Well now, that was quite the number of impassioned comments. I did realize that by writing about Laura’s Law (Assisted Outpatient Treatment) there would be some contention, but I didn’t realize quite how much. Thanks to everyone who wrote in well clear, thoughtful comments. (For those whose comments weren’t of that ilk, please review the comment policy here at the Bipolar Burble.)
Due to the number of responses, I have been unable to address them each individually, but I would like to point a few things out in general.
Misperceptions of Laura’s Law (Assisted Outpatient Treatment)
To be clear, and this is something most people seemed to miss in the first article, Assisted Outpatient Treatment (AOT) in California and other states cannot force medication. While medication may be part of a treatment plan, medication cannot be given without consent without going through the normal court procedures already in place. I don’t know how frequently this is done but it seems infrequent.
“Laura’s Law,” “Kendra’s Law” vs. Assisted Outpatient Treatment
As one person astutely pointed out, it is emotionally charged to give the law the name of a previous victim. I’m sorry to add to this as I know it’s political in nature but unfortunately people won’t necessarily know what I’m talking about if I don’t use those names.
Studies on Assisted Outpatient Treatment
Additionally, there was much disagreement on the numbers I cited regarding Assisted Outpatient Treatment. To be clear, some of those numbers come from New York where “Kendra’s Law” is in place and has been for longer (and thus has been more studied).
Numbers from California are based on a tiny population (as it turns out) and thus are of low quality.
Randomized Controlled Studies of Assisted Outpatient Treatment
A reader commented on how studies have rarely used randomized controlled samples when reviewing the Assisted Outpatient Treatment programs. This is a fair statement, but I have an issue with this concept of a randomized controlled sample in this group. How would this be possible? If a person qualifies for the AOT program, how could you include them in a study and not put them in a program? Does it not go against ethical standards to offer no treatment to a person who needs it? In short, I’m just not sure it’s possible. People who are selected for the AOT program are always going to be different than those who are not selected by very definition of the program.
An Example of One Such Study
One reader did point to a study that attempted to use randomized controlled samples to evaluate AOT-type programs in the US. While they did come up with some interesting conclusions, there are problems with their data.
What this review found is that there was no difference in those in an AOT vs. those who were not on the following measures:
- Readmission to hospital by 11-12 months
- Compliance with medications by 11-12 months
- Arrest by 11-12 months
They did find that those in AOT significantly had fewer:
- Arrests for violence by 11-12 months
- Homelessness
- Victimization by 11-12 months
Those look like pretty big wins to me.
However, there was a significant increase in those in AOT programs who perceived coercion in care.
However, as I said, there are issues with this data:
- Data quality is considered “low” by study authors
- Data does not include those with a history of violence (For some reason the studies excluded these people. I suspect their inclusion would change the numbers substantially.)
And by excluding those with a violent history, you’re actually excluding most of the people who would even be affected by Laura’s Law (Assisted Outpatient Treatment in California).
Check out more resources on Laura’s Law questions and answers.
Question for Those Who Are Anti-Assisted Outpatient Treatment
So, a question for all those who wrote in an said that Assisted Outpatient Treatment was horrible.
If I were to take a person who would fall under the qualifications for Laura’s Law:
- The person has a serious mental illness
- The person refuses treatment
- The person has a history of violence
- The person has been in jail twice in 3 years
What would you have the system do with this person? What is the right thing to do? Someone please suggest something other than outpatient/inpatient treatment or incarceration that would work. Because what I’m seeing is a person in desperate need of help and who are we if we do not offer any?
Hallo Fiachra,
Sorry about the name (I promise you its representative).
As regards ‘violence’ – I have attempted suicide a number of times on ‘control type’ psychotropic medication – and made full recovery off it. For me it wasn’t so much about not taking medication as it was about taking something that didn’t disable me – my solution was to take very low doses suitable for milder ‘illness’ and these eventually phased themselves out. I also found very good longterm answers within psychology.
(I have all the relevant extreme diagnoses as well)
Fiachra
There are a few studies that show the ineffectiveness of AOT programs. One was in the UK by Tom Burns.
Kisely, Steve (February 2011), “Compulsory community and involuntary outpatient treatment for people with severe mental disorders”, The Cochrane Collaboration, retrieved 2013-05-30 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004408.pub3/abstract
Burns, Thomas; Jorun Rugkåsa, Andrew Molodynski, John Dawson, Ksenija Yeeles, Maria Vazquez-Montes, Merryn Voysey, Julia Sinclair, Stefan Priebe (11 May 2013). THE LANCET 381 (9878): 1627–1633. PMID ISRCTN73110773 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60107-5/abstract |url= missing title (help). Retrieved 30 May 2013
Chemical lobotamys are not the awnser to “help” people.
The effect of a chemical lobotamy (nueroleptics):
A nueroleptic life is not a life for many people. The normal way of describing the effect of these drugs is ” I feel like a zombie ” or anhedonia.
Anhedonia: Loss of the capacity to experience pleasure. The inability to gain pleasure from normally pleasurable experiences. Anhedonia is the reaction to these drugs.
An anhedonic mother finds no joy from playing with her baby. An anhedonic football fan is not excited when his team wins. An anhedonic teenager feels no pleasure from passing the driving test.
Of couse It takes forced treatment ..
Treatment means giving up all the feelings that make a persons life worth living.
It is almost a “killing of the soul” and just the body lives.
Informed_consent,
As I’ve already stated, that is ridiculous. Many people choose to go on and stay on antipsychotics (neuroleptics) because it’s the only thing that helps them _have_ a life and _not_ experience anhedonia.
Do they help everyone? No, of course not, but they help many.
– Natasha Tracy
I was on court ordered treatment for one year. What this meant was that I saw a specialist psychiatrist and was monitored very closely. The essence of this contract (by law) was that I had to attend appointments and be honest about medications and usuage. If the psychiatrist had felt I was a danger to myself (which is why I was put on COT) he could put me back into the hospital. I could apply at certain intervals to have the decision reviewed however was very comfortable with the care I received and stayed on the program for the mandated one year. I have been on antipsychotics for about four years now (along with mood stabilzers) for bipolar and can tell you that they have never left me feeling like a zombie nor diminished my ability to experience pleasure. They allow me to parent without the mood swings and outbursts that constantly controlled my life and where counter productive to good parenting. I laugh, I cry, I hug my children dearly and without fear I will fly of the handle. They have given me back a life. Of course there are some side effects (for me severe akathesia, smilar to restless leg syndrome which makes it impossible to lye down) however that is controlled by another drug and currently I have found a good antipsychotic which does not give me this side effect. While I understand that some have the experience of seeing others as zombies (or their own experience) it does not mean that all antipsychotics correctly prescribed and monitored have this effect. I have for example had personal experience of seeing my schizophrenic brother be more sedated with thorazine however he still bowled, drove his car and lived an active life. I wish more balance could be placed in these discussions rather then a blatent attitude which does not adequately describe each individuals experience. During COT I received excellent care and continue to work with this psychiatrist as my choice he is extremely compassionate. At the time I was placed on COT I was in grave danger and it only helped to stabilize and maintain me.
True if not this treatment then it would be jail. Which would just increase jail population and worse treatment. Anything that decreases incarceration without harming the public is good.
Dan
Hi Dan,
Yes, it’s thought that 1-in-4 people in jail have a serious mental illness. Just imagine what we could do if we could get those people help instead of just locking them up. Sure, some of them still might end up in jail (you can’t save everyone) but it would be nice to know that we’re saving some of them from that life.
– Natasha Tracy
In regard to the Cochrane study you summarize their findings by stating that:
“Data quality is considered “low” by study authors”
Maybe I’m misreading you but it reads as if you’re downplaying the significance of the Cochrane Review by stating that the authors assessed the studies they based their systematic review upon as being of low quality.
These kind of reviews use the best available evidence. The authors of the Cochrane review searched through various medical databases and returned 7356 citations for scholarly papers on the subject of CTOs. 71 of these were regarded as potentially relevant to their review of the evidence. 61 of these studies were excluded as they did not meet the inclusion criteria (i.e. were not of a high enough standard). That left 10 papers based on 2 studies and these two studies, as representing the best evidence available, formed the basis of their review.
That the authors assessed the data to be of low quality indicates that their is problem with the evidence level in support of AOTs/CTOs generally at least as measured against the norms of evidence based medicine.
Hi Fiachra,
I’m not sure that I’m downplaying the importance of the review, just stating what the authors themselves state which is that the evidence is of low quality and that new evidence may significantly change the results of the review.
What they did is admirable, but I agree with them (and you) better quality research on the topic would be beneficial for everyone.
– Natasha Tracy
Natasha in your blog post above you make the following statements in regard to the Cochrane Review:
“They did find that those in AOT significantly had fewer:
Arrests for violence by 11-12 months
Homelessness
Victimization by 11-12 months
Those look like pretty big wins to me.”
I think there might have been a little misreading of the Review here. There was only a statistically significant difference between those on ATOs or CTOs and those receiving standard care for victimization. Defined as being the victim of violent or non-violent crime, those on ATOs/CTOs *were* significantly less likely to have been victimized than those receiving standard care. It would be really interesting and potentially useful to know why this was so.
The relevant section of the Review states:
1.2 Patient level outcomes – by 11-12 months
1.2.1 Social functioning: trouble with police
People receiving compulsory community treatment were no more likely to be arrested than those receiving standard care (2 RCTs, n = 416, RR outcome ‘arrested at least once’ 0.97 CI 0.62 to 1.52). Results also showed people allocated compulsory community treatment were no more likely to commit a violent act than those in standard care (2 RCTs, n = 416, RR 0.82 CI 0.56 to 1.21). In terms of numbers needed to treat, it would take 238 OPC orders to prevent one arrest.
1.2.2 Social functioning: homelessness
Although the results appeared to favour the compulsory community treatment group, we found no statistically significant difference in the risk of being homelessness between groups (2 RCTs, n = 416, RR 0.67 CI 0.39 to 1.15). In terms of numbers needed to treat, it would take 27 OPC orders to prevent one episode of homelessness
1.2.3 Quality of life: victimisation
Swartz 1999 provided data for this outcome. Those receiving compulsory community treatment were significantly less likely to have been victimised (been a victim once or more of either violent or non-violent crime) than those in the standard care group (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8, NNT 6 CI 6 to 6.5).
Hi Fiachra,
I don’t think I misread it but thanks for supplying more detail.
– Natasha Tracy
They DIDN’T find a SIGNIFICANT difference in the arrest or homelessness rate between those on AOTs/CTOs and those in standard care
Hi Fiachra,
You’re right about that. But they did mention, “it would take 27 OPC orders to prevent one episode of homelessness.” They may not consider that statistically significant but I’d say it was real-world significant.
– Natasha
Aside from the fact that that’s a hell of a lot of CTOs to prevent one episode of homelessness, If it’s not statistically significant than that level of difference could be due to chance.
Hi Natasha,
Sorry for the delay in posting.
In regard to your remarks on randomised control trials, you state, “I have an issue with this concept of a randomized controlled sample in this group.How would this be possible? If a person qualifies for the AOT program, how could you include them in a study and not put them in a program? Does it not go against ethical standards to offer no treatment to a person who needs it?”
In reply, it’s certainly possible to conduct an RCT as it has been done for the both the AOT programme in New York and the CTO programme in North Carolina. Those are the two available RCTs which the Cochrane review analyses. As regards the ethics of doing so that would only be a problem if the benefit of the treatment had been conclusively and scientifically established. In todays world of evidence based medicine RCTs are the established way of providing such evidence. Arguably, the lack of credible RCTs of ECT treatment played a major role in its classification by the FDA recently as a Class Three (High Risk) Medical Device. You’re assuming the effectiveness of the programme has already been conclusively established when it has not. Moreover, it is not as if those not selected for AOT would receive no treatment – they would have to get all the other treatments (assisted housing, ACT, intensive case management, etc) that those on AOT would get. One would just be comparing the impact of the legal leverage exercised by the AOT not all the ancilliary services.
This is not to say that there are not problems with RCTs nor advantages with naturalistic studies which we could go into, I guess.
You refer to the Cochrane review of the two available RCTs and state that “there are problems with their data”. This is true and the authors freely acknowledge this (indeed that is part of the authors point in regard to the generally poor level of evidence in support of AOTs/CTOs). However, as with all such Cochrane reviews, theirs was based on the best available evidence. In other words they used the only two studies in existence for the operation of CTOs that had randomised
In regard to the exclusion of people with a recent history of violence from their review you state “Data does not include those with a history of violence (For some reason the studies excluded these people. I suspect their inclusion would change the numbers substantially.)”. The issue here is that Swarz’s studies (lead author of the RCTs on which the review was based) did not randomise this group. In other words, they did not form part of the original RCTs and were treated separately and thus could not be included in the Cochrane review.
I’ll post again when I get a chance.
Forcing a person to take medication contravenes the UN Convention on the Rights of Disabled People. Article 17: Every person with disabilities has a right to respect for his or her physical and mental integrity on an equal basis with others. Easy read version: You have the right to refuse treatment.
For your information, Natasha, the UN is a body which concerns itself with International Law and its Conventions are intended to set an example to the world. The UN was formed in the aftermath of the second world war to ensure that the atrocities of the Nazi regime were never repeated. The legacy of Nazism to the world is psychiatry. Many of the founding fathers of modern psychiatry were Nazi doctors who took up residence in the USA after the second world war. Nations may be free to set up whatever stupid and draconian laws they delude themselves into beleiving are necessary but the UN holds the Moral Truth and is the ultimate test of them.
Hi Jean,
I’m starting to get concerned people can’t read. I shall say it again, Laura’s Law cannot compel medication.
If you have issues with its legality, you might try arguing with your supreme court as they have upheald the lawfullness of AOT laws.
– Natasha Tracy
By the way, you are also wrong that the state cannot force medication. It can and it can be given via injection. If the person refuses, they can be — and are often — hospitalized. (in NY)
Hi Erika,
I can’t comment in New York but in California Laura’s Law cannot compel medication. As I’ve stated, there are other laws that can be invoked for that, however.
– Natasha Tracy
Another thing, medication compliance can be mandated when it comes to injectables. You can call 911 and that person will be picked up and taking to the hospital for evaluation. With injectable medication, it’s consider a life or death situation. I seen AOT work with consumers who are preoccupied with suicide, high # of suicide attempts, and rehospitalization. Side note: suicide attempts, suicides occur more in train stations than homicides but the government tries not to share the statistics with the public.
I suffer from Bipolar illness & I also do case work in NY for adults with SMI. I myself have gone to court to get some of my consumers in treatment. Across the 4 yrs, i worked as intensive case manager, the quality of service has changed. I have seen AOT programs close, so now consumers are less likely to get the help. It’s not just for history of violence but history of hurting yourself. I font regret making such referrals. it has until this year helped the consumers I referred get their life back. The families, if you can see how supportive families lose hope, you can understand.
I think a better alternative would be weekly talk therapy or rehab for recovery (in a not so hospital like place; ie. Cornell in Weschester). AOT “sucks”now, the AOT coordinators rarely make a removal & they have a higher # of consumers in their case load. They are less likely to go into the community & see the consumer and evaluate the crisis.. AOT now is just a program to protect law suits because it’s all about documentation.
Rosa
Can you please contact me via http://mentalillnesspolicy.org I would love to hear what you have to say. tx
dj
Hi Rosa,
Thank-you for sharing that information. I suspect you are correct, if people could meet the grateful people involved, they might understand the position.
I’m sorry to hear services have declined. My understanding is that once a person is placed on AOT the state is mandated to provide the treatment. It’s sad if they aren’t following through on their part of the bargain.
I’m surprised to hear talk therapy and rehab isn’t part of the treatment plan.
– Natasha Tracy
Most studies that cite no difference in violence between those with mental illness and others use one of the following statistical slights of hand
1. Define ‘mental illness’ broadly so that the ‘n’ includes 50% of population rather than the 3-8% who have severe mental illness
2. Include people in treatment, not just those who are not in treatment. (The former would have decreased violence but it would be due to their medication, ie, the meds lower the number considered violent)
3. Exclude the incarcerated, hospitalized, suicided, and homeless. By only focusing on say, people released from hospitals to live with their moms, those who are more likely to be violent are excluded from the study.
You can read an analysis I did with Sally Satel on these mathematical perversions here: http://mentalillnesspolicy.org/consequences/macarthur-violence-mental-illness.html
The best recent meta-analysis of the association between serious mental illness and violence concludes that while there is a relationship between psychosis and violence most but by no means all of the increased risk is mediated by comorbid substance abuse.
In the discussion of their findings the authors conclude:
“Our findings suggest that individuals with substance use disorders may be more dangerous than individuals with schizophrenia and other psychoses, and that the psychoses comorbid with substance abuse may confer no additional risk over and above the risk associated with the substance abuse. As substance use disorders are three to four times more common than the psychoses public health strategies to reduce violence in society could focus on the prevention and treatment of substance abuse at individual, community, and societal levels.
[…]
In summary, there is a robust body of evidence that demonstrates an association between the psychoses and violence. This association is increased by substance abuse comorbidity and may be stronger in women. However, the increased risk associated with this comorbidity is of a similar magnitude to that in individuals with substance abuse alone. This finding would suggest that violence reduction strategies could consider focusing on the primary and secondary prevention of substance abuse rather than solely target individuals with severe mental illness.”
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000120
Interestingly, the data on violence and medication adherence appears to be contradictory.
See:
Asher-Svanum H, Faries D, Zhu B, Ernst F, Swartz M, et al. (2006) Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. J Clin Psychiatry 67: 453–460.
Swanson JW, Swartz MS, Van Dorn RA, Volavka J, Monahan J, et al. (2008) Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia. Br J Psychiatry 193: 37–43.
in response to both Chrisa and Natasha, what can services do if someone does not want treatment but you are worried about them:
The Open Dialogue Approach in Western Lapland addresses just this problem by not seeing the individual as the problem. They treat the social network and anyone who is concerned about someone can ask for help. They then ask this person to convene a meeting and ask the significant others in the distressed persons along. The clinicians then facilitate a series of meetings with these people. The distressed person is invited but does not have to attend. If they really do not want to attend they ask if they would like to sit in the next room with the door open and listen.
I have just been reading some documents about such meetings where family violence was involved. So they do have experience of working with people who have been violent. They do involve police and other from the criminal justice department if they are already in the persons life.
http://taos.publishpath.com/Websites/taos/Images/ResourcesManuscripts/seikkula-OpenDialoguesWithGoodAndPoorOutcomes.pdf
This is very successful and uses very few drugs and is non coercive.
However very few mentally distressed people are violent, some figures say no more than the rest of the population, some say more, but no significantly more. So some people think that Laura’s law and such like are a bit of an overreaction.
Looking further at Natasha’s ideas,ie:
* The person has a serious mental illness
* The person refuses treatment
* The person has a history of violence
* The person has been in jail twice in 3 years
This seems to be a bit of an indictment of the prison system. If someone has been in prison and they have not helped the person deal with their mental distress and perhaps a tendency to be violent then the prison service is not doing a very good job. There seems to be a good reason to campaign for better psychologically based treatments in prisons rather then for Laura’s law.
I trained with Dr Bob Johnson in the UK who worked successfully with a range of very disturbed people, including serial killers in two UK prisons. He helped them look at why they killed and the traumas that drove them to violence. Most of the people he worked with were violent in prison. But after working with him they became non-violent. The fact that he successful did this, using low medication regimes, often with no medication, with some of the most violent offenders in the UK prison service shows that the prisons you refer to are failing people if they are turfing out mentally unstable, potentially violent people. Your scenario is an indictment of the rehab of prisoners in the USA rather than a case for Laura’s law.
I do know someone who refuses treatment and gets very angry and annoys her neighbours. She refuses treatment because she does not like the treatment that is on offer. She would accept therapy because her anger is fuelled by a traumatic childhood which she wants to deal with. A drug based, medical model means that she is not offered this. She is very worried that she will be put on a CTO, as the equivalent of this law is called in the UK, and be forced to take drugs. So maybe people refuse help because the services are drug based and is not interested in the person as a human being and how their life has been?
I feel there is an interesting piece of research into why people refuse treatment, from the point of view of the people refusing treatment that would be well worth doing. I do not know of any such research but if you could find some Natasha it would make an interesting addition to the debate.
The information you give does not give enough information to say what could be done. I would need to know if the violence happened before the diagnosis of mental distress, what seemed to have caused it in the past, what had changed about the persons living situation since they first got the diagnosis and since they have been violent, how had they changed in the meantime, what help had been offered in the past and whether it had been helpful, what other services have and are involved in the persons life and how they operate, what kind of help the person had refused and other factors before I might be able to give an answer if I had a definite scenario to work with. It might be that leaving the person alone is the best thing, as it would be for a friend of mine who is on a CTO and forced to take drugs by injection against their will right at this moment (although she does not fit the criteria you have listed, not having been in prison or been violent. She does have a mental health diagnosis but does not want it and does not find what the services offer, forced or otherwise of any help)
It is my understanding that the successes Bob Johnson had were with patients/prisoners who had been diagnosed with personality disorders – mostly psychopaths. I personally doubt those successes would have extended to those who have organic mental illnesses – as bipolar disorder or schizophrenia – especially since he seems to advocate the view that any mental illness can be cured without medication – at least, this is how I understand his position. This is not so different from Dr Patch Adams, who I understand thinks the way to cure mental illness is by giving love, not drugs. Forgive me if this bipolar bloke seems skeptical … especially as I see no evidence of anyone ever having been cured of bipolar disorder or schizophrenia. (Mind you, 99.9999% of dermatologists will tell you that severe pemphigus vulgaris is fatal if it is not treated, and still a life-long illness if it is; however, my mother gave up medication (steriods) even though the doctors told her she would not live beyond 9 months, and she adopted a method of treating the blisters. It was effective, if painful, done by bursting them with sterile needles and drying them out with Alum. 30 years later she is still alive and free of the illness. So, I will accept the “impossible” sometimes is possible! But it’s as rare as hens teeth and rocking horse droppings … )
Hi John,
One of the major problems with family/friend interventions is that it assumes that the person has any. Many people who are in need of treatment are on the street with no friends or family to speak of. There is no one to help them. No one to pose discussion or an intervention.
As for my theoretical scenario, I never said that a treatment plan _shouldn’t_ involve counselling. It’s a treatment plan, it can include anything. In fact, I would suggest that the vast majority of people could be helped, to some degree, with therapy.
– Natasha Tracy
Hi,
I really like the OD approach and would like to see it trialed elsewhere but it is mistaken to state that they do not use compulsory treatment. They do and it is, indeed, referred to at the bottom of page 265 in the Seikkula article that you refer to. Quite what is meant in this context by “compulsory treatment” other than involuntary hospitalisation is not clear to me. Nor is it clear to me at what rate it is used.
The other issue is that their studies in English at least mostly report on first episode psychosis. While the programme has appeared to have an highly encouraging success rate judging by the decline of *incidence* rates for psychosis in Western Lapland since OD was put into operation the target population here is a little different and mostly constitutes people who have undergone repeat hospitalisation.
thanks for pointing that out (about the forced hospitalisation). They do however have very little hospitalisation compared to other parts of Finland, and my comments were more about how this could be used as an alternative to CTO type laws.
However I recently saw Jakko Seikukela (not sure about the spelling) and he has been developing this work with people who have been using services for a long time, so people who have, and are hospitalised. He said he was having some success, even after decades of being service users. I discussed using open dialogue with agoraphobic hoarders and he thought it would be applicable. Basically it is a type of intense social support that concentrates on the family but invites others into the meetings, so I think it is likely to be of use to anyone in mental distress, whatever the diagnosis
HI John Hoggett, re lowered hospitalization rate that makes sense given the lowered incidence rate for non-affective psychosis at least. Do you have access to any figures for the hospitalization rate in Western Lapland though?
OD might be applicable to the kind of population that Natasha is talking about here but their circumstances may be much more extreme and the ability to mobilise social and family networks may be significantly reduced.
For every person who says that AOT laws violate personal rights, I ask them if they’d rather be actively psychotic, homeless, victims of crime, or dead, like Kelly Thomas.
As the parent of a teen with a severe mental illness, even legal guardianship can’t help me in ensuring my son stays with the treatment that keeps him stable, should he choose to stop it. As a minor, I couldn’t get him into a hospital unless he was an active danger to himself or others. How is that treatment? How is that in his best interest?
AOT laws, to the families that love persons with mental illnesses, are step in the right direction to helping us give our loved ones the lives they deserve.
It’s not in his best interest. The law, however, is not written (solely) to protect one’s best interest–it is also written to protect one’s rights. AOT is unconstitutional by nature — I would argue in violation of Equal Protection (you only apply this standard to the mentally ill. What about the non-complaint Diabetic who becomes severely ill — including, perhaps, a short term coma and loss of limb function, can’t work, is on disability — because he won’t take insulin. When there is a law passed saying you can force him to take his medication, I will consider AOT more Constitutional), Donaldson V O’Connor, etc — and, as such, it should not be legal. As awful as the reality of mental illness is, laws should not be created based upon our instinct and emotion (help them, get them to take their medication, etc).
Furthermore, their benefit is, in my opinion, debatable. In most cases, AOT will end. It legally has to — after a year (six months + six month extension), it is over. You can attempt to recommit someone, certainly; however, having to do presents a poor long-term impact (to be clear, there are no studies on life after AOT). Also, while AOT is very successful at reducing incarceration and hospitalization, with many harmful behaviors, over 50% of the group continues to engage in them.This shows me that, while you are keeping people in the community, you are not restoring their functioning to the best that is possible.
Another key fact: Kendra’s death could have been prevented with better access to voluntary outpatient services. The man who pushed her had only ever been hospitalized voluntarily, was mostly complaint and was on waiting lists (that HE put himself on) for long-term care programs. Due to budget cuts, there was not enough room. Another man that was injured around the same time (similar story — mentally ill man pushed him into an oncoming subway; he lost both legs) had been at the ER earlier that day asking to be hospitalized and has been sent home; he was not on his medication because his Medicaid was terminated and he could not afford it; he was also homeless.
To answer your original question: No, I would not prefer to have a person psychotic, violent, homeless, etc. Not at all.
That preference, however, is not what public policy should be based off of (this idea is expressed in Donaldson V O’Connor).
Also, though Chrisa knows who I am, for the purpose of disclosure, I am a sufferer of Schizoaffective Disorder and have numerous family members, all of whom refuse treatment, with a wide variety of mental illnesses. So I do know how awful it is and, though I would like my family to comply with treatment (and, as a child, having stable parents would have made my life less Hellish), I consider it a step backwards Constitutionally and in terms of Human Rights. I also live in an AOT state — NY, in fact — and have met those involved with it as patients, case workers, etc.
Hi Erika,
You raise an interesting point about others being forced into treatment too. One thing I must say though, it is not equivalent to forcing a diabetic to take his insulin as:
1. AOT cannot force medication
2. Diabetics can appreciate their condition mentally.
Those two significant differences put AOT and mental illness in a different category.
– Natasha
Chrisa,
Thank-you for your personal perspective on this. I know many people who are at their wit’s end as they can’t get their loved ones help. It’s impossibly difficult to watch someone you love fall apart. I’m sorry you’ve had to experience that.
– Natasha Tracy
Natasha,
During the period that I was actively participating as a Guardian Advocate in Florida, which required a training program, testing and a State of Florida appointment, I can personally validate your words that “cannot force medication…without consent without going through the normal court procedures already in place.”
Warmly,
Herb
vnsdepression@gmail.com
http://www.vnstherapy-herb.blogspot.com