants will only be awarded to applicants that have not previously implemented an AOT program. “Not previously implemented” means that even though the state may have an AOT law, the eligible applicant has not fully implemented AOT approaches through the courts within the jurisdiction that they are operating in.
In addition, grants will only be awarded to applicants operating in jurisdictions that have in place an existing, sufficient array of services for individuals with SMI such as Assertive Community Treatment (ACT), mobile crisis teams, supportive housing, supported employment, peer supports, case management, outpatient psychotherapy services, medication management, and trauma informed care. A portion of the grant funding may be used to enhance the array of services.
AOT (also known as involuntary outpatient commitment, conditional release, and other terms) involves petitioning local courts to order individuals to enter and remain in treatment within the community for a specified period of time. AOT is intended to facilitate the delivery of community-based outpatient mental health treatment services to individuals with SMI that are under court order as authorized by state mental health statute.
The AOT grant program aligns with SAMHSA’s Strategic Initiatives on Trauma and Justice and Recovery Support. For more information on SAMHSA’s six strategic initiatives, you can visit http://www.samhsa.gov/about-us/strategic-initiatives.
The AOT grant program is one of SAMHSA’s services grant programs. SAMHSA intends that its services grants result in the delivery of services as soon as possible after award. Service delivery should begin by the 4th month of the project at the latest.
AOT grants are authorized under Section 224 of PAMA. SAMHSA has consulted with the National Institute of Mental Health, the Department of Justice, the HHS Assistant Secretary of Planning and Evaluation and the Administration for Community Living on the FOA. This announcement addresses Healthy People 2020 Mental Health and Mental Disorders Topic Area HP 2020-MHMD and Substance Abuse Topic Area HP 2020-SA.
The National Alliance on Mental Illness (NAMI), a public national supporter of the Murphy Bill, endorses a weaker standard of care to AOT (read involuntary commitment). Excerpts from the Public Policy Platformn of The National Alliance on Mental Illness can be found via the NAMI Public Policy Committee of the Board of Directors and the NAMI Dept. of Public Policy and Research, found on the web at http://nami.org.
Analysis of 10 independent studies of AOT
|Study | Analysis|
|May 2011 Arrest Outcomes Associated With Outpatient Commitment in New York State Bruce G. Link, et al. Ph.D. Psychiatric Services||For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment.”|
|October 2010: Assessing Outcomes for Consumers in New York’s Assisted Outpatient Treatment Program Marvin S. Swartz, M.D., Psychiatric Services||Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.|
|February 2010 Columbia University. Phelan, Sinkewicz, Castille and Link. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Psychiatric Services, Vol 61. No 2||Kendra’s Law has lowered risk of violent behaviors, reduced thoughts about suicide and enhanced capacity to function despite problems with mental illness. Patients given mandatory outpatient treatment – who were more violent to begin with – were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.|
|March 2005 N.Y. State Office of Mental||Danger and Violence Reduced|
|Health “Kendraʼs Law: Final Report on||• 55% fewer recipients engaged in suicide attempts or physical harm to self|
|the Status of Assisted Outpatient||• 47% fewer physically harmed others|
|Treatment. “||• 46% fewer damaged or destroyed property|
|• 43% fewer threatened physical harm to others.|
|• Overall, the average decrease in harmful behaviors was 44%.|
|Consumer Outcomes Improved|
|• 74% fewer participants experienced homelessness|
|• 77% fewer experienced psychiatric hospitalization|
|• 56% reduction in length of hospitalization.|
|• 83% fewer experienced arrest|
|• 87% fewer experienced incarceration.|
|• 49% fewer abused alcohol|
|• 48% fewer abused drugs|
|Consumer participation and medication compliance improved|
|• Number of individuals exhibiting good adherence to meds increased 51%.|
|• The number of individuals exhibiting good service engagement increased 103%.|
|Consumer Perceptions Were Positive|
|• 75% reported that AOT helped them gain control over their lives|
|• 81% said AOT helped them get and stay well|
|• 90% said AOT made them more likely to keep appointments and take meds.|
|• 87% of participants said they were confident in their case manager’s ability.|
|• 88% said they and case manager agreed on what is important to work on.|
|Effect on mental illness system|
|· Improved Access to Services. AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.
· Improved Treatment Plan Development, Discharge Planning, and Coordination of Service Planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.
· Improved Collaboration between Mental Health and Court Systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.
o There is now an organized process to prioritize and monitor individuals with the greatest need;
|o AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve;
o Increased collaboration between inpatient and community-based providers.
|February 2010 Columbia University. Phelan, Sinkewicz, Castille and Link. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Psychiatric Services, Vol 61. No 2||• Kendra’s Law has lowered risk of violent behaviors, reduced thoughts about suicide and enhanced capacity to function despite problems with mental illness.
• Patients given mandatory outpatient treatment – who were more violent to begin with – were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment.
• Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.
|October 2010: Changes in Guideline- Recommended Medication Possession After Implementing Kendra’s Law in New York, Alisa B. Busch, M.D Psychiatric Services||In all three regions, for all three groups, the predicted probability of an M(edication) P(ossesion) R(atio) ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and “neither treatment,” improving 8–19 points). Some regional differences in MPR trajectories were observed.|
|October 2010 Robbing Peter to Pay Paul: Did New York State’s Outpatient Commitment Program Crowd Out Voluntary Service Recipients? Jeffrey Swanson, et al. Psychiatric Services||In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.|
|June 2009 D Swartz, MS, Swanson, JW, Steadman, HJ, Robbins, PC and Monahan J. New York State Assisted Outpatient Treatment Program Evaluation. Duke University School of Medicine, Durham, NC, June, 2009||We find that New York Stateʼs AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients.
• Racial neutrality: We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.Court orders add value: The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.
• Improves likelihood that providers will serve seriously mentally ill: It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.
• Improves service engagement: After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.
• Consumers Approve: Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.
|1999 NYC Dept. of Mental Health, Mental Retardation and Alcoholism Services. H. Telson, R. Glickstein, M. Trujillo, Report of the Bellevue Hospital Center Outpatient Commitment Pilot||• Outpatient commitment orders often assist patients in complying with outpatient treatment.
• Outpatient commitment orders are clinically helpful in addressing a number of manifestations of serious and persistent mental illness.
• Approximately 20% of patients do, upon initial screening, express hesitation and opposition regarding the prospect of a court order. After discharge with a court order, the majority of patients express no reservations or complaints about orders.
• Providers of both transitional and permanent housing generally report that outpatient commitment help clients abide by the rules of the residence. More importantly, they often indicate that the court order helps clients to take medication and accept psychiatric services.
• Housing providers state that they value the leverage provided by the order and the access to the hospital it offers.
|1998 Policy Research Associates, Study of the NYC involuntary outpatient commitment pilot program.||• Individuals who received court ordered treatment in addition to enhanced community services spent 57 percent less time in psychiatric hospitals.|
 Jennifer M. Padron, M.Ed, CPS, PhDc, Baltimore, Maryland.
 Amanda Barnabe, Baltimore, Maryland.
 The New York Times Editorial on Reinstitutionalization and Return to the Asylum, Retrieved May 1, 2016 from http://www.nytimes.com/2015/02/18/opinion/the-modern-asylum.html.
 Humphrey v. Cady, 405 U.S. 504, 509 (1972).
 Specht v. Patterson, 386 U.S. 605, 608 (1967).
 O’Connor v. Donaldson, 422 U.S. 563, 574 (1975).
 Position Statement 22: Involuntary Mental Health Treatment, Retrieved May 1, 2016 from http://www.mentalhealthamerica.net/positions/involuntary-treatment.
 This is the same standard accepted by the Bazelon Center: “The Bazelon Center opposes involuntary inpatient civil commitment except in response to an emergency, and then only when based on a stanrdard of imminent danger of significant physical harm to self or others and when there is no less restrictive alternative.” http://bazelon.org.
 Position Statement 22: Involuntary Mental Health Treatment, Retrieved May 1, 2016 from http://www.mentalhealthamerica.net/positions/involuntary-treatment.
 Bazelon Center Position Statement on AOT, Retrieved May 1, 2016.