Assisted outpatient treatment: Myth vs. reality

SUMMARY: Assisted Outpatient Treatment (AOT) programs allow judges to order certain mentally ill individuals to stay in treatment as a condition of living in the community. While many view it as less-restrictive, less-expensive, than it’s alternative, inpatient commitment, others raise concerns. Most are based on misinformation or misunderstanding. This document addresses those concerns.

MYTH: Assisted outpatient treatment is about “forced” treatment.

REALITY: There is no provision for forced treatment in Kendra’s Law. In New York State individuals must meet the criteria established in Rivers v. Katz in order to be forced treated. That decision is not superceded by Kendra’s Law.

MYTH: Assisted outpatient treatment is going to fill hospital wards.

REALITY: Assisted outpatient treatment (AOT) is designed to help people function successfully out of the hospital. Participants in New York’s AOT program, Kendra’s Law, experienced a 77 percent decrease in psychiatric hospitalizations while in the program, as compared to the three years prior to AOT. In a North Carolina study, long-term AOT combined with routine outpatient services (three or more outpatient visits per month) reduced hospital admissions by 57 percent and length of hospital stay by 20 days compared to individuals without court-ordered treatment. For individuals with schizophrenia and other psychotic disorders, long-term AOT reduced hospital admissions by 72 percent and length of hospital stay by 28 days compared to individuals without court-ordered treatment.

MYTH: Assisted outpatient treatment does not work.

REALITY: Studies and experiences in Arizona, Hawaii, Iowa, New York, North Carolina, and other states prove assisted outpatient treatment works. For example, in New York, during the course of court-ordered treatment when compared to the three years prior to participation in the program, AOT recipients experienced far less hospitalization, homelessness, arrest, and incarceration. Specifically:

  • 74 percent fewer experienced homelessness;
  • 77 percent fewer experienced psychiatric hospitalization;
  • 83 percent fewer experienced arrest; and
  • 87 percent fewer experienced incarceration.

A 1998 study of a pilot AOT program at Bellevue Hospital in NYC showed assisted outpatient treatment cut hospital stays in half, from 101 days in the 11 months following discharge for those without court orders to 43 days of hospitalization for those with them.

MYTH: Assisted outpatient treatment will bust the budget.

REALITY: Assisted outpatient treatment is not expensive because it does not mandate any services that individuals with severe mental illnesses are not already eligible for (such as case management, medications, or rehabilitation).

The savings in hospital costs, forensic costs and other costs far offset any incremental expense of assisted outpatient treatment. In an article in Schizophrenia Bulletin, Drs. Peter Weiden and Mark Olfson calculated that nationwide, over two years, the direct costs of rehospitalization attributable to neuroleptic noncompliance is approximately $700 million.

MYTH: Assisted outpatient treatment is unconstitutional.

REALITY: Forty-two states and the District of Columbia have assisted outpatient treatment laws – some almost 20 years old. The U.S. Supreme Court has not overturned any of these laws. Courts have ruled AOT is an appropriate exercise of police powers or parens patraie powers.

AOT laws have been upheld wherever challenged. For instance, Kendra’s Law in New York has been upheld through a series of challenges. With the latest ruling In the Matter of K.L., a total of twelve judges in New York have examined the constitutionality of Kendra’s Law; each of them has found the law constitutional, including the state’s highest-ranking ones.

MYTH: Assisted outpatient treatment infringes on civil liberties.

REALITY: It is the illness and its consequent symptoms, not the treatment that restricts civil liberties. Assisted outpatient treatment minimizes the need for incarceration, restraints, and involuntary inpatient commitment, allowing individuals to retain more of their civil liberties. Treatment can free individuals from the “Bastille of their psychosis” and enable them to engage in a meaningful exercise of their civil liberties.

MYTH: AOT discriminates

REALITY: Kendra’s Law is racially and ethnically neutral. A group that opposes Kendra’s Law created their own ‘study’ that purported to show Kendra’s Law is disproportionately applied to African Americans. In response, the NYS legislature funded an independent study. That study concluded:

  • 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.
  • Parallel analyses for Hispanics and other minority populations show this same pattern and no appreciable racial disparities are evident in selection of these groups for AOT.
  • Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity.

In spite of this, opponents still quote the non-scientific study in the hopes or raising the ugly specter of racism in their effort to defeat Kendra’s Law. It should be noted that Kendra’s Law reduces incarceration, arrest, homelessness and 80% of those in it say it helps them get well and stay well.

Myth: Kendra’s Law requires people to take life threatening medications.

REALITY: Medicines used to control neurobiological disorders have been determined by the U.S. Food and Drug Administration to be safe when used according to labeling requirements. Overdosing on these medicines is difficult. However, all medicines, including those used to treat neurobiological disorders, have different efficacy and side effect profiles. The practice of balancing the side effects of the medicines with the likely benefits is not superceded by assisted outpatient treatment laws. Medications are one of the services a judge may order, but the judge is not required to. The only mandatory service is case managment.

MYTH: If we had more community treatment, we wouldn’t need assisted outpatient treatment.

REALITY: There is no doubt that an improved community-based system would reduce the number of individuals who need intervention. AOT is not an alternative to community treatment; it is a way to see that community treatment is utilized by those who lack insight into their illness (anosognosia). Even if psychiatric services were plentiful, attractive, and culturally relevant, some individuals with serious mental illnesses will not utilize them . To be eligible for Kendra’s Law, you must have previously refused treatment.

MYTH: All consumers oppose assisted outpatient treatment.

REALITY: There are a variety of viewpoints within the consumer community. Many consumers support assisted outpatient treatment. The Treatment Advocacy Center has consumers on its board and staff, and in its membership, all of who support it.

The most compelling argument for assisted outpatient treatment comes from those consumers who’ve actually participated in an AOT program. Researchers with the New York State Psychiatric Institute and Columbia University conducted face-to-face interviews with AOT recipients in New York to assess their opinions about the program, perceptions of coercion or stigma associated with the court order and, most importantly, quality of life as a result of AOT. While the interviews showed that the experience of being court-ordered into treatment made about half of recipients feel angry or embarrassed, after they received treatment, AOT recipients overwhelmingly endorsed the effect of the program on their lives:

  • 75 percent reported that AOT helped them gain control over their lives;
  • 81 percent said that AOT helped them to get and stay well; and
  • 90 percent said AOT made them more likely to keep appointments and take medication;
  • 87 percent said they were confident in their case manager’s ability to help them;
  • 88 percent said that they and their case manager agreed on what is important for them to work on.

MYTH: Andrew Goldstein, the man who pushed Kendra Webdale into the train, tried to get help but was repeatedly refused community and voluntary services.

REALITY: The New York Times did a story on Andrew Goldstein that started at the point at which he was turned away from voluntary services. Had the author started his story earlier, Mr. Goldstein would clearly have been helped by AOT.

According the New York State Commission on Quality of Care for the Mentally Disabled, Mr. Goldstein received 199 days of inpatient and emergency room services, on 15 different occasions, in six different hospitals from 1997 to 1999 (the year Kendra was killed). In 1998 alone, the State of New York spent $495,075 for his mental health and residential care.

The two years prior to Kendra Webdale’s death were characterized by repeated emergency room visits, medication noncompliance after release from the hospital, and at least eight incidents of unprovoked violence against others, most likely while not in treatment. New York did not have assisted treatment at the time, and there was little that could be done to ensure he stayed in it. WhenMr. Goldstein did request services, he either changed his mind before arrangements could be made or failed to follow through. This is the type of person AOT was designed to help

MYTH: AOT programs such as Kendra’s Law destroy the therapeutic relationship between the consumer and his or her treatment team.

REALITY: This unsubstantiated myth is often perpetuated by opponents of AOT. Actual data from studies of individuals participating in AOT programs show that AOT fosters working alliances between recipients and their case managers, while ensuring that individuals receive care who would otherwise be lost to the symptoms of their illness.

An ongoing study of individuals in New York’s Kendra’s Law program found

  • 75 percent reported that AOT helped them gain control over their lives,
  • 81 percent said that AOT helped them to get well and stay well, and
  • 90 percent said AOT made them more likely to keep appointments and take medication.

When interviewed concerning the effect AOT had on their working alliance with their case manager, 87 percent of AOT recipients said they were confident in their case manager’s ability to help them – and 88 percent said they and their case manager agreed on what is important for them to work on.

MYTH: AOT ignores the fact that the majority of individuals with severe mentally illnesses are nonviolent.

REALITY: Individuals placed in assisted outpatient treatment (AOT) are among the most severely ill. This does not mean that every person with mental illness is violent.

MYTH: Law enforcement agencies will oppose AOT because of its cost and increased responsibilities for officers.

Assisted outpatient treatment enjoys broad support from law enforcement agencies. In 2004, the Florida Sheriffs Association led their state’s successful legislative drive to enact AOT legislation. AOT is supported by the National Sheriffs Association, the Florida Chiefs of Police, the New York State Association of Chiefs of Police, the New Jersey State Association of Chiefs of Police, the Maine Sheriffs’ Association, the Maine Chiefs of Police Association and many others.

DJ Jaffe is Executive Director of the non-partisan Mental Illness Policy Org., and author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is a critic of the mental health industry for ignoring the seriously ill, and has been advocating for better treatment for individuals with serious mental illness for over 30 years. He has written op-eds on the intersection of mental health and criminal justice policy for the New York Times, Wall St. Journal and the Washington Post. New York Magazine has credited him with being the driving force behind the passage of New York’s Kendra’s Law and Congress incorporated ideas proposed by DJ in the Helping Families in Mental Health Crisis Act.