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.

A week of tragic consequences

The tragic consequences of untreated severe mental illness were evident across the country this week.


In Georgia, a 33-year-old man bludgeoned his girlfriend to death. Shannon Marrow has schizophrenia and had been in and out of treatment centers for years. He had recently stopped taking his medication


In Maryland, Timothy Hayes Marsh was fatally shot in the head. His sister says Marsh struggled with bipolar disorder for years, and had substance abuse problems from self-medicating. She suspects Hayes was in the midst of a drug deal when he was killed.

In New York, David Tarloff had been in and out of hospitals for years before he killed psychologist Kathryn Faughey. Tarloff has schizophrenia and relatives say he had recently stopped taking medication.

In Florida a mother has been declared insane and sent to a psychiatric hospital after she repeatedly stabbed her 5 year-old daughter. Olga Fererra has a history of mental illness including bipolar disorder and psychosis.

Is a double homicide a requirement for getting treatment?

Lizards and frogs were reading his lips, CSPAN newscasters were calling him a terrorist, he was the target of a conspiracy involving the KKK and the CIA, and comedians on BET were making jokes about him, but Franklyn "Frankie" Duzant wasn’t getting treatment for his mental illness.

There was no treatment until -19 months ago -Duzant slashed his son and wife to death with a sword because he believed his wife was going to be kidnapped and his son was going to be tortured by dogs.

Now, Duzant is getting treatment. Since the killing he’s been restored to competency and is ready to stand trial. All it took to get there was a double murder.

Tragic endings to a bad situation

Over the weekend we were reminded again of the role law enforcement is forced to play in dealing with severe mental illness. The failure of the mental health community to properly treat those with severe illnesses so often ends in tragedy across the country.

In Florida –
A sheriff’s deputy in Indian River County shot and killed Byruss Green, a man with a mental illness who had not been taking his medication.

In Illinois –
A jury determined that officers were not to blame in the March 2000 shooting of Joseph T. Zagar that had been called a suicide-by-cop. Officers had been to the home of Zager multiple times and had taken him in for mental health treatment. This time, Zager was threatening the officers with what they thought was a gun.

In Kentucky –
Brenda Joy Woosley, a woman with a mental illness had been driving erratically and avoiding police attempts to pull her over. Two officers fatally shot her after she drove her car into them.

In New York –
A man with a mental illness in Brooklyn was fatally shot by police officers after he repeatedly charged at them with a broken bottle. Before charging the officers, Dragan Kostovski stabbed his roommate.

Evidence-Based Advocacy

While personal stories and anecdotes can help to inspire elected officials to make change, they also need to present evidence to their colleagues to persuade them to adopt reforms. Sadly, many state mental health services provide little information about assisted treatment – how many people need it, how many people do not receive it but are repeatedly in crisis, how many petitions are filed for involuntary psychiatric evaluations, how many orders are issued for hospitalization, how many orders are issued for outpatient treatment, how often is law enforcement on the front line instead of mental health professionals…

Florida provides a good example of data reporting. The recent Baker Act Report provides an overview of what is happening with some of the most ill patients in their mental health system. For example, the report shows that:

“Nineteen percent of all people experiencing a Baker Act examination [involuntary psychiatric evaluation] in 2006 had more than one exam in that calendar year.”

Does your state keep good records about treatment for people with severe mental illnesses who need intervention? Is it easy for the public to access?

An exercise in futility

The title of a recent editorial in the Tallahassee Democrat says it all: "Incarerating mentally ill is futile."

"The cost in human suffering by the ill person, by his or her family and any victims is no doubt equaled by the cost to the state when it uses self-defeating systems. Even on county levels, authorities such as Leon County's Sheriff Larry Campbell decry the current system as ineffective, with no end of costs in sight, but no real improvements either."

Using AOT in Florida

Florida has an AOT law, but it’s rarely used outside of Seminole County. As a recent Miami Herald article shows, using AOT has been a great success for this county. Perhaps it’s time for others in Florida to do the same.

Fewer than 100 orders have been issued statewide, while thousands of people have been committed to mental hospitals. 'It's been hugely successful in Seminole County,'' said Sheriff Don Eslinger, who pushed for the law after one of his deputies was killed by a mentally ill man who wasn't taking his medication. "It's dramatically decreased homelessness, hospitalizations and violence in this population.''

Forty-four people have been committed to outpatient treatment at the Seminole County Mental Health Center, according to Dr. Valerie Westhead, the clinical director. "It's something that helps clients stay in their home community, prevents them from having to go to state hospital, and helps them to live their lives more the way they would like to live their lives.''

Deinstitutionalization knows no borders

“Canada is not alone in jailing the mentally ill. The United States, too, deinstitutionalized a large number of psychiatric patients. There, too, law-enforcement agencies increasingly are left to pick up the pieces.

In New York City, according to statistics compiled by the Treatment Advocacy Centre, the number of police responses to complaints about "emotionally disturbed persons" climbed from 20,843 in 1980 to 64,424 in 1998. In Florida, mentally ill people in crisis must be assessed under the state's mental-health treatment law. In 2000, there were 80,869 mental-health assessments, a figure that handily surpassed the 60,337 drunk driving arrests that year.”

More from the Montreal Gazette …

For more information on ensuring appropriate treatment for people with severe mental illnesses in Canada, visit: http://www.cfact.ca/

DCF settles feud over treatment of jailed mentally ill

Back in December, we wrote about the battle between DCF and local jails in Florida. While the state Department of Children & Families argued that they had too few hospital beds, people with severe mental illnesses were languishing and dying in county jails. The problem had gone on for years (as noted in this 2002 Florida Sheriffs Association resolution.) DCF maintained they did not have the bed space for the inmates even though they were required by statute to provide them hospitalization AND even after district court judges ordered the department to follow the law.

With new leadership at DCF and an increase in funding from the state legislature, the department is now trying to make good on its responsibilities to some of the states most vulnerable citizens.

Remembering Kendra Webdale, her family and so many others

Eight years ago today, Kendra Webdale a vibrant, beautiful young woman was pushed to her death from a subway platform in New York City by a man with schizophrenia who had a documented history of assaults and failing to follow prescribed medication regimens.

At the time, advocates like DJ Jaffe had been working for at least 10 years in New York toward a statewide assisted outpatient treatment law. Kendra family’s commitment to prevent the tragedy of untreated mental illness coupled with Governor (then-Attorney General) Elliot Spitzer’s political will finally succeeded in achieving the reality of Kendra’s Law for assisted outpatient treatment in New York. All those who are being helped by Kendra's Law in New York today are indebted to the Webdales, particularly Kendra’s mother Pat, who continues to advocate and Chairs the AOT Quality Improvement Panel sponsored by New York’s OMH.
In addition to mourning Kendra, today is a day to remember some other random victims of the violence that is sometimes a result of untreated mental illness ... and the families who have, like the Webdales, opened their hearts to try to help others.

Edgar Rivera, who lost his legs after being pushed from a NY subway platform in April 1999, epitomized grace and understanding when he lamented that although he lost his legs, at least he had his mind, unlike his assailant. Linda Gregory partnered with Alice Petrie, the sister of the man who shot her husband in the line of duty as a sheriff’s deputy. Their successful advocacy lead to Florida’s adoption of AOT and they continue to advocate for more humane treatment. Amanda and Nick Wilcox’s daughter was killed at a mental health center in California by a man with untreated mental illness. They are fighting to get their county to adopt Laura’s law.

There are so many others, too many to mention here, but we particularly want to remember 11-year-old Gregory Katsnelson who was killed, while riding his bike, by a young man whose family was told he was not “dangerous” enough to be helped. Before he killed Gregory that day, he also killed his own mother. Gregory would be 15 years old now - the Katnselsons have spent the last 4 years trying to persuade New Jersey legislators to become the 43rd state to adopt an AOT law. The Senate, under the leadership of Governor Codey, passed the bill last year.

Our hope for the New Year is that the Katsnelsons will succeed as other families have in making a terrible tragedy into a legacy of hope for others ... and that better laws and better usage of and understanding of the laws that exist will mean fewer sad anniversaries like today.

Posted by TAC executive director Mary Zdanowicz.

Florida DCF told: Treat inmates now

A Florida appellate court has ruled inmates must get treatment.

Notice that once again, it is law enforcement/corrections stepping up to fill the gap where the mental health system has failed ... .

''I can commiserate with them somewhat because we've had to deal with overcrowded jails, but they're going to have to operate overcrowded forensic hospitals until the Legislature steps up to the plate,'' he said. 'We never thought we could go into court and say, `We know how to solve that problem; we're not going to accept any new arrestees.' ''

- Assistant Miami-Dade County Attorney Randy Duvall

Overbuilt prisons, underfunded mh systems

Mary Beth Pfeiffer weighs in on the terrible situation in Florida in today's Miami Herald.

Pfeiffer is author of the forthcoming book Crazy in America: The Hidden Tragedy of the Criminalized Mentally Ill.

Pfeiffer, a well-respected author, notes that the small number of inmates who are drawing all the attention are just the tip of the iceberg. We would like to add that Florida has one tool that could help - a reformed Baker Act allows people to get court-ordered community treatment. Counties just need to start using it and may then be able to help some of these people who end up instead behind bars.

These inmates are a vivid reminder of the price to be paid when a society overbuilds ts prisons and underfunds its mental-health system, a demonstration of how long erm care of the mentally ill has shifted to the place where there is always a bed. Since 1997, Florida's prison population has swelled by 44 percent, to 89,000 inmates. Meantime, in a state that had 56 state psychiatric beds per 100,000 people in 1990, there are now eight. Squeezed by flagging reimbursements, 36 private psychiatric hospitals have closed in Florida since 1992 -- taking an additional 4,400 beds ....

Just 5 percent [of those inmates] were known to the mental-health system before they were jailed. Had they received care, they likely would not have gotten so sick -- and their prospects for recovery would not be so dim. They also might not have committed crimes that put them behind bars.

SHORT BITS

• One Florida judge gives the state 60 days to figure out how it will move mentally ill inmates out of Orange and Osceola jails and get them the treatment they need, saying “"I wanted to have something done today, but years of neglect of the mental health system is nothing something that's going to be fixed overnight."
• A Maine advocate applauds Robert Bruce’s lawsuit against the state claiming state negligence played a role in his wife's death at the hands of their son. The letter-writer noted “What a shame when the difference between life and death are a few pills a day, and you can't make your loved one take them. His fight isn't just for him, but for all of us who have been there.”
• A Virginia paper comes out in support of Virginia State Supreme Court Chief Justice Leroy Hassell’s Commission on Mental Health Law Reform.
• Kaiser Permanente is charged in skid-row dumping in Los Angeles, California.

Heroic judges

As you know, Florida judges are threatening to jail a Florida mental health official for failing to transfer more than 300 jail inmates to state psychiatric hospitals for treatment. But it should not surprise anyone considering that the state closed a 382-bed state psychiatric hospital in 2002.

If judges with contempt powers can’t get the state to hospitalize mentally ill inmates, imagine the obstacles that Florida families now must face in trying to get hospital care for a loved one.

TAC applauds the Florida judges for holding the mental health administrators accountable for the neglect of the states severely mentally ill citizens. It’s about time somebody did.

Beds in Florida ...

In Florida, DCF officials may soon be in cells next to the hundreds with severe mental illnesses waiting for hospital placement, committed to what DCF claims are nonexistent inpatient beds.

Long waits for placement in state psychiatric hospitals are nothing new in Florida. One man, ordered into care on Oct. 18, 2005, waited 176 days to be transported to a hospital. Two other men, found incompetent in June, waited 82 and 86 days.

Brevard County is acting to create more psychiatric beds - too bad the 288 beds being added aren't in a new psychiatric hospital, but in a new wing of the prison.

Acting when nobody else will ...

What choices do they have?

• A Florida jail has installed 4 padded cells with cameras (at the cost of $131,00) in the wake of the deaths of two inmates with mentall illnesses.
• A Virginia Supreme Court justice has launched a mental heath commission – as one legislator notes: "They [the judiciary] have been put in the situation where at every level and at every court, the people with mental illness are confronting the judges. And they don't have the tools for confronting these people. I think [the judges] are acting responsibly and reacting to our actions and lack of actions."

Corrections officers, judges, law enforcement officers … all of them are filling the gap left by the mental health community. People are left untreated, land in the criminal justice system and … surprise … we expect the criminal justice system to make everything OK.

We’ve said it before … where are the grand juries to investigate the mental health system?

The criminal justice system has no other choice but to build in safety nets for the many people who have fallen through the cracks.

But instead of fixing the cracks, the mental health community seems intent on criticizing the quality of the nets.

The forgotten floor

Miami's CBS station broadcast a two-part news series spurred by Pete Earley's book Crazy. The jail psychiatrist calls conditions in the Miami-Dade jail "morally incomprehensible" for inmates with severe mental illnesses. Miami Judge Steven Leifman is outraged.

“There are five times as many people in our jail with mental illness than any psychiatric hospital in Florida,” pointed out Judge Leifman. “Five times, right here.” ...

Judge Leifman said, “It’s a tough place. It’s not a great condition for anybody that is sick because it is not conducive for treatment. People with mental illness stay in jail eight times longer than sometime without mental illness for the exact same charge and it cost the taxpayers seven times more to treat him here. It doesn’t really accomplish anything here. It’s a warehouse.”

Watch part 1 and part 2 on the website, or read the transcripts.

It is the mental health "system" that is stigmatized, and rightfully so

Reading through newspaper clips today sparked an epiphany. It is not the mentally ill that are stigmatized by the public as much as it is the mental health “system” that is responsible for their care.

Another revelation is that the mental health system’s apparent impotency is responsible for the virtual extinction of successful “not guilty by reason of insanity” (NGRI) pleas. In Canada, one observer lamented the “crazy system” that is responsible for 2 people found NRGI there. The writer gives the impression that he is not so much concerned that “[t]he system is willing to take a chance that the offender, with the right medication and therapy, can be released into the community without re-offending.” What he really found scary was “What if he goes off his meds?”

Such concerns are understandable considering a story from Florida in which a woman who was found NGRI for killing her parents was released after 17 years in a state psychiatric hospital. (By the way, so much for the theory that NGRI’s have short hospital stays). She was released on condition that she take her medication and be monitored by a Jacksonville mental health contractor. But the contractor apparently did nothing to ensure her success. In fact, they never even reported any problems to the court despite the fact that she stopped taking her medication, stopped going to her day program, and disappeared for a month before airport officers in Washington noticed her behaving bizarrely and took her for a psychiatric evaluation.

There are many mental health programs and providers that are very competent and committed to protecting and improving quality of life for their patients. They should be furious with their incompetent colleagues that stigmatize the whole system. And the system’s clients, the mentally ill, should be even more appalled by the injustice and stigma that has been wrought upon them under the guise of “protecting their rights.”

Using the internet to save lives

Are you searching for a person with mental illness who has gone missing? Do you know someone else that is? USA Today reported on how the Internet can be a helpful tool to find people. There are a number of social networking tools and websites that might be helpful. For example:

Tina Gorman of Webster, Fla., has been searching for 3½ years for her missing son, John Townsend, 31, who has bipolar disorder. She posts messages on the Internet in hopes someone with information will contact her. She also included a link on her work website to her son's profile at the National Center for Missing Adults.

We hope Tina Gorman's son, and all the other missing family members who are out there, will be found unharmed.