Why doesn't Oregon have Laura's Law?

A blogger in Oregon recently posed the question – why doesn’t Oregon have Laura’s Law?

I wonder why we don't have something like Laura's Law (see previous entry) in Oregon. Is it because we don't have the resources? When you think of all the damage that happens without Laura's Law, doesn't it make sense that we find the resources? In the end, I believe it would be cost-effective, since it could keep people out of the hospital and/or jail and could help them to function better through counseling and meds. Doesn't this seem like a humane way to deal with people who are deteriorating, by keeping them from getting worse? Families would have some sort of recourse when their loved one starts going out of control. It just seems a shame we aren't looking at this law as being one of our solutions.

Laura’s Law or assisted outpatient treatment (AOT) is an effective and humane way of helping people with severe mental illnesses who need treatment.

Oregon does have AOT, but it’s rarely used, and a person must be a danger to themselves or others before it’s ordered.

The question posed by the blogger is an excellent one for Oregon legislators – Why does Oregon make it so difficult for its citizens with severe mental illnesses to get outpatient treatment?

Assisted outpatient treatment is helpful

"There is no question . . . that outpatient commitment can be very helpful for some individuals."
- John Petrila in Psychiatric Services

AOT: Effective but underused

As regular TAC Blog readers know, 42 states have Assisted Outpatient Treatment (AOT) laws that permit a court to order community based treatment for some people with severe mental illness who meet the state’s strict eligibility requirement. This legal mechanism has been proven to reduce consequences of nontreatment like hospitalizations, incarcerations, victimization, and violence.

Florida passed its law - known in that state as “The Baker Act Reform” and “Involuntary Outpatient Placement” - in 2005. At the time the legislature was considering the measure, opponents asserted that the law would affect several thousand people resulting in a total hardship on the courts, public defenders, and the mental health system. As it turns out, the reality is that it is used for a very select few individuals and to great benefit.

But the most important question to ask is, “Does assisted outpatient treatment help some people with severe mental illness to achieve better outcomes?” And the answer in Florida, as in other states and in the research, is a solid “YES.” Results from the most used program in Florida were recently published in a letter in Psychiatric Services. For patients in the program, when the length of time in the program was compared to an identical length of time before the patient entered the program:

• The average number of hospital days per patient decreased from 64.0 to 36.8, a 43% decrease.
• The savings in hospital costs averaged $14,463 per patient.
• The average number of days incarcerated per patient decreased from 16.1 to 4.5, a 72% decrease.

Using Laura's Law in California

Too many times we are reminded that having laws on the books providing for Assisted Outpatient Treatment (AOT) does not necessarily translate into the actual use of the treatment mechanism.

In California, Laura’s Law was passed in 2002, offering every county the opportunity to adopt an AOT program. In Los Angeles, a small pilot program was implemented soon after the law was enacted and has been helping a few dozens of people with severe mental illnesses each year. California’s first county-wide program will soon start in Nevada County. However, so far, Laura’s Law has not yet been implemented anywhere else in the state.

This is largely because the initial bill was saddled with limitations by opponents during the legislative process. Laura’s Law now provides that it is up to each county to decide whether or not to implement the law and to establish a program for it. Among other cumbersome restrictions, the law also requires a finding at the county level that no voluntary mental health program will be reduced as a result of adopting an AOT program, that AOT can only be used in conjunction with an extremely costly and often unnecessary outpatient service program and that counties must have very high thresholds of general services, most of which are unrelated to the use of AOT.

Thankfully, Senator Leland Yee from San Francisco has recently introduced SB 1606 that aims to remove many of the limitations included in the initial law. If passed, this law will make the treatment tool available in all counties throughout California.

Consequences of Nontreatment: Victimization

The media and general public often overlook tragedies facing those with untreated severe mental illnesses. The reality is that they are much more likely to be victimized than the general population.

In fact, multiple studies have shown that individuals with severe psychiatric disorders are especially vulnerable to being victimized. This frequently involves acts such as theft of clothing or money but also includes assault, rape, or being killed. Women who have a severe psychiatric disorder are especially vulnerable. Some of the studies suggest that individuals who are victimized are less likely to have been compliant with their medication. This association is strongly supported by the 2002 North Carolina study by Hiday et al., which showed that individuals with severe psychiatric disorders who were on outpatient commitment, and thus were taking their medication regularly, were victimized only half as often as those who were not on outpatient commitment.

Outpatient commitment (aka AOT) is a humane intervention that can help some to get the treatment they need to avoid becoming victims of psychosis and criminal behavior.

The real cost of assisted outpatient treatment

Virginia has the opportunity to enact meaningful mental health reform by passing Senate Bill 177. This Assisted Outpatient Treatment (AOT) bill enjoys bipartisan support and will allow for people incapacitated by severe mental illnesses to be placed in court ordered community treatment. The availability of such a program might well have prevented the terrible tragedy that happened at Virginia Tech last April.

Sadly, the passage of Senate Bill 177 is now threatened by those who mistakenly claim it will impose too great of a financial burden. This is a myth.

The implementation of AOT as provided by Senate Bill 177 will not be expensive. This program will not mandate any services that individuals with serious mental illnesses are not already eligible to receive. AOT orders merely require the system to facilitate treatment compliance for noncompliant individuals by providing them with the existing services they need to remain stable and to prevent the severe consequences associated with untreated mental illnesses.

The proof that AOT will not require the creation of new services can be found within the language of Senate Bill 177 itself. One of the requirements for granting an AOT order under this new law is a finding that:

“the community services board that serves the jurisdiction where the person resides has the capacity to provide the prescribed treatment or services.”

Not only will AOT not be expensive, it will ultimately save Virginians millions and millions of dollars in alternative costs that come from hospitalizations and incarcerations of persons who do not benefit from the availability of court supervised treatment. In other states where AOT has been enacted, such as New York and North Carolina, participants have experienced a dramatic decrease in both hospitalizations and incarcerations.

Virginians must separate fact from fiction so that true reform can finally occur. The greatest cost that will be paid by Virginians is not in implementing AOT but in failing to do what is necessary to provide for effective and timely treatment for people lost to acute psychiatric illnesses like Cho Seung-Hui.

"Heck of a job, New Mexico"

We hope New Mexico legislators who failed to pass Kendra’s Law last year are thinking hard about the consequences of their failure to act. And we hope New Mexico’s correctional facilities are prepared to help more people like Justin Quintana, since apparently killing your mother and being incarcerated is the clearest way to treatment in that state.

Patrick Kuchma said he has a "tremendous amount of anger" toward Quintana and feels he should spend the rest of his life in prison or in a mental health facility. Kuchma said he doesn't view lifelong incarceration as a tool for revenge, rather he views it as a way for Quintana to receive treatment that he has in the past refused to undertake.

"Basically what I'm getting at is, I don't think needs to be out in the public," Kuchma said. "He does not need to be out on his own because the fact still remains, he's mentally ill, he is a paranoid schizophrenic and he has the capability of not taking medication and this could happen to somebody else."

Remember Million-Dollar Murray?

Remember Million-Dollar Murray? So does Washoe County, Nevada. After cycling in and out of the county jail for 10 years, Murray, a homeless man with a mental illness, cost the county an estimated $1 million. He’s also the inspiration for a study completed by the University of Nevada that outlines the cost of homelessness in Washoe County.

According to the Reno Gazette Journal in its report on the study:

The Washoe County Jail is one of the largest providers of mental health services to the homeless, who are further burdening an already-crowded facility. But the jail and court system are the only places for many homeless to receive mental health treatment.

It costs just under $84 a day to house an inmate at the Washoe County Jail. Homeless inmates comprise about 7 percent of the population. In 2004, there were 443 homeless inmates compared with 746 in 2005. Comparatively, 96 of the inmates in 2004 were housed in mental health units while 169 of the homeless inmates in 2005 were housed in the mental health unit. In 2006, it was estimated that homeless inmates cost the county more than $890,000.

Researchers concluded that local officials could save money if they addressed the reasons why people become homeless rather than primarily responding to them during crisis, which leads to costly trips to jail or the emergency room.

"Homelessness is not a problem, it's a symptom," Bartholet said. "If someone is a chronic inebriate and you only provide them with a meal and a place to sleep, you may save their life by keeping them from freezing to death, but you're not doing anything to address the chronic condition they're in.

Yet that’s what the entire state continues to do. Without access to programs like assisted outpatient treatment (AOT), housing will remain nothing more than a band-aid for many of Nevada’s severely mentally ill citizens. The cycle from street to jail will continue. Remember million-dollar Murray?

Finding someone to blame

Who is to blame when tragedy results from untreated severe mental illness?

At the end of October in Richmond, VA, Johnny Hughes, a man with untreated schizophrenia, fatally stabbed a woman while she was walking her dog.

The author of a new blog - “families for timely mental health treatment laws” – noticed some of the comments posted on the website of the Richmond Times Dispatch regarding this story. Many blamed the family of Johnny Hughes for not monitoring him.

Posted October 30, 2007 @ 09:55 AM by Anonymousafter reading this man's rap sheet i too am finding compassion a hard sell. i agree the family dropped the ball, this man needed to be under lock and key somewhere and his family should own up to their responcibility.

The author of the “families for treatment” blog responds to these comments with the perspective of someone who has tried to help a loved-one get treatment.

Blame and pointing a finger at families who try desperately to get help for their loved ones and who often are involved in advocating for the changes needed will not resolve the issue of ensuring that someone with a mental illness receives the treatment they need. Enacting common-sense, timely assisted outpatient treatment (AOT) laws with adequate services and programs, as well as providing sufficient support in a hospital when needed, is what should happen.

Bracing for the cold - and bitter tragedy

Every winter, we read sad news stories about homeless people with severe mental illnesses who fall victim to the elements. While the weather gets blamed for the deaths, the truth is more disturbing: About 1/3 of the nation’s homeless are people with severe mental illnesses.

• Many of these individuals are homeless BECAUSE of their illnesses.
• Most are not being treated for their illness and often the lack of treatment is because they have impaired awareness of their illness.
• The headlines overlook the daily victimization and brutal realities on the streets for people with severe mental illnesses.

Next time you read one of these sad stories, consider the fact that Assisted Outpatient Treatment can prevent tragedy. In New York, 74% fewer participants experienced homelessness while in the AOT program as compared to before they entered the program.

Reform is long overdue

Few issues have dominated a political landscape like mental health has in Virginia. With the tragedy at Virginia Tech, the death of two police officers in Fairfax County, and the recent murder of Susanne Thompson in Richmond, it is clear that reform is long overdue.

Virginia Capitol Connections Magazine recognized the unprecedented role that mental health will play in the upcoming legislative session, and made it the subject of their fall issue. Contributors include Governor Kaine, Delegate Phillip Hamilton, and TAC’s own John Snook, who calls on the legislature to recognize the reality of severe mental illness and the need for assisted outpatient treatment.

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.

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.

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.”

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.

Stop. Read. Think.

Liz Spikol gets respect around our offices because she seems to think about and weigh the issues surrounding mental illness treatment carefully. (Even telling visitors to "please do read the entire text of the bill before making any judgments, pro or con. I think people don't do that enough." Amen.)

For instance, on SB 226, a bill under consideration in Pennsylvania to change that state's treatment law, she writes:

As I've said before, I have concerns about this type of legislation, but on the whole, am in sympathy with its intent, which is to get severely ill people treatment when they desperately need it -- providing enough safeguards so people's rights will not be trampled. I know it's a tall order. Is Senate Bill 226 the answer? I can't say.

Of course, a kind word from us will probably make some distrust her. (Sorry Liz.) But we wish more people would stop the knee-jerk reactions and read ... and think ... a little more.

Oprah on bipolar and violence

Andrea Petrosky killed her child. On The Oprah Show today, she talks about it, and about her bipolar disorder.

Petrosky is one in a long line of mothers whose untreated or wrongly treated severe mental illness had such a sickening result. In fact, of children killed by a parent, 15.8 percent of defendants had a history of untreated mental illness.

What she has to say about it sounds very familiar.

Andrea says the person who killed her son "wasn't me. It wasn't the real me. It was a very sick me, because I would never hurt him. Never," she says.

Her voice is an eerie echo of many who have been through similar circumstances. Like Naomi Gaines, who killed her 14-month old twins.

"I know how I was feeling that day. I know I was not the same Naomi who got up with my kids a million times before and fed them and bathed them and walked them and breast-fed them and cared for them," she says. "I wasn't that same person. So I know that I would never hurt them if I had had my sanity."

It isn’t the disease that leads to violence, it is the lack of timely and effective treatment for that disease.

People with severe psychiatric disorders are not more dangerous than the general population - if they are being treated. But without treatment, some commit acts of violence because of their delusions and hallucinations. Many of the cases in the news eventually uncover the fact that the person who killed their child was not taking medication. And research shows that the most common reason that people with severe mental illness refuse treatment is because they are too sick to realize they need treatment.

Don’t believe the hype you will hear today from some in the mental health community – that these cases are extremely rare. In Texas just last week, Alysha Green doused her three-, five-, and seven-year old daughters with gasoline and lit them on fire. The three-year-old has since died. Alysha’s husband says his wife had a history of mental illness with a past diagnosis of bipolar disorder. She was prescribed medication. She stopped taking her medication and, her husband reported, her behavior deteriorated in the three weeks prior to the tragedy. That same week, Helen Kirk was found insane in her murder trial in Massachusetts – she told police she believed her son Justin was “the devil” after she strangled him.

Oprah also talks to General Hospital star Maurice Benard and actress Jenifer Lewis from their perspectives as people with bipolar disorder. Benard returns to the issue of violence when he recounts what happened one evening when he was off medication.

“I started yelling. And I told [my wife] if she didn't stop [crying], that I was going to kill her—in my mind I didn't believe I would."

As much as we don’t want it to be true, violent behavior is one of the consequences of failing to treat. Even NIMH gets that now.

Oprah doesn’t delve into the concept of assisted outpatient treatment, which is too bad. The obvious question after a show like this is “how can we help people before they get so sick?” Maybe in a future show, they will include the perspectives of so many who can attest to the importance and value of earlier intervention.

Until then, we call this a good beginning.

Advocating from an ivory tower

We always assumed that Michael Allen and his cronies at the Bazelon Center (Michael is a former employee) were just ignorant of the science behind the need for commitment laws, or perhaps too busy to actually READ the statutes on outpatient commitment and thus assumed the worst. They certainly are eager to shut down the nation’s psychiatric hospitals, so one would think they would be strong proponents of outpatient commitment – a way to get people help in the community.

Is it possible that they have been in that ivory tower for so long they don’t actually know what life is like behind bars if you have a mental illness?

How else can you explain Michael Allen’s bizarre comment on NPR that he doesn’t know if it is worse for a person with a severe mental illness to be in a psychiatric hospital or in prison.

We wish someone would push Bazelon and their ilk to offer some real solutions – it seems now that they are opposed to psychiatric hospitals, mental health courts, and outpatient commitment. So perhaps they have no choice but to downplay the victimization and brutality that face people with mental illnesses who are locked up. After all, if Michael Allen has his way, looks like that is where more and more of them will be ending up.

Support for assisted outpatient treatment (AOT)

While the Treatment Advocacy Center is the only organization that has a dedicated mission to increasing the use of AOT, numerous other organizations and individuals support AOT including:

• NAMI’s official policy states that AOT should be used as a last resort and that “Court ordered outpatient treatment should be considered as a less restrictive, more beneficial and less costly alternative to involuntary inpatient treatment.”
• The National Sheriffs Association recognizes that “the consequences of non-treatment can also be prevented by having laws that allow a court to order treatment in the community for individuals who are in need of treatment but refuse it (also known as Assisted Outpatient Treatment).”

Treatment via criminal conviction

A 34-year-old Massachusetts woman will finally be getting the treatment she needs for her schizophrenia. Unfortunately, she had to enter the forensic system to get it.

Denise Bonilla pleaded guilty to assault and battery in court on Friday. As a result, she is ordered to participate in a treatment plan devised by the state.

Doctor’s examinations of Bonilla say she’s a different person when on her medication.

It’s too bad Massachusetts doesn’t have assisted outpatient treatment, and that citizens like Bonilla have to commit a crime to get meaningful treatment.