Wednesday, October 31, 2007

Keeping children safe

As a community tries to understand the shocking deaths of three children at the hands of their own mother, today’s Deseret Morning News reports on the link between severe mental illness and filicide:

In the medical community, the practice of parents killing their children is known as filicide. A study printed in a 2005 Journal of the American Academy of Psychiatry and the Law article found about 2 percent of homicides are filicides.

Another study found about 40 percent of filicidal parents previously had been treated for psychosis, but about 75 percent likely were suffering from symptoms of mental illness.

While people who are being treated for their severe mental illness are no more violent than the general population, those who are not properly treated for their symptoms do pose a greater risk to themselves, others and, sadly, even their own children.

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Tuesday, October 30, 2007

New resource for privacy laws

Questions over privacy laws were among the many concerns surfaced after the Virginia Tech tragedy. Gov. Tim Kaine’s Va. Tech panel pointed to the misunderstanding and confusion surrounding laws like HIPAA and FERPA. And, as families of those with severe mental illnesses know all too well, privacy laws often create barriers to care and treatment of severe mental illnesses.

The US Department of Education, along with the Department of Homeland Security and the Department of Commerce released guides for the Family Educational Rights and Privacy Act (FERPA) for schools, families, and colleges and universities.

The guides are available here.

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Monday, October 29, 2007

Housing the homeless...who aren't psychotic

In an op-ed in the LA Times, two experts on homelessness and skid row wrote:

The central antidote to homelessness is not a police sweep or a shelter bed. It's housing.

Once housed and given appropriate support and services, formerly homeless people with mental and addiction disabilities -- those for whom we used to think a bowl of soup and a blanket was the best we could do -- have a good chance of staying off the streets.
Certainly, they are right. For many of the people on skid row housing and services are enough. But what about people with mental illnesses so severe they have anosognosia, or a lack of insight into their illness? What about those who are so sick they will never chose mental health treatment? (Remember Nathanial?)

Without assisted outpatient treatment to accompany housing and services, the sickest of the sick are still being ignored.

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Friday, October 26, 2007

Shouldering the burden of inadequate treatment

When we think about the added burden untreated mental illness causes for law enforcement, we often think of things like overcrowding in jails or the increased risk in responding to a call for someone who has been deemed an imminent danger.

But untreated mental illness also burdens law enforcement in less apparent ways. Take the case of Mark L. Jackson – a man who allegedly made multiple bomb threats in the Chesapeake, Virginia area. Obviously, every threat of this type must be taken seriously, requiring significant law enforcement resources and manpower. But this isn’t the sort of cost that can be easily included in a budget request – it’s simply another hidden cost of Virginia’s failure to provide effective mental health care.

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Thursday, October 25, 2007

Movies and severe mental illness

The movie “Michael Clayton” (starring George Clooney and Tom Wilkinson) asks questions about state civil commitment laws.

While many Hollywood depictions of severe mental illnesses have been grossly inaccurate, there are some movies that do make serious attempts to portray individuals with illnesses like schizophrenia and bipolar disorder. The book Surviving Schizophrenia suggests a few flicks that are worth watching:

Through a Glass Darkly (1961). Directed by Ingmar Bergman. Winner of the 1961 Academy Award for Best Foreign Language Film in 1961.

Clean, Shaven (1993). Directed by Lodge Kerrigan. Roger Ebert called it a “must see” for anyone with a serious interest in schizophrenia.

Angel Baby (1995). Directed by Michael Rymer. Winner of seven Australian Film Institute awards for 1995.

People Say I’m Crazy (2003). Directed by John Cadigan. Winner of NAMI’s Outstanding Media Award in 2004.

Wednesday, October 24, 2007

A little too late

According to a psychiatrist Elartrice Ingram’s schizophrenia symptoms are now under control. He has been in treatment and he’s no longer a threat to himself or others.

It’s too bad that treatment came AFTER he stabbed eight people.

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Tuesday, October 23, 2007

"A system that is complex, confusing and dysfunctional..."

Excerpts from the Dolorosa Journal – a blog on mental illness:

In this day and age of the Americans with Disability Acts (ADA) it is inconceivable that a program would be in operation that would REQUIRE a sight and hearing impaired quadriplegic to navigate and manipulate stairs and intricate locked doors and gates in the process of access to receiving care for their physical afflictions. Yet this is the reality that many individuals suffering from mental illness perceive and experience as they long for help from their afflictions.

It is not always a matter of BEING WILLING to receive help and care. It is more often a matter of being ABLE TO ACCESS the care that is needed. When someone struggling with delusional, paranoid realities confronts a system that is complex, confusing and dysfunctional the result is often failure.

The inability to access is also fueled by the medically recognized factor of anosognosia, or the unawareness of the illness. To require someone to want care and help when they may not even realize their sickness or danger is uncaring if not absurd.

The streets, jails and morgues of our communities are no longer acceptable places of care for the mentally afflicted unable to access care.


Monday, October 22, 2007

AOT helps reduce crime

In Moscow, Idaho residents met to discuss the rise of crime in their community. The main incident in discussion was Jason Hamilton’s deadly rampage in May. Hamilton – who had a history of mental illness – killed his wife, a Moscow police officer, a church sexton and then himself, in the deadliest shooting in the town’s history.

Among the suggestions of increasing officer training and weapons bans, Second District Judge John Bradbury offered the following perspective:

He said society has criminalized mental illness because the current system does not allow intervention before a crime is committed.

“It's the only time, when we have a medical problem, that we wait until it has gotten so bad that somebody's actually in physical danger, that we intervene. And, I'm equally concerned about civil rights for people who are mentally ill, but I think it's much healthier and much better for the person involved if we intervene at an earlier stage and prevent that person from killing another person, then ends up being incarcerated for life, which is what we were trying to avoid when we reformed the system, in the sixties."

Deadly encounters with police, violent episodes, and incarceration are the results of years of misunderstanding the true nature of civil liberties. Idaho allows the state to intervene – with many protections – to save someone before they become another statistic. Those looking for a quick way to make improvements would do well to start with wider implementation of AOT.

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Friday, October 19, 2007

An unprecedented focus

In November, Virginia will hold a General Election. Every seat, both in the state Senate and in the House of Delegates is up for election. At the same time, the failings of Virginia’s mental health system have been crystallized by the work of the many commissions and task forces and especially the tragedy at Virginia Tech.

There has never been a better time to contact your legislators!

The upcoming legislative session will see an unprecedented focus on mental health, and legislators want to hear from you. They want to know what seeking treatment for someone is like, and what can be done to make it better. Take a few moments this weekend to find out who is running for office in your area, and where they stand on reforming Virginia’s treatment system.

Make sure they know that a winning campaign platform must include a plan for effective mental health treatment reform.

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Thursday, October 18, 2007

Suicide at UCLA

In Los Angeles, 19-year-old Simon Latimer committed suicide last Friday by walking off a balcony at a UCLA campus. Latimer’s mother, Dianne Taylor said Simon had schizophrenia, and toward the end of his life heard voices from God and wandered around LA looking for God.

Like so many other parents whose grown children have a severe mental illness, Simon’s parents tried to get him help.

“He did well in school, got awards, and then about a year ago, he started hearing voices and became schizophrenic. His personality changed, and he refused treatment,” Taylor said.

Though his parents tried to get him into programs, Simon declined. Since he was over 18, his parents had no choice but to let him go his own way.

“Because he wasn’t considered ‘bad enough’ by the authorities, I couldn’t get him into a hospital,” Taylor said.

She added that this was especially hard since refusing treatment is a common symptom of schizophrenia.

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Wednesday, October 17, 2007

Important message in "Michael Clayton": location matters

It wasn’t the climax of the movie. It wasn’t even a major part of the plot. But, for those struggling to get treatment for a loved-one, a short portion of the new George Clooney movie – Michael Clayton- reveals something they know all too well - location can make all the difference in the world when trying to get treatment for someone with a severe mental illness.

In the movie, Arthur, a powerful, smart, well-respected attorney with bipolar disorder has a psychotic break and strips naked in a courtroom in Milwaukee, claiming he’s Shiva the god of death. Arthur refuses to take his medication, saying life is clearer than it’s ever been. He’s even been through a re-birth in which he was covered in placenta while he was walking down the street.

Later in New York, in a scene no longer than two minutes, Michael Clayton is trying to convince Arthur to take his medication and seek treatment for his bipolar disorder. Arthur responds by saying, “to involuntarily commit me, I have to be a danger to myself or someone else. If you wanted to commit me, you should have left me in Wisconsin.”

And he’s absolutely right.

As Arthur alluded to in the movie, in Wisconsin he probably could have gotten involuntary treatment for stripping naked in a courtroom and running around outside in a snowstorm wearing only socks. Wisconsin probably would have sensibly permitted a court to place someone as sick as Arthur in either inpatient or outpatient care. Wisconsin’s “Fifth Standard” essentially permits such treatment interventions for those who can’t make informed treatment decisions, need care or treatment, and will suffer severe mental, emotional or physical harm resulting in either the inability to function in community or a loss of cognitive or volitional control. Arthur’s condition and actions would have likely met those criteria.

Meanwhile in New York, there was nothing Michael Clayton could do to get treatment for his friend. In New York Arthur had to be an immediate physical danger to himself or others in order to be placed in inpatient treatment.

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Tuesday, October 16, 2007

This is the one place that can't say no

The Richmond Times Dispatch has been conducting an extensive expose on the suffering of the mentally ill in Virginia’s corrections system. But as the Times Dispatch’s editorial board laments, for many, it may seem “almost old news.” The most severely ill are increasingly being abandoned by a mental health system all too willing to shift the burden onto law enforcement and corrections. And so Richmond will be forced to invest even more resources for mental health care in its jails, while the mental health system continues to pick and choose who it will treat -a mental health system that cannot even be bothered to know what their treatment laws say.

Does this pattern sound familiar? You call for help for your loved one in crisis, only to be told that nothing can be done until they’re dangerous. So you wait. And worry. And hope that nothing terrible happens. Finally, there’s an incident and you call back, only to be told, “call the police, we don’t come when people are dangerous.”

Most would call that absurd. But for Virginia’s mental health system, it’s business as usual.

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Monday, October 15, 2007

The new mental institutions

Today's Roanoke Times explores an alarming reality of today's forensic system. When the mental health community abdicates its responsibility to treat people with severe mental illnesses, the responsibility too often falls on those who can't say no - jails and prisions.

We really are doing a disservice to our people when we put them in jail," said Bill Farrington, president of the state chapter of the National Alliance on Mental Illness…

Even if there's bed space available, the civil commitment process can be so time-consuming that police officers who encounter the mentally ill are often reluctant to use it, Farrington said.

"They recognize that it's a mental health issue, but they also recognize that 'I brought this person in three times before for the same thing' " on a civil commitment order, he said. "So the easier thing to do is to take them to jail and let the jail deal with it."

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Friday, October 12, 2007

Michael Clayton, Slate and an important question and the movie Michael Clayton bring up an important question regarding mental health treatment. Do you know what getting someone involuntary care entails in your area?

If you have a loved one that may need involuntary care at some point, it pays to research the answer now, before a crisis occurs. A crisis situation is no time to begin understanding the confusing and often nonsensical process of commitment.

Take some time to look up your state’s commitment laws. Find out what forms you’ll need to fill out and who you’ll need to contact if the situation ever arises. Research what your area’s standard for commitment actually says (you may find it’s quite different than what people think!)

Check out your state/local mental health departments to see what materials they provide. In the 45 jurisdictions that allow direct petitioning for commitments, the clerk at the local court should also have copies of the necessary forms. If possible, talk to your loved one about filling out an advance directive when they are doing well.

More tips and strategies, including information on creating a CARE kit, are available on our website.

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Thursday, October 11, 2007

Forest fires and untreated mental illness

Colorado is a dangerous place to be homeless. In Colorado Springs temperatures hover in the low 20s in December and January.

The freezing temperatures drive many chronically homeless to build fires rather than seek shelters.

Recently in Colorado Springs and Manitou Springs a fire tore through area forests destroying 30 acres and causing $30,000 worth of damage. The fire was believed to be started by a homeless camp.

Dr. Bob Holmes an advocate for the homeless says the fire is a by-product of a bigger problem.

“The bigger problem is an issue that plagues many of the nearly 2,000 homeless people living in Colorado Springs and Manitou Springs, mental illness. We have some mental health issues that are pretty rampant with the chronic homeless. That's why they are chronically homeless. There's not enough treatment available for them."

Homelessness, victimization, suicide, and now forest fires – some of the many consequences of failing to treat severe mental illness.

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Wednesday, October 10, 2007

Why counties need to care about treatment laws

A story in today’s St. Paul Pioneer Press serves as yet another reminder why counties need to support laws permitting timely and humane treatment for severe mental illnesses. As the story illustrates, failure to properly treat someone can result in huge liability issues for counties. The best way to avoid this? Ensure proper treatment.

The parents of a 28-year-old New Richmond man who died in the St. Croix County Jail six months ago are accusing the county of wrongful death and are seeking $3 million in damages… his father has said his son's death should have and could have been prevented…

Hessler had battled mental illness, and his father had him committed to institutional care in 2000. With care and medication, Hessler's condition improved, and he was released. He had several run-ins with law enforcement in subsequent years.

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Tuesday, October 09, 2007

What assisted outpatient treatment can... and can't... do

Last Saturday, Lee Coleman evaded his family’s attempts to have him hospitalized and went on a rampage – stabbing two people with knives he stole from a Manhattan restaurant before being shot by an off-duty police officer who had just paid his check.

It is the type of gripping tragedy that leads to unfortunate, big-lettered headlines in a city’s papers, such as PSYCHO STABBER from the New York Post, as well as editorial pleas with titles like Stop The Insanity On The Streets. And when the general community peers into the most often ignored world of severe mental illnesses, the possibility of reform emerges. On Monday, Governor Eliot Spitzer expressed his support for creating a panel tasked with investigating how to treat the most severely ill and thereby protect the public from those in that group whose symptoms would otherwise escalate to violence. New York is home to Kendra’s Law, the best-known and most thoroughly documented assisted outpatient treatment (AOT) law in the United States. Yet despite the availability and success of Kendra’s Law, tragedies intertwined with non-treatment continue in New York. Does that mean Kendra’s Law has failed? Hardly.

Kendra’s Law neither is nor is purported to be a cure-all.

For starters, an AOT program cannot help someone who is not in it. As is appropriate with any form of court-ordered treatment, the eligibility standard for Kendra’s Law is targeted at those incapable of managing and maintaining their own care. And even if Coleman was eligible at some point, the Kendra’s Law program is not tasked with searching out those who are sick and need AOT.

AOT is also not a mechanism designed for times of extreme crisis. The law has no mechanism for immediate intervention other than for those already under AOT orders.

The purpose of Kendra’s Law is to give intensive and sustained outpatient treatment to those that courts order into the program, treatment designed to help some of those most overcome by severe mental illnesses stay out of the hospital, off the streets and away from jail. It does that exceptionally well.

Failure in the case of Lee Coleman can be pinned to New York’s still-restrictive standard for emergency intervention and inpatient hospitalization, which requires immediate and demonstrable physical danger. Coleman’s uncle pled with police for help after his nephew frantically fled attempts for treatment and disappeared. The police told him they were powerless because “there was no history of violence.”

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Monday, October 08, 2007

Mental health week

This week (October 7-13) is national mental health week; a time to “raise awareness of mental health issues.”

Doubtful Teresa Gonzales needs a week of mental health awareness.


Friday, October 05, 2007

California needs Laura's Law

Columnist, C.W. Nevius wrote about treating severe mental illnesses and outpatient committment in a recent column in the San Francisco Chronicle.

While the issue of the beds at S.F. General is important, there is a much larger issue. Across the country, and particularly in California, we need to take an honest look at the consequences of letting mentally ill people decide whether they want to accept treatment. Remember, in these cases their own parents are begging to have them confined to a safe, secure facility where they will have to take their medication and hopefully begin to find themselves. Leaving the choice up to them, as a consequence of patient rights movement, is a recipe for failure.

As Nevius explains, the current system isn't working:

Officer Martin, who walks a beat in downtown San Francisco, estimates that "six to seven out of 10 of our contacts have mental health issues." The police have limited recourse, even in the most extreme cases. One thing they can do is file a 5150 under the California welfare and institution penal code, which is a "72-hour psychiatric hold." But Martin says even that confinement is often "a pipe dream."

"There's been times when I've 5150'd somebody," he says, "and they'd be walking out when I was getting back into my patrol car."

And yet, most counties in California still haven't implemented Laura's Law. What are we waiting for?

Interested in getting Laura's Law implemented in your county? Visit the California Treatment Advocacy Coalition (CTAC) website for resources on implementation.

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Thursday, October 04, 2007

Pennsylvania advocates speak out

The Treatment Advocacy Center received the following email in response to our blog entry yesterday:

I'm not really sure how anyone who heard or read this story could walk away thinking that her son should just continue to live his life this way, just because that is his choice. There are services in his county, he doesn't want or need them though because he thinks he is fine.

As you'll see from others who testified [at a hearing in Pennsylvania for SB 226] some think that just adding services will solve the problem. All the services in the world are not going to benefit someone who refuses to accept them. Helping someone remain in treatment, however, may in time help them to regain the insight to take charge of their treatment. That's really all we're trying to accomplish with SB 226 for the small minority of people who need this type of assisted outpatient treatment for an initial period of six months, in order to be able to one day be doing well enough to live a healthy life in their community, moving forward in their own recovery.

Want to join the conversation? Send us an email!

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Wednesday, October 03, 2007

A mother testifies in Pennsylvania

In Pennsylvania yesterday, the Senate Committee on Public Health and Welfare heard testimony on SB 226, including this all-too-typical story from a mother who supports the bill.

Thank you for inviting me to speak to you this morning. My name is Dorothy Tengler.

This is my only son, Todd – a blue-eyed, blonde-haired, gentle little boy not unlike all the other little boys on the block. He was smart. He was funny. He was loving. That was 35 years ago. Today, Todd roams the streets of his town, believing he is a member of the United Nations. He has tried to force his way into the back rooms of a local supermarket to investigate a murder he believes to have happened. He has stood outside the elementary school, copying down the numbers of the school buses, telling police officers and wary onlookers that all the children inside the school belonged to him. As a member of the UN, Todd believes he does not need to pay his electric bill, so his electricity is turned off on a regular basis. I can’t reach him on his cell phone anymore because he has taken out the chip, looking for evidence of surveillance. Todd believes that most of us are somehow connected to Hitler. Even me. He doesn’t believe I am his mother. He believes that I ran an illegal sperm bank when he was a little boy, and somehow he is a result of that. Before all this happened, Todd earned a degree in computer graphics, was a talented musician, and loved spending time with the rest of his family.

But when Todd was in his early thirties, he was diagnosed with schizophrenia. Todd’s delusions have been chilling, including being hunted by the FBI in helicopters for, among other evil acts, the murder of his grandfather. He has been hospitalized more times than I care to count. He has been mandated to periods of outpatient therapy, and when forced to take a low dose of antipsychotics, Todd has been highly functioning and able to live a fairly normal life.

But Todd doesn’t believe he is sick. So, he refuses to take medication.

In fact, it has been at least 3 years since Todd last took medication. And his paranoia is escalating. Recently, he was arrested for simple harassment. He didn’t appear for the hearing because, of course, as a member of the UN, he has the power to veto court orders. So, a bench warrant was issued. Todd still doesn’t quite understand what he did to be arrested. He spent 3 weeks in prison before he had someone call me to post bail. He faces a trial at the end of October.

Todd is a ticking bomb. And I wait each day for his life to explode.

Now, I believe that each of us has the right to exert control over our lives – be able to decide if we want treatment for our diseases, be able to say yes or no. However, there comes a point when the very nature of many mental illnesses precludes the ability to reason and destroys any trace of insight. To that end, I believe that as moral human beings, those of us standing on the sidelines of these devastating illnesses need to extend a hand and help these individuals become stable and reclaim their lives. What I don’t believe is that those with mental illness be left alone in
their darkness until they reach a certain level of dangerousness before receiving treatment – like waiting for a certain number of fatalities to occur at a dangerous intersection before erecting a traffic light.

As a family member, a mother, I support PA’S SB 226. With assisted outpatient treatment, we can bring many of these loved ones back to their families, their friends, and importantly, their communities. Pass SB 226 for the millions of untreated persons with mental illness. Pass it for my son, Todd.

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Tuesday, October 02, 2007

Severe mental illness: a mother's perspective

On today’s San Francisco Chronicle blog two mothers each tell heart-breaking stories of their grown sons’ struggles with severe mental illnesses. As the Chronicle writes in the introduction to the video clips:

California is a state that has a strong belief in patient rights. It sounds like a good and reasonable theory until you talk to the mothers of severely mentally ill children.

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Monday, October 01, 2007

PACT teams need AOT

Assisted outpatient treatment drastically improves PACT teams’ ability to provide treatment.

Sometimes called a “hospital without walls,” PACT (Program in Assertive Community Treatment) teams, also called ACT teams, bring critical treatment services to the patient. NAMI calls ACT teams “highly effective” and SAMHSA notes that experts consider them to be “an essential treatment option.”

What isn’t widely publicized is that PACT incorporates the state hospital function of using civil commitment to ensure treatment compliance. In fact, the PACT Manual states that the program has a “consistent record of serving involuntary outpatient treatment clients at no less a level of effectiveness than voluntary ones.”

Of course, if you live in a state with no option to use AOT, like New Jersey, PACT teams don’t have that tool. In these cases, PACT teams are powerless to help someone who refuses treatment. This is even more troublesome in states like New Jersey, because refusing clients remain with PACT even if they refuse its help. That means New Jersey citizens are paying for people to refuse the most expensive services the state has to offer – 1 out of every 4 people enrolled in PACT does not participate.

Even in the 42 states that have AOT laws on the books, PACT teams in the field do not always use it. An article in the journal Social Service Review compared two PACT teams – one team located in a state where outpatient commitment was legal, but not an established practice. The other team used outpatient commitment in about 10% of cases to require treatment participation and, in some cases, to mandate patients to take medication.

Both teams report using similar interventions to promote adherence – monitoring, listening, persuasion --- until a client becomes nonadherent at which point their practices are strikingly different.

Staff on team where AOT is used in about 10% of cases:

  • In order to avoid any potential conflict that court-ordered treatment may produce between the team and the client the team tries to treat mandated clients the same as they treat the rest of the clients, for example, by focusing on the client's own recovery goals.
  • Some clients readily accept the formal mandate in court, agreeing to comply "because they've been in the program and it means really not a whole lot different than the day before it happened."
  • Team members routinely supervise mandated clients in taking medication and remind the clients that the court order will be enforced if they do not adhere.
  • Some clients attempt to defy orders by "cheeking" medications. In those cases, the team uses creative ways of enforcing the order.

Staff on the team in state that doesn't use AOT:

  • Because they do not use outpatient commitment, involuntary commitment to inpatient treatment is the primary means of pressing nonadherent clients to accept treatment.
  • Team members reported watching clients undergo a downward spiral, because there is often a long interval between the early signs of decompensation and the clients meeting the standards for commitment.
  • They essentially play a waiting game until the client exhibits some sort of violent or self-harming behavior that warrants involuntary commitment.
  • They describe one patient who stopped taking medication and didn't want to see the team. They knew if they tired to hospitalize her, the hospital staff "can decipher in like 15 minutes that she doesn't need to be hospitalized. We just see that if she, you know, physically or willfully abuses somebody, then we can have documentation."

The PACT comparison shatters (yet again) some of the oft-repeated myths about assisted outpatient treatment.

  • Dragnet for all patients - The team used court orders sparingly, for about 10 % of clients. The vast majority of patients did not get orders.
  • Easy way out for providers - The team used traditional methods of soliciting adherence first and only used the court order as a last resort.
  • Damage to therapeutic alliance - The team found ways of preserving the relationship by working with the client's recovery goals and trying to treat them like other clients. Besides, the team that didn't use treatment orders still didn't have a therapeutic alliance because she refused to see them.
  • Mandating treatment won't work - The team reported that most clients followed the order. The team took steps to enforce the order when clients didn't comply
  • Services aren't available - In this case, these were clients who were already receiving services- that wasn't the issue. The court order provided a means for the team to encourage compliance and ensure that the client benefited from those services.
  • Limits autonomy- The teams that used medication orders were able to ensure that patients remained compliant and therefore stay in the community which offers significantly more autonomy than the hospital.
  • Court orders take too much time - It takes much less time to get a court order than it does to watch someone spiral downward - basically managing their psychosis and hoping that you are there when they do something that can get them hospitalized... and hope they don't hurt themselves or someone else in the process.

According to Dr. William Knoedler, who directed and worked as the psychiatrist for the original PACT team in Madison, Wisconsin, from 1972-1997 and currently provides consultation on and training for the PACT model nationally and internationally, “the PACT teams he works with have 20-25% of clients under a civil commitment and another 5% on probation/parole.” He explained, “Obviously, we do not shy away from use of involuntary services when called for and take seriously our charge to implement the court’s wishes.”

PACT is extremely successful. But without using AOT, it is just another excellent tool unavailable to those who are the most ill.

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