This just in: AOT stirs emotions ...

"Controversy is only dreaded by the advocates of error." Benjamin Rush

“No great advance has ever been made in science, politics, or religion, without controversy.” Lyman Beecher – American Presbyterian Minister Revivalist

“All great ideas are controversial, or have been at one time.” Gilbert Seldes

New Jersey has finally decided to take on the issue of providing assisted outpatient treatment to its most severely ill citizens. AOT is often controversial, eliciting strong feelings on both sides, as the hearing held earlier this week shows. But controversy itself isn’t negative, and strong emotions don’t undercut the fact that assisted outpatient treatment saves lives.

We at TAC salute Acting Governor Codey for his courage to not shy away from controversy and do what needs to be done for those in need.

Wait until he "escalates"

More details on the sad story of John Hyde, who allegedly killed 5 people in New Mexico in mid August. His family is speaking out about how they tried to get him help but the system failed them.

Robert Hyde then said he spent two weeks trying to contact his brother's psychiatrist, even hand delivering three copies of a letter to Presbyterian doctors and therapists, asking for help for his brother and detailing his bizarre behavior.

He said his brother often became disoriented, was incapable of focusing on simple tasks, listened to satanic music and turned the heat up in his house to above 100 degrees.

On April 27, Presbyterian officials had Hyde picked up and taken to the hospital. He was released after four hours. Robert Hyde said when he questioned his brother's therapist about the decision he was told that they would have to wait until John Hyde "escalates."

Of course, now that he meets the criteria for intervention, 5 people are dead and he is headed to prison.

Dr. Torrey talks about CATIE study

TAC President Dr. E. Fuller Torrey will be on the Diane Rehm Show (88.5 FM) Thursday, Sept 22, from 10-11, discussing the results of the CATIE trials comparing antipsychotic medications. NIMH director Thomas Insel will also be interviewed.

PACT teams and AOT

For those able to access them, Program for Assertive Community Treatment (PACT/ACT) teams are a phenomenal service. PACT teams bring 24/7 mobile treatment directly to the most severely ill individuals, in their community.

States with PACT teams are fortunate. But in states with restrictive treatment laws, if a person says they don’t want the services, there is nothing more PACT can do. In fact, one study of a voluntary PACT team showed that one-third of the subjects were noncompliant with medication at any given time.

A better treatment law would empower these teams to go further and keep delivering services.

Even the manual for the model program recognizes that sometimes a court order may be required for clients who, because of their illness, are incapable of adhering to treatment.

… some clients who enter PACT treatment voluntarily later refuse treatment and may become candidates for involuntary services if they relapse… In this case the PACT team first tries to stay involved with the client who declines treatment … If the client’s behavior … meets the commitment law criteria, the PACT team participates in the commitment process.
Allness, D., Knoedler, W.H. (2003, June). A manual for ACT start-up: Based on the PACT model for community-based treatment for persons with severe and persistent mental illnesses (2003 ed.). Virginia: NAMI.

When “rights” are wrong

We often hear the argument that individuals, no matter how severely their symptoms have affected them, have the “right” to make their own decisions regarding mental health care.

In Virginia, one woman’s “right to be ill” trampled her right to a life free from psychosis.

Ms. Fields, diagnosed with a severe mental illness, repeatedly refused to take her prescribed medication, stating that it made her feel that she was “sizzling,” and that the drugs were “foaming” through her skin. Even when faced with the prospect of the complete termination of her parental rights, Ms. Fields still did not believe that she needed mental health treatment and instead felt that she had a “hearing problem.”

In the protection of Ms. Fields’ right to refuse treatment, the Virginia courts terminated her parental rights, stating that she “remained unwilling to accept her mental illness and obtain treatment and medication that might permit her to parent successfully.”

What might the outcome of this case have been if Ms. Fields lived in a state like New York – a state that could have provided her with medication by court order (assisted outpatient treatment) until she was well enough to maintain her treatment voluntarily?

Jailed instead of treated

It is true across the country – as hospitals close, people who are extremely ill are ending up in a different institution – prison.

“… we are fully aware that we are going to become the mental health institute of first resort rather than last resort,” Jeff Blum, mental health coordinator of the Davidson County [Tennessee] Sheriff’s Office, said.

You read that correctly - the SHERIFF will become the county's main mental health provider. If only this were unusual. In fact, it has become the norm.

Being incarcerated is particularly hard on people with untreated brain diseases. It is not a policy answer to send people to prison for having a brain disease.

Yet some actually prefer incarceration to living on the streets. (Going from the streets to jail, then back again.)

What is wrong with this picture? Aren't there any options between prison and homelessness?

They have one suggestion in Miami.

TAC’s stance on talking about violent episodes

Yesterday's post on violence coincided with a thoughtful email we received from someone questioning why the Treatment Advocacy Center talks about violent episodes. We removed only the emailer's name and identifying information.

The email:

I totally support the Treatment Advocacy Center's desire to obtain legislation in all 50 states requiring "assisted treatment" for the mentally ill but I am getting disgusted at the misrepresentation of violence and mental illness. The statistics are that the seriously mentally ill constitute 5-6% of the United States population and they commit 4-5% of violent crimes (I use homicide as the basis).

SOME ELEMENTS of the Treatment Advocacy Center use "1000 homicides a year" as a sensationalist approach to getting assisted treatment legislation without putting the figure in the total perspective of the percentage of the general population. I am bitter because I feel that this does the same disservice [to] the mentally ill that Alfred Hitchcock's movie "Psycho" did for the mentally ill.

The basic predictors for violence among the mentally ill appear to be the same as in the general population: alcohol or drug abuse and a previous history of violent behavior. My support for assisted treatment is simply humanitarian reasons - to ensure that people who cannot take care of themselves and who lack the basic cognitive skills to understand this fact get into appropriate settings and on appropriate medications, for the same reason we treat a well established biological brain disease, Alzheimer's disease, this way.

TAC’s response:

Thank you for thoughtfully expressing your concern about the violence issue. This is a very difficult issue, but it is not one we can afford to ignore.

TAC is very concerned about the consequences of non-treatment. It is well documented that one of the consequences of non-treatment is harmful behavior. We would not be credible if we discussed other consequences of non-treatment (such as homelessness, hospitalization, victimization or suicide) and ignored violence.

In fact, I believe we would do a disservice to people with mental illnesses, their families and others if we did not discuss this issue intelligently. Stories about random acts of violence involving people with severe mental illnesses appear in papers literally every day.

TAC attempts to educate media, the public and policymakers that it is not all people with mental illness, but rather those who are not getting the treatment that they need, who are most often the perpetrators of such violence. That approach does more to reduce stigma that ignoring the problem.

Similarly, it is a disservice to families -- I know of too many cases in which mental health professionals dismissed families' concerns about a loved one becoming violent, so that those families were not prepared when their loved one did hurt themselves or someone else.

Assisted outpatient treatment has been shown to reduce violent behavior. Researchers in North Carolina found that people who had long-term court orders (at least 6 months) combined with regular mental health services (3 or more service contacts per month) were 50% less likely to be violent. Similarly in New York, Kendra’s Law resulted in dramatic reductions in the incidence of harmful behaviors for AOT recipients at six months in AOT as compared to a similar period of time prior to the court order. Among individuals participating in AOT: 55 percent fewer recipients engaged in suicide attempts or physical harm to self; 47 percent fewer physically harmed others; 46 percent fewer damaged or destroyed property; and 43 percent fewer threatened physical harm to others. Overall, the average decrease in harmful behaviors was 44 percent. This is information that must be shared.

I applaud your support for assisted treatment for "humanitarian reasons." We share your goals and take your concerns seriously. It is our intention to educate the public, media and policymakers about all of the consequences of non-treatment so that people with SMI can get the support and treatment they need and deserve.

Thank you again for sharing your thoughts and for your advocacy.

Mary Zdanowicz, Executive Director

Violent acts in retrospect

Benjamin Harrison murdered his mother. At his sentencing hearing, he said "If I was on my medication I wouldn't have done what I did."

You don’t see a lot in the media about what happens after being medicated in prison restores someone to competency. Andrew Goldstein made an eerily similar statement on his killing of Kendra Webdale in New York. And Michael Ouellette, who killed a priest in Connecticut, said "I didn't know I had the illness. I thought everything was real."

In that case, Ouellette’s father noted that after being incarcerated, his son was “now the most rational he's been in a decade."

There have been some studies done on consumers’ perceptions of assisted treatment. It would be interesting to ask Harrison, Goldstein, and Ouelette whether, in retrospect, they wish someone had forced them to take medication before they committed such dreadful acts.

Victimization study

People with severe mental illnesses are far more likely to be victims of crime than those not similarly afflicted.

A new comprehensive Northwestern University study shows that, compared with members of the general population, people with severe mental illnesses are:

8 times more likely to be robbed;
11 times more likely to be victims of violent crime;
15 times more likely to be assaulted;
23 times more likely to be raped; and
140 times more likely to have property stolen from their person.

Support builds for NJ reform

“For New Jersey's mental-health reform to be truly comprehensive, we must reach those individuals who fall between the cracks,” notes Phil Lubitz, Director of Advocacy Programs for the New Jersey chapter of NAMI in a letter to the editor this week in the Philadelphia Inquirer.

New Jersey is one of only 8 states without the option for assisted outpatient treatment (AOT) – support from power players like acting Governor Codey and a recommendation for passage from the task force he created are a hopeful sign. Letters like this are another.

Hurricane Katrina and people with mental illnesses

Our hearts are with everyone dealing with the aftermath of Hurricane Katrina. The Nathan Kline Institute has some coping tips for families in times of disaster that may be helpful in some situations; the National Alliance for the Mentally Ill has also provided a resource guide.

Psychologist with schizophrenia selected for federal panel

TAC Board Member Fred Frese, Ph.D. has been selected by SAMHSA to serve as a member of the Steering Committee of its Partners for Recovery project, which “provides the framework to help define, develop, and implement strategies to enhance treatment systems and service outcomes nationwide.” Who is Fred?

Frederick Frese's astonishing story is simply this: Thirty years ago, he was locked up in an Ohio mental hospital, dazed and delusional, with paranoid schizophrenia. Twelve years later, he had become [a] chief psychologist for the very mental hospital system that had confined him.

For anyone in the area, Fred will be speaking this weekend (Sept. 10) at the NAMI South Carolina meeting …

APA president calls AOT "caring coercion"

The issue of assisted outpatient treatment (AOT) often elicits emotional responses, so it is particularly refreshing to see today's article in Psychiatric News by Dr. Steven Sharfstein, President of the American Psychiatric Association.

He terms AOT (also known as involuntary outpatient commitment) and mental health courts "caring coercion," calling AOT "a preventative approach to trying to avoid not only inpatient care but also the much more deleterious outcome of homelessness and incarceration-the modern epidemic for severely and persistently mentally ill people in America."

That the president of APA would make the issue of assisted outpatient treatment such a high priority signals again how important the issue is in psychiatry today. Dr. Sharfstein should be applauded for taking a position on such a difficult issue.

New Mexico’s latest tragedy spurs call for reform of treatment law

John Hyde, 48, shot and killed five people in Albuquerque, New Mexico, in mid August, including two police officers dispatched to bring him in for an evaluation.

For at least five months, according to his family, Hyde had been off medication for schizophrenia and bipolar disorder – in April, police responded to his home at the request of his 80-year-old mother, but there was nothing they could do to help. New Mexico remains one of eight states without an assisted outpatient treatment law (also known as involuntary commitment). Now many are questioning if it is time to change that.

Treatment Advocacy Center launches new web blog

The staff of the Treatment Advocacy Center (TAC) is pleased to announce the launch of BLOGTAC, which will focus on the issues surrounding lack of treatment for severe mental illnesses and the need for more humane treatment laws.

Since its inception, the Treatment Advocacy Center has worked to inform and educate, to change ineffective treatment laws and policies and the long-held misconceptions that keep them from being improved and used. Founding president Dr. E. Fuller Torrey noted that TAC exists in part to:

… educate the legal profession, media, and general public that the failure to treat individuals with severe psychiatric disorders is a major reason so many end up homeless, in jails, and being victimized. And that failure to treat leads to episodes of violence that, in turn, are the greatest cause of stigma against individuals with psychiatric disorders. Above all, we must continue to be a coordinating center to geographically link those affected, their families, state legislators, and local media to work together on these problems. [“Truth and courage: Looking ahead for TAC”]

TAC’s web blog will be another means of connecting and communicating, another way to educate and build awareness. We will keep you posted on our efforts, bring context to stories in the news, and shine light both on laws and policies that are working to help people with severe untreated mental illnesses, as well as those that are failing.