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    Recidivism: Reducing Non-Compliance or Victim Blaming?

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    Court-mandated outpatient treatment in New York State, known as Assisted Outpatient Treatment (AOT), is a program designed to compel outpatient treatment and medication for individuals with serious and persistent mental illness who refuse to comply with treatment and become hospitalized or violent as a result.  However, this program fails to acknowledge the impact of mental health treatment shortages.

    forcedmentalhealthThis error arises because the AOT program, and others like it around the country, falsely associates repeat hospitalization with treatment non-compliance. In many cases, treatment shortages, particularly housing shortages, are a major source of risk for repeat hospitalization. As such, thousands of individuals who struggle or are unable to secure limited mental health services are mischaracterized as dangerous, stripped of their rights to choose their treatment options, and are forced to submit to a court mandated treatment and medication regiment.

    Since the creation of AOT in 1995, nearly 12,000 people in New York State have been subjected to court-mandated outpatient. As of 2012, approximately 3,330 people were currently compelled to the program. There are also major racial and geographic discrepancies in the implementation of the AOT program.

    According to New York Lawyers for the Public Interest (NYLPI) (2005), African Americans and Latinos are subject to AOTs at five and two and a half times the rate of their Caucasian counterparts, respectively. Furthermore, people living in New York City were four times as likely to receive an AOT compared to those living in the surrounding state (NYLPI, 2005). These disparities indicate a major bias in the implementation of AOTs and suggest that other factors are influencing the application of this severely restrictive program.

    Current Policy and Background

    Assisted Outpatient Treatment was introduced in New York through the 1999 legislation known as “Kendra’s Law.” This law was named in memory of Kendra Webdale, a 32-year-old journalist who was killed when Andrew Goldstein, a man with a severe and persistent mental illness, pushed her front of a subway (Hartocollis, 2006).

    Kendra’s Law provides the AOT mandate for people over the age of 18 suffering from a mental illness who are unlikely to survive safely in the community without supervision. AOTs can only be authorized by a judge and a hearing must prove either, A) lack of treatment compliance led to hospitalization at least two times in the last three years, or B) lack of treatment compliance led to threats or acts of serious violence to self or others in the last four years. In addition, the court must prove that the person’s mental illness makes them unlikely to participate in community-based treatment and that such treatment would be beneficial to prevent relapse and deterioration. (New York State Office of Mental Health, 2014)

    600_subwayOnce approved, AOTs require case management services or an assertive community treatment (ACT) team. The person is required to follow a detailed treatment plan, which typically includes both services and medication.

    If a person chooses not to comply with the treatment plan, they will be arrested and locked in a psychiatric hospital for 72-hours. After such time, the standard civil commitment process begins where it is determined whether they should remain hospitalized or be released into the community. (New York State Office of Mental Health, 2014)

    Critique of Assisted Outpatient Treatment

    Some advocates for the mentally ill consider the AOT program a positive step because it mandates providers to ensure care for the mentally ill and prevents people from falling through the cracks (Van Dorm, 2010). There have also been many documented benefits from the AOT program including a decrease in homeless, hospitalization, incidences of harmful behavior (New York State Office of Mental Health).

    While the positive outcomes should not be overlooked, we must ask ourselves, at what cost are we accomplishing such feats? What are the unintended consequences of compulsory treatment and are there hidden victims behind the data?

    A major critique of the AOT program is that it is likely applied to a wider rang of individuals than the intended population. Specifically, it is applied to individuals for whom services are scare. Recall that the first requirement for AOT is at least two hospitalizations within the last three years. While courts must prove these hospitalizations were caused by treatment non-compliance, it is often difficult to identify non-compliance when voluntary services are limited or substandard.

    In a tragic and ironic example, Andrew Goldstein, Kendra Webdale’s assailant, was determined treatment non-compliant because he was not taking his medication when he pushed Ms. Webdale onto the subway tracks. However, this ruling was made despite the fact that Mr. Goldstein’s family and social worker had been fighting desperately for years to obtain medication assistance and supervised housing for him (Wineripe, 1999). Mr. Goldstein was countlessly denied treatment due to shortages and was on a waiting list for housing at the time of Kendra’s death. Mr. Goldstein had been hospitalized fourteen times in the two years preceding Ms. Webdale’s death and was given no priority access to community-based services upon his release.

    The assumption underlying the resulting legislation was that Mr. Goldstein was too ill to comply with treatment and should thus be striped of his rights in order to maintain public safety. This is an unfair and victim-blaming perspective. Mr. Goldstein was failed by the system.  He was denied services and then punished for not accessing them. This is not to say that people with mental illnesses never refuse treatment. Rather, it is to say that inadequate mental health services are a much greater cause of hospital recidivism than treatment refusal. Instead of addressing this problem by improving services, Kendra’s Law and the AOT program has focused on stripping the mentally ill of their rights.

    Mr. Goldstein’s experience is not unique, as many mental health services in New York are limited. According to the National Alliance for Mental Health (NAMI, 2009), New York State is in “Urgent Need” of acute care facilities, mental health housing, and crisis intervention teams. According to a report by the U.S. Substance Abuse and Mental Health Services Administration (2013), only 38.5 percent of individuals with a mental illness in New York receive adequate treatment. The shortage of housing services for people with mental illnesses is particularly significance because, “Without appropriate housing in place, recidivism is especially high within this population” (NAMI, 2013). As of 2013, NAMI estimated that 21,000 additional housing units were required to adequately address the needs of the mentally ill.

    Because of service shortages, two major distortions of the AOT program have occurred. First, hospital recidivism, rather than a history of violence, has become the dominant mechanism of AOT authorization. According to a comprehensive evaluation of the program commissioned by the state, 66 percent of all AOT cases were opened at hospital discharge to reduce recidivism (Swartz, et.al. 2009). They also found that the majority of AOTs were obtained before seeking an Enhanced Voluntary Service Agreement (EVS). Furthermore, only 15 percent of AOT participants were found to have any history of violence.

    The second distortion of the AOT program due to treatment shortages is that court mandates have become the most reliable avenue for an individual in New York to obtain mental health services.  According to NYLPI (2005), because court mandates provide individuals with a “right to treatment” and priority access, AOTs are sometimes sought simply to get people treatment. This unfortunate and perverse distortion of the AOT program is of grave concern because it required the mentally ill to subject themselves to a subordinate legal status in order to be provided the care they need to live healthy, safe and productive lives.

    Policy Recommendations

    In order to improve the AOT system and ensure only those who are truly non-compliant are court-mandated treatment the following recommendations are provided. First, treatment shortages must be eliminated. This requires a significant increase in mental health financing and an increase in the number of supportive housing facilities, day program services, medication management, and intensive case management.

    Second, individuals with a history of hospitalization should be provided priority access to community based services and a “right to treatment.” This includes creating Enhanced Voluntary Service Agreement (EVS) for all individuals who have been hospitalized at least two times in the last three years, rather an the current requirement that these individuals are prescribed AOTs. Third, AOT authorization for individuals with a history of hospitalization should be amended to include proof that non-compliance occurred in the presence of reasonably accessible services.

    With these recommendations, the need for court-mandated outpatient treatment will be significantly diminished.  People with mental illness will have the resources that prevent hospitalization and those in critical conditions will have full-access to the services they need to get better.  Most importantly, mental health consumers will maintain their rights, dignity, and freedom to choose their providers, medications, and service-delivery methods. Treatment shortages should not be tolerated and neither should the further disenfranchisement of the mentally ill.

    While there may be limited instances where court mandates are necessary, we should resist these mechanism whenever possible. Court-mandates are an oversimplified solution for a challenging program. Ultimately, the currently AOT system unfairly robs individuals of their liberties, dignity, and falsely blame the mentally ill for treatment shortages when the onus is on society.

    References

    Hartocollis, A. (October 11, 2006). Nearly 8 Years Later, Guilty Plea in Subway Killing. The New York Times. Retrieved from:

    National Association of Mental Health. (2009). Grading the states 2009 report card: New York. Retrieved from:

    National Association of Mental Health. (2013). Legislative agenda: the need for safe and affordable housing for people with mental illness. Retrieved from:

    New York Lawyers for Public Interest. (2005). Implementation of Kendra’s Law is Severely Biased. Available at

    New York State Office of Mental Health (NYOMH1): Summary of Kendra’s Law. Available at:

    New York State Office of Mental Health (NYOMH2: Assisted Outpatient Treatment Reports: Outcomes. Available at:

    Swartz, M.S., Swanson, J.W., Steadman, H.J., Robbins, P.C. & Monahan J. (2009). New York State assisted outpatient treatment program evaluation. Durham, NC: Duke University School of Medicine (June, 2009). DOI: 10.1176/appi.ps.61.10.976

    Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: New York, 2013. HHS Publication No. SMA-13-4796NY. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

    Van Dorn, R.A., Swanson, J.W., Swartz, M.S., Wilder, C.W., Moser, L.L., Gilbert, A.R., Cislo, A.M., & Robbins, C.P. (2010). Continuing involuntary outpatient treatment: medication and hospitalization outcomes in New York. Psychiatric Services, 61(10) 1-6.

    Winerip, M. (Nov 1999). Report faults care of man who pushed women onto tracks. New York Times.

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    Stephanie Pinsky is the Political Staff Writer for Social Work Helper. She recently completed her MSSW from Columbia University where she focused on Public Policy. She completed her field placement at the Center for the Study of Social Policy, where she worked on the Child Welfare Systems Change team. As a passionate social justice advocate and political fanatic, Stephanie writes on a wide range of social work policy issues including child welfare, immigration, public assistance, mental health, education, and race equity. You can read her blog Social Justice & Beyond at SocialWorker4Change.wordpress.com and follower her on Twitter @StephaniePinsky

    Health

    Poverty, Racism and the Public Health Crisis in America

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    Although extreme poverty in the United States is low by global standards, the U.S. has the worst index of health and social problems as a function of income inequality. In a newly published article, Bettina Beech, clinical professor of population health in the Department of Health Systems and Population Health Sciences at the University of Houston College of Medicine and chief population health officer at UH, examines poverty and racism as factors influencing health.

    “A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe,” Beech reports in Frontiers in Public Health. “Racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. The U.S. has one of the highest rates of poverty in the developed world, but despite its collective wealth, the burden falls disproportionately on communities of color.” The goal of population health is to achieve health equity, so that every person can reach their full potential.

    Though overall wealth has risen in recent years, growth in economic and financial resources has not been equally distributed. Black families in the U.S. have about one-twentieth the wealth of their white peers on average. For every dollar of wealth in white families, the corresponding wealth in Black households is five cents.

    “Wealth inequality is not a function of work ethic or work hour difference between groups. Rather, the widening gap between the affluent and the poor can be linked to unjust policies and practices that favor the wealthy,” said Beech. “The impact of this form of inequality on health has come into sharp focus during the COVID-19 pandemic as the economically disadvantaged were more likely to get infected with SARS CoV-2 and die.”

    A Very Old Problem 

    In the mid-1800’s, Dr. James McCune Smith wrote one of the earliest descriptions of racism as the cause of health inequities and ultimately health disparities in America. He explained the health of a person “was not primarily a consequence of their innate constitution, but instead reflected their intrinsic membership in groups created by a race structured society.”

    Over 100 years later, the Heckler Report, the first government-sanctioned assessment of racial health disparities, was published. It noted mortality inequity was linked to six leading causes of preventable excess deaths for the Black compared to the white population (cancer, cardiovascular disease, diabetes, infant mortality, chemical dependency and homicide/unintentional injury).

    It and other reports led to a more robust focus on population health over the last few decades that has included a renewed interest in the impact of racism and social factors, such as poverty, on clinical outcomes.

    The Myth of Meritocracy

    Beech contends that structural racism harms marginalized populations at the expense of affording greater resources, opportunities and other privileges to the dominant white society.

    “Public discourse has been largely shaped by a narrative of meritocracy which is laced with ideals of opportunity without any consideration of the realities of racism and race-based inequities in structures and systems that have locked individuals, families and communities into poverty-stricken lives for generations,” she said. “Coupled with a lack of a national health program this condemns oppressed populations such as Black and Hispanic Americans, American Indians, and disproportionately non-English speaking immigrants and refugees to remain in poverty and suffer from suboptimal health.”

    Keys to Improvement

    The World Health Organization identified three keys to improving health at a global level that each reinforces the impact of socioeconomic factors: (1) improve the conditions of daily life; (2) tackle the inequitable distribution of power, money and resources; and (3) develop a workforce trained in and public awareness of the social determinants of health.

    The report’s findings highlight the need to implement health policies to increase access to care for lower-income individuals and highlight the need to ensure such policies and associated programs are reaching those in need.

    “Health care providers can directly address many of the factors crucial for closing the health disparities gap by recognizing and trying to mitigate the race-based implicit biases many physicians carry, as well as leveraging their privilege to address the elements of institutionalized racism entrenched within the fabric of our society, starting with social injustice and human indifference,” said Beech.

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    Environmental Justice

    How American Cities Can Promote Urban Agriculture

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    In his original plan for the city of Philadelphia, William Penn declared that every home should have ample space “for gardens or orchards or fields, that it may be a green country that will never be burnt and always be wholesome.” Before militiamen or throngs of protestors, the Boston Common nourished grazing cattle. Urban agriculture has cropped up again and again in cities throughout American history – from “relief gardens” for the poor in the 19th century, to “victory gardens” of World War II – and for good reason. If embraced and encouraged, urban agriculture can create economic, cultural, environmental and educational benefits. In recent years, various cities have developed good urban agriculture programs. By distilling their successes and struggles, my colleagues and I identify a series of best practices in this area.

    Tailoring Programs for Varied Communities

    “Urban agriculture” is an umbrella term encompassing a wide array of practices. Good programs take account from the start of community preferences that vary. Beekeeping or backyard chickens, for example, might be considered progress in Portland but backwardness in Baltimore. Controversies often arise, but they offer opportunities for dialogue. When disputes erupted about the 140-acre Hantz Farms proposal in Detroit, for example, officials convened public meetings to fashion a vision of urban agriculture. Cities like Portland and Vancouver have formed urban agriculture task forces composed of private citizens, government representatives, and organizational partners to advise the cities on planning and code issues.

    In most cities, urban agriculture of some form is already practiced, whether regulations officially enable it or not. It is important to take stock of these existing operations and practices. Important elements to consider include: the number of gardens and gardeners, their demographics, the type and location of existing gardens, popular agricultural practices, and where space exists to expand urban agriculture. Numerous cities have benefited from conducting “urban agriculture land inventories,” in which mapping professionals use satellite imagery and public records to determine which publicly-owned plots are best suited to urban agriculture.

    Communities should develop an independent agency or department to manage urban agricultureBecause urban agriculture is a multi-faceted process, many city agencies currently regulate its disparate aspects; Parks, Public Works, Environmental Protection, Sustainability, Health and Sanitation, Land Banks, and other departments all have their hand in working with growers. Centralizing this authority under one department can streamline regulation and simplify the process of establishing gardens and farms. Boston’s Grassroot program, Chicago’s Neighborspace program, and New York’s Green Thumb program are all excellent examples.

    Municipalities should audit existing codes and laws. Although most relevant regulations will be found in local zoning ordinances, other codes might have unexpected effects on urban agriculture – including ordinances regulating produce sales, market stands, shade trees, and noise. In Los Angeles, a near-forgotten, yet narrowly-worded, 1946 “Truck Gardening Ordinance” threatened to limit agricultural sales exclusively to vegetables before it was amended by the city’s governing body. Municipalities should also be aware of state and federal regulations that might affect agriculture policy decisions. Right to Farm laws typically operate at the state level and may restrict localities. Notably, Detroit and other large cities in Michigan had to postpone regulation of urban agriculture until they were exempted from their state’s Right to Farm rules.

    Ways to Facilitate Urban Agriculture

    Although public sentiment should determine where urban agriculture is appropriate, there are opportunities to incorporate some form of agriculture or gardening in every land use zone. Cities from Seattle to Philadelphia have incorporated urban agriculture into existing land use codes. Small acreage projects unlikely to create nuisances include backyard gardens typical of single family homes and should be permitted virtually anywhere. Yet large acre, high nuisance projects – such as multi-acre urban farms relying on heavy machinery or animal husbandry – are better suited for the city edges or industrial zones.

    While permitting urban agriculture outright in this fashion has proven successful, other creative ways that cities have enabled urban agriculture include:

    • Creating new zones for urban agriculture specifically, as in Boston and Cleveland.
    • Permitting urban agriculture as “conditional” or “accessory” rather than primary use. This allows local planning and zoning boards to maintain control over how such uses are developed, without restricting them. However, this approach can become too cumbersome and likely to disproportionately burden applicants with fewer resources.
    • Land can be directly supplied — through adopt-a-lot programs and leasing underused spaces to citizens or qualified urban farmers. Offering flexible, medium- to long-term leases is critical, as security of land is vital to the success of urban farms.

    Good Management to Sustain Citizen Projects

    Finally, municipalities must take steps to ensure that citizens practicing urban agriculture do so responsibly. Some of the most effective approaches include:

    • Passing or revising codes that limit the use of pesticides and fertilizers
    • Enforcing time restrictions on the use of noisy farm equipment (although this is not typically an issue on small plots where hand tools are most common)
    • Providing training opportunities through city departments or local cooperative extension services
    • Requiring preliminary testing of land and monitoring of soil toxicity, soil nutrition, and any utility lines running through a property
    • Offering  access to rain barrels or municipal water hookups
    • Including urban agriculture in all future urban planning efforts, including master plans.
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    Justice

    The Covid Pandemic Increased Vulnerability to Forced Labor in Global Supply Chains

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    Comprehensive evidence points to increased vulnerability of workers to forced labor in global supply chains during the Covid-19 pandemic, an analysis published today by the Modern Slavery and Human Rights Policy and Evidence Centre (Modern Slavery PEC) has found.

    The Centre, which was created to enhance understanding of modern slavery and transform the effectiveness of law and policies designed to address it, is funded by the Arts and Humanities Council.

    The Modern Slavery PEC has carried out an analysis of evidence, including new academic research funded by the Centre, on the impact of Covid-19 on modern slavery across the world.

    The analysis has found that the pandemic has increased vulnerability to modern slavery all over the world, including in the UK, as many of the underlying wider factors underpinning modern slavery have worsened, such as poverty, inequality and unemployment. Construction, manufacturing, including ready-made garment production, as well as accommodation and food services have been the sectors most affected by the pandemic.

    It found that the increased vulnerability of workers to forced labor is often linked to long and complex supply chains, of which businesses have limited visibility. Already vulnerable groups, such as migrant and informal workers, were most affected, particularly in the lower tiers of supply chains.

    There is evidence of an increase in the risk of forced labor both in supply chains that experienced a significant reduction in demand, such as garments, and those that experienced demand spikes, such as PPE production.

    The problems were compounded by businesses struggling with the immediate impact of the pandemic making it difficult to mitigate the modern slavery risks in their supply chains, including by making it very challenging to carry out due diligence processes on suppliers on the ground.

    Additionally, some of the early response by business to the pandemic exacerbated vulnerability to modern slavery, for example by cancelling contracts and withholding payment for goods already produced.

    Modern Slavery PEC Partnership Manager Owain Johnstone, one of the authors of the analysis, said:

    “Covid-related supply chain disruption is a wake-up call for businesses. The evidence that the pandemic has worsened people’s vulnerability to forced labor in global supply chains is overwhelming.”

    “The pandemic has highlighted the complexity and fragility of many supply chains and reinforced the link between the lack of visibility over supply chains and the vulnerability of workers to modern slavery. More transparent, resilient supply chains are better for business and better for workers”, he added.

    Dr Jo Meehan, Senior Lecturer in Strategic Purchasing at University of Liverpool Management School, who led the Modern Slavery PEC project on the impact of Covid-19 on the management of supply chains, said:

    “Demand volatility has been extremely high during the pandemic. It acts as a driver of modern slavery as it erodes profits, encourages the use of temporary and precarious workers, and destabilises capacity in supply markets.”

    However, the Modern Slavery PEC’s analysis has also pointed out that the pandemic may lead to longer-term positive changes to supply chain dynamics. This includes greater visibility and awareness of supply chains that Covid has forced on businesses and increased awareness of exploitation affecting supply chains.

    Dr Meehan said: “Our study revealed that because of the pandemic, two-thirds of businesses sourced from new suppliers and undertook additional supply chain mapping. Therefore, there is an opportunity for businesses to use these new relationships as springboards to understand the impacts of their own business model and practices, and how they may change to collectively tackle, and prevent, modern slavery.”

    For example, evidence suggests that some businesses have already moved towards the ‘localisation’ of their supply chains, working to shorten them and bring suppliers closer to home to avoid future disruption, which is likely to decrease modern slavery risks. Another example includes extending inventory planning cycles to take their longer-term demand into account and enable better workforce planning.

    Johnstone said: “It’s clear that the crisis has pushed businesses to strengthen their hold on their entire supply chains, which can make it easier to address any exploitation issues potentially affecting them.

    “We urge businesses to use the pandemic experience as a platform to increase visibility and transparency over their supply chains, as well as improving collaboration with their suppliers and peer companies.”

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