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4 Myths About Assisted Outpatient Treatment

4 Myths About Assisted Outpatient Treatment


  • After lounging on the doorstep of respectability for the past decade, assisted outpatient treatment is here to stay. But some still balk at the notion. Scroll throuh the slides for some common misconceptions.

  • AOT is court-supervised treatment of severe mental illness within the community. It is a 2-way commitment that requires mental health systems to serve participants at the same time it commits participants to adhere to their treatment plans. "In December the [APA] Board of Trustees approved a position statement that directs our ongoing advocacy efforts on involuntary outpatient commitment (IOC)/assisted outpatient treatment . . . The APA position is that IOC/AOT can be a useful intervention for patients with severe mental illness and documented histories of poor compliance leading to repeated relapses and rehospitalizations. It can be effective when accompanied by adequate resources and intensive, individualized outpatient services and when the initial commitment period is 180 days." -Renée Binder, MD: Assisted Outpatient Treatment: APA’s Position Statement. Psychiatric News


  • This argument has been soundly rejected in the courts. In the 2004 case Matter of KL, the plaintiff challenged Kendra’s Law, arguing it authorized “forced treatment” without adequate due process. The New York Court of Appeals, widely regarded as a champion of civil liberties, unanimously held that AOT is not forced treatment. The court noted Kendra’s Law prohibits forcible administration of medicine and only allows re-hospitalization if the usual commitment criteria are met. Thus, the court found the law relies on “the compulsion generally felt by law abiding citizens to obey court directives,” not force. [See Reference 12 here]


  • This misconception ignores the key factor addressed by AOT—anosognosia. Approximately half of individuals with serious mental illness experience anosognosia, damage to the parts of the brain used to think about ourselves, confirmed by at least 20 studies. [See Reference 13 here] People who think nothing is wrong with them—the signature symptom of anosognosia—have no reason to seek treatment. It is simply illogical to assume system improvements will draw in these patients, and the experience of many communities unfortunately bears this out.


  • There is simply no defensible evidence that this is true. In fact, when individuals receiving AOT under Kendra’s Law in New York were asked, 81% said AOT had helped them get and stay well.[See Reference 14 here]


  • Research shows that the population served by AOT disproportionately uses public resources. Consequently, research has found that mental health services, including voluntary services, can actually be expanded when AOT is used because of savings associated with decreased resource utilization by a small population.[See Reference 15 here] More broadly, addressing the outsized costs associated with high utilization is a growing concern for public health and policymakers.


  • For more on this topic, see Assisted Outpatient Treatment Enters the Mainstream, on which this slideshow is based.

Comments

It is successful follow up as a team and working with other resources , engaging the person in assisting them to live a full and independent life, as possible and as much as any of us. We are all interdependent and intraconnected at different points in our lives. We need others for assistance too. It may or may not be for our mental health but it may be for other aspects of our life that we struggle . Why should we institutionalize human beings and confine or want th to conform to something that is not humane or human or denies fundamental rights?

Brenda E @

It is successful follow up as a team and working with other resources , engaging the person in assisting them to live a full and independent life, as possible and as much as any of us. We are all interdependent and intraconnected at different points in our lives. We need others for assistance too. It may or may not be for our mental health but it may be for other aspects of our life that we struggle . Why should we institutionalize human beings and confine or want th to conform to something that is not humane or human or denies fundamental rights?

Brenda E @

"It is a disgrace that the USA is unable to join other developed nations in the moral obligation of providing adequate help and consistent treatment to those that are unable to use good judgment, because of a mental illness."

This is the bottom line, and, yes, there may be ways to bend ourselves out of shape to deal with the crisis of the homeless or incarcerated mentally distressed, but these all avoid the issue Dr. M-C puts his finger directly on. My neighborhood 'houses' two schizophrenics who are homeless and both disturbed and disturbing. The children call one of them 'the Yeti" because he is always hidden within an immense parka. These people should be protected and well cared for in a safe setting with adequate medical attention, not left to drift at the mercy of the weather and the whims of the surrounding society.

Alex @

I'll answer your question William. What happens when they refuse? (their medications). They will relapse and become psychotic, meaning they may start hearing voices, sometimes telling them to rid the world of this or that type of person; they may think that something catastrophic might happen and in order to prevent it, they must take things into their own hands and wipe out that group of people standing at the bus stop; they may think someone is trying to poison their mind by telepathy or water. If they live with family members, those family members may be terrorized over the real possibility of aggression or violence which they have experienced time and time before. I have been caring for schizophrenics for over 30 years and the best type of care was in the old institutions in which they were not vulnerable to preying addicts and thieves, had all their daily needs met including exercise, nutrition and socialization and were continually monitored by medical/psychiatric professionals. Instead, we threw them out on the streets, to live under bridges and be easy prey for ruthless predators in our society. It is shameful. And the person who talked about anosognosia was exactly right. The biggest challenge is keeping them on their medications. The best approach I have found is the long acting injectible, but even that they object to and are non adherent. So what is a society to do? AOP is a long awaited for intervention that could make an enormous difference in our schizophrenic population.

Carol @

The AOT program mostly helps to deal with the reality of the high prevalence of homelessness within the severely mentally-ill patients. Even the ACT teams will fail in keeping the person in treatment, if they don’t have a place to live. Furthermore, it is poorly-kept secret that many shelters are gathering places for illegal drug users and that many patients get their ID cards, debit cards (to withdraw SS money) and their belongings, while sleeping in shelters. To add insult to the injury, many shelter are only open at night and the admission is not guarantee…first come, first served. Under those circumstances, what can be expected from a person that is “hearing voices” or having racing thoughts, bout of anger or depression and does not have a place to rest quietly?
It is a disgrace that the USA is unable to join other developed nations in the moral obligation of providing adequate help and consistent treatment to those that are unable to use good judgment, because of a mental illness. I suspect that I am not the only one that have treated MDs, lawyers, engineers, teachers, gifted artists, etc. that became homeless because of schizophrenia or severe mania. I bring up this aspect of the situation because I have encountered ill-informed persons that believe that mental illness is a “thing” of the poorly educated or the weak.
I believe that the AOT program would be of substantial help for the psychiatric patient, if the public officials get serious about funding the housing needs and transportation to and from appointments.

Dr. Manuel Mota-Castillo
Chair of Psychiatry, Burrell College of Osteopathic Medicine
and Director of Behavioral Health Services at Memorial Medical Center
Las Cruces, New Mexico

Manuel @

Unless specifically and adequately funded, AOT takes resources from systems as a whole and makes it impossible to obtain timely voluntary care for non-urgent problems.

Linda @

The primary issue with AOT is lack of real teeth

Marilyn @

Myth 1: it depends on point of view, and law standards, Soviet psychiatry, which assaulted dissidents in a way not too different from some uses of mental therapy in western world, was in concordance with positive legislation there, perfectly legal, as it was forced sterilization laws in Nazi Germany, USA, Sweden, and elsewhere.
Myth 2: people would consult more, in a voluntary way, if having any mental disorder wasn't an unbearable stigma, and if professionals were more respectful to autonomy, identity, informed consent, double checking restrictive measures, and adequate follow-up, more careful about freedom and dignity, in single terms. The recently publicized fact that some hospitals refused discharge to children if it hadn't had circumcision performed, a mental health procedure, is illustrative.
Myth 4. Stratify, asses risks, strictly define 'dangerous' behaviors that may garant an actual, perhaps not with legal requirements, incapacitation.
Arbitrariness, ordinancism may help someone keeping their positions, but will make many innocent victims.
A Court rule was probably that it's better having a guilty person free than an innocent punished, does this deserve consideration in mental health?

Jose @

Need to address diabetes. Tardive diskenesia. Weight gain. And all the other elements of Anti psychotic medications.
Is "informed consent" to take these medications possible? And what happens if they refuse? Jail? For the crime of shizophrenia? Please.

William @

That they should be SO lucky, William!

Hardly a jail, where one may refuse food, water and the most potent, "soul-destroying" of psychotropics, and know one's charges, judgment and sentence.

More likely indefinite incarceration among others deprived of the most basic of human rights.

And if that sinister euphemism, "assisted" is not sufficient to awaken us to the Orwellian nature of the beast, what could be?

Meanwhile, the WHO says that those with, meaning those accused of having, "mental disorders" (undefined) ought not be discriminated against....while continuing to baulk at ceasing to condone the deprivation of all human rights, up to and including that of life itself - if by "life" one means the freedom to enjoy one's own state of consciousness unsullied by forced psychotropics - of those subhumans ("miscreants?") accused of being "mentally ill" or "mentally disordered," and so falling beneath the laws which apply to "other" citizens.

When I mentioned the term “personality disorder” to our sixteen-year-old, Elizabeth, her immediate retort was,

“PersonALity disorder?! How could you have a personALity disorder?! That’s who you ARE! That’s like, THE rudest thing, Ever!”

Yes, miscreants with personality disorders, and those “schizophrenics” among us who do not have “good” judgment or do not make “good” judgments…

But we have all been miscreated, or none of us has; we are all sinners, or none of us is; we are all heretics, in our own way, or none of us is; we all have personality disorders, or none of us has; we each have a right to be here, or none of us has. And our entire cosmos is in utter chaos and completely indifferent to our fates, or it is more absolutely, exquisitely, infinitely and divinely ordered, intelligent and loving that we have yet been graced with the wisdom to attempt to appreciate.

Have a great day!

Tom Kelly, veterinarian.

"The most incomprehensible thing about the universe is that it is comprehensible!"

tom @

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