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Assisted Outpatient Treatment: A Helping Hand in the Community

Living with a loved one afflicted with a mental illness who does not comply with his or her treatment plan can have a tremendous negative impact on the family as well as the individual. Assisted Outpatient Treatment, or “Kendra’s Law,” is a valuable tool for families and others who seek to help individuals who often refuse services in the community and are frequently hospitalized. The law was enacted in November, 1999, after earlier that year a man suffering from chronic schizophrenia, with repeated hospitalizations, pushed Kendra Webdale in front of a subway resulting in her death. The intention of Kendra’s Law is to prevent incidents of violence as a result of outpatient treatment non-compliance, as well as the revolving door of hospitalizations that so many clients experience. According to New York’s Office of Mental Health, it appears that Kendra’s Law has been largely successful in these goals. However, Kendra’s Law is not without its flaws. This article will address the question of who qualifies for services under Assisted Outpatient Treatment, how a petition is initiated, who is a proper person to be a petitioner, and a review of the services that are typically provided to an individual who is the subject of an Assisted Outpatient Treatment Order. Furthermore, this article will delve into some of the statistics maintained on Kendra’s Law indicating its success as well as some difficulties that Kendra’s Law has created.

The Nuts and Bolts of Obtaining Assisted Outpatient Treatment

To successfully obtain an Assisted Outpatient Treatment Order, there must be a proper applicant (the Petitioner) and subject (the person in need). There must also be a plan of treatment approved by the county or local Assisted Outpatient Treatment Program. The county or local program is responsible for ensuring the quality of benefits offered, case management services, and other administrative duties.

New York’s Mental Hygiene Law, Section 9.60, is the statutory framework for the Assisted Outpatient Treatment program. The Mental Hygiene Law delineates the criteria for a person to be the subject of an Assisted Outpatient Treatment Order as follows: The subject must be at least 18 years of age and suffering from a mental illness, he or she must be unlikely to survive safely in the community without supervision, based on a clinical determination and a history of lack of compliance with treatment for mental illness that has; (i) at least twice within the last 36 months been a significant factor in necessitating hospitalization in a hospital, or receipt of services in a correctional facility, or; (ii) resulted in one or more acts of serious violent behavior toward self or others or threats of, or attempts at, serious physical harm to self or others within the last 48 months. In addition, the subject, as a result of his or her mental illness, must be unlikely to voluntarily participate in the recommended treatment plan and in view of the patient’s treatment history and current behavior, the patient must be in need of Assisted Outpatient Treatment in order to prevent a relapse or deterioration that would be likely to result in serious harm to the patient or others. Lastly, the subject must likely benefit from Assisted Outpatient Treatment.

New York’s Mental Hygiene Law, Section 9.60 also lists the individuals who can petition for a court order for Assisted Outpatient Treatment as follows; (i) Any person at least 18 years of age with whom the subject of the petition resides; (ii) the parent, spouse, sibling at least 18 years of age, or child at least 18 years of age; (iii) the director of a hospital in which the subject of the petition is hospitalized; (iv) the director of any public or charitable organization, agency or home providing mental health services to the subject of the petition in whose institution the subject of the petition resides; (v) a qualified psychiatrist who is either supervising the treatment of or treating the subject of the petition for a mental illness; (vi) the director of community services, or his or her designee, or the social services official, as defined in the social services law, of the city or county in which the subject of the petition is present or reasonably believed to be present; or (vii) a parole officer or probation officer assigned to supervise the subject of the petition.

Once an Assisted Outpatient Treatment Order is granted many services are put in place with a treatment plan that is approved by the county’s Assisted Outpatient Treatment Program. The individual is given intensive case management services (ICM), either with a case-manager or ACT team (Assertive Community Treatment team) that provides comprehensive assistance and supervision of all facets of treatment and daily living. Additional services include: alcohol and drug counseling, psychiatric treatment, therapy and medication management and distribution; and supportive housing is also provided, if necessary.

It must be noted that an Assisted Outpatient Treatment Order cannot mandate that the subject of the Order comply with the recommended treatment plan. In other words, the subject of the Order cannot be forced to attend psychiatric treatment or even take medication. However, the out-patient psychiatrist charged with providing treatment under an Assisted Outpatient Treatment Order can have the police bring an individual who is not complying with his/her treatment plan to the hospital for evaluation. This provision provides the teeth, so to speak, to Kendra’s Law. The removal power allows trained professionals caring for the subject of an Assisted Outpatient Treatment Order to monitor that person’s progress and hopefully maintain that person’s, as well as the community’s, safety during periods of non-compliance.

The Successes and Failures of Assisted Outpatient Treatment

The Office of Mental Health keeps rather extensive statistics regarding Assisted Outpatient Treatment. According to these statistics it appears that Assisted Outpatient treatment has been a substantial benefit both to the community at large and individuals subject to an Order. In 2004 there were over 10,000 referrals and/or investigations of potential individuals in need of Assisted Outpatient Treatment. Of those, over 4,000 Petitions were filed in court and nearly 3,800 of these Petitions were granted. After an initial six-month period with an Assisted Outpatient Treatment Order, physically harmful acts to self or others were reduced by over half, drug and alcohol abuse fell nearly 50% and threats of physical harm to self or others fell just about 50%. Arrests and convictions for crimes feel nearly 85% and psychiatric hospitalizations fell 77%. Perhaps one of the most astounding statistics is the reduction of time spent in the hospital as a result of an Assisted Outpatient Treatment Order. On average, Assisted Outpatient Treatment patients spent 50 days in the hospital during the six-month period prior to an Order being granted. Compare that with 22 hospital days while the Order was in effect and only 13 days during the six-month period following the completion of the Assisted Outpatient Treatment Order. The foregoing statistics makes it difficult to argue with the overall effectiveness of Kendra’s Law. The Law has reduced acts of violence in the community to others as well as self-injurious behavior and has significantly tightened the revolving door of hospitalizations that so many psychiatric patients struggle with.

However, despite the glowing statistical evidence of Kendra’s Law success, there remain complaints and difficulties with the Law. Naturally, many individuals subject to an Assisted Outpatient Treatment Order lament the restriction of freedom that is attendant with an Assisted Outpatient Treatment Order. One is required to comply with the recommended treatment plan in order to avoid hospitalization, which often times means numerous meetings per week with treatment team members. While some find the structure of the program to be beneficial others find it smothering and have difficulties complying with such a strict regimen.

Moreover, one of the largest difficulties with Assisted Outpatient Treatment is a lack of resources. While this is generally a problem common to all government programs it is particular onerous in the realm of Assisted Outpatient Treatment. For patients that have a prior history of non-compliance with treatment, inpatient treating psychiatrists will often apply for an Assisted Outpatient Treatment Order. While this is wise clinical practice, the lack of resources often leads to increased hospital stays for individuals waiting for an Assisted Outpatient Treatment Order to be granted. The problem lies with county Mental Health programs that run the Assisted Outpatient Treatment programs that lack adequate resources to timely provide the services that an inpatient psychiatrist thinks are necessary. For instance, it often takes weeks if not months for Intensive Case Managers or ACT teams to be provided. While waiting for these services to be put into place, many inpatient treating psychiatrists, and rightfully so based upon the prior conduct and non-compliance of Assisted Outpatient Treatment candidates, do not feel comfortable discharging the patient until an Order is in place. Accordingly, individuals who are otherwise psychiatrically stable enough to leave the hospital often spend unnecessary time as an inpatient, waiting for county mental health offices to scramble for scarce resources.

Conclusion

In all, Assisted Outpatient Treatment has been of great benefit to those that suffer from mental illness and the community they reside in. The numbers are simply hard to argue with. Less time in the hospital and fewer incidences of violence and arrests are clearly a benefit to everyone. While problems do exist, when looking at the program as a whole the positives clearly outweigh any downsides.

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