5 Ridiculous Myths You Probably Believe About Schizophrenia

In any given year, approximately 1.1% of the U.S. adult population is affected by schizophrenia, according to the National Institute of Mental Health (NIMH). That’s over two million people in the U.S. alone. In 2008, the National Alliance on Mental Illness (NAMI) found schizophrenia was twice as common as HIV/AIDS, and a major report revealed most Americans knew very little about the illness. Most people recognize the name, but beyond that, their facts get blurry.

A lot of what people think they know about this difficult condition is flat out wrong. Here are five of the most common myths about this condition, and why they aren’t true:

Myth #1: People who have it are dangerous and violent.

This is what the movies would have us believe, because that makes for a more exciting story and higher ticket sales, but in fact people most people with this illness never become violent or dangerous. In fact, they are much more likely to become the victim of a violent crime than to commit one.

Although research does show some association between people who have this condition and violence, it’s not nearly as tightly linked as many people believe. A small percentage of sufferers may become violent when they are experiencing acute symptoms, such as hallucinations, delusions or extreme paranoia.

The likelihood of aggressive or violent acts increases when alcohol or drug abuse is added in, something that’s also true for people with no mental health diagnosis.

Overall, however, the majority of people with mental health conditions, including this one, are no more violent than their neighbors. In fact, research conducted by the National Alliance on Mental Illness (NAMI) found that affected individuals “typically withdraw from social interaction and simply prefer to be left alone.”

Myth #2: People who have it will never be able to hold down a productive job.

Struggling with the illness can make holding down a “regular” job more challenging, but it’s often still possible.

In fact, there are quite a few famous people who became career stand-outs in their fields, despite experiencing this condition. Famed mathematician John Forbes Nash Jr., whose life story is told in the book “A Beautiful Mind,” won a Nobel prize in Economics and other accolades.

American novelist Jack Kerouac was reportedly diagnosed with it during his service in the military, yet he went on from there to become a beloved poet and novelist.

For people whose symptoms prevent them from traditional employment, non-traditional work that provides a more flexible schedule may be a workable alternative.

Even if someone goes through a period where they are unable to work due to a symptom flare-up, their condition may substantially improve in the future and allow a return to work on a limited or even full-time basis.

Myth #3: People who have it have multiple personalities.

NAMI research about public attitudes regarding the disease discovered that 64% of people wrongly think that “split or multiple personalities” is a symptom of the condition.

This myth most likely originated from the nature of the word itself.

The prefix schizo means split, but in this case, the split refers to a breakdown in the relation between thought, emotion, and behavior, not split personality.

People who are experiencing hallucinations and delusions may behave erratically, but it has nothing to do with having multiple personalities. That’s an entirely different condition named dissociative identity disorder (DID).

Myth #4: If a parent or sibling has it, you’ll get it too.

People who have a family member with this condition often want to know: Is schizophrenia genetic or not? Inheritance does play a role, but does not guarantee whether someone will or won’t get it.

Having a relative who has it doesn’t mean you are certain to develop it also, although it can increase the likelihood.

According to published research, identical twins have the highest genetic risk, with nearly a 50% chance of developing the disease.

A child of two parents who have the illness is at high risk as well – about 46%. The risk drops off substantially for other family members but is still significant.

According to research studies, the child of a person with it has about 13% chance of developing the condition. A sibling has a 9% risk of also developing the disease.

Genetics are only one of many factors in the development of the condition. Life trauma, drug abuse, and other components of a person’s environment can contribute to triggering the condition as well.

Myth #5: Schizophrenia is untreatable

This myth has its roots in the persistent and debilitating nature of the illness.

It’s hard to treat, and for some people it’s a lifelong struggle, but it’s also possible to recover completely from it.

With treatment, 25% of patients fully recover and never experience another episode again. Half or more are able to achieve improvement in their symptoms with medication and therapy.

It’s is a challenging and difficult condition, but ultimately treatable and even curable. According to a study by the National Alliance for Mental Illness (NAMI), the average age first symptoms appear is 20.5 years old – just when individuals are entering their adulthood and making key decisions regarding family and career.

Typically, 5 years or more pass before the condition is diagnosed. While some people struggle with it throughout their lives, others achieve complete recovery. Most people are able to achieve improvement in symptoms and live an independent life.

It’s understandable why these myths have graduated to the status of real thoughts in our minds, but for those who suffer from schizophrenia, having informed people around them is at least one less problem to deal with. Let’s do us all a favor and keep an open mind!

Therapy 101 Series: Lesson One is Knowing Your ABCs

If you’re a therapist, ideally, you have access to intervention training and a good clinical supervisor. What if you don’t? Many new therapists, social workers, and other psychosocial professionals enter the field without concrete psychotherapy intervention training, and most without sufficient experience to know  how to immediately implement it in every unique presenting situation. One may be an intern and are hopefully closely supervised and guided. Another may have earned an entire, relevant graduate degree without specifics on evidence-based psychotherapy practice included. There is hope, however, since this is where most of us started either way. Being a therapist may wrack your nerves at baseline.

Articles in the Therapy 101 series will focus on tips, tricks, and tools that can help get you started if you can’t get intervention training immediately and/or you can’t use clinical supervision to get you over the anxiety. What follows is only the beginning, and does not necessarily make you more qualified, magically clinically licensed, and does not offer specific intervention training.

Please note: This series is not intended to endorse practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

So where to start?

If you’re not new to providing therapy, imagine the last time a client said something that really threw you for a loop. You didn’t know what to say. You didn’t know what to do. Maybe you sputtered a bit. Maybe you were just silent. Maybe you communicated volumes with shocked nonverbal cues. Either way, you felt like there was a void or crisis you couldn’t adequately fill or resolve. If you are new to providing therapy, this may very well describe your day job! Congrats! It’s pretty exciting even with that semi-regular feeling of helplessness.

What is therapy anyway?

Therapy generally defined in the dictionary is “medical treatment of disease”, but since you are probably a social worker or social work student, we will assume you are more likely to be curious about psychotherapy, which we will refer to simply as “therapy” for the rest of this article, and which the National Alliance on Mental Illness defines:

Psychotherapy, also known as “talk therapy,” is when a person speaks with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviors and gain coping skills.

That could very easily be you with or without specific intervention training. If you have a Master of Social Work degree, you are trained in Human Behavior in the Social Environment and Social Work Practice, at the very least. That me be little consolation to you as a new or inexperienced practitioner of therapy, so what do you do first when you don’t know what to do next?

Know Your ABCs

  • A for Affect – How do you feel? What emotions are you experiencing?
  • B for Behavior – What do you do? What actions do you take or have you taken?
  • C for Cognition – What are your thoughts? What are you thinking?

These are the most core questions you will ask any client/consumer and once you connect them to a trigger/context, you’re one hop, skip and jump away from many forms of therapy. They can come in any order. In fact, many psychotherapy styles specifically focus on thoughts, feelings, actions, and behavior so being comfortable asking these questions, or falling back to them when you’re not sure what else to say and the “strategic silence” you improvised or rationalized is going on a little too long.

Imagine a client describes something you have never heard about before, have never heard described to you by someone who experienced it, or is quite clearly traumatic. You may picture yourself as the perfect therapist knowing just the right question to ask to pop the clearly present keg of catharsis. Chances are, you will not have the perfect question in a situation like this. But you can always ask the following:

“What are your thoughts on that?”

“How do you feel about that?”

“What did you do beforehand? Afterwards? As it was happening?”

These three questions can (almost) literally be repeated into infinity:

What did you think and feel after you did that thing?

What thoughts and feelings led up to doing that thing?

What did you do/think/feel next?

How often do you think/feel/do that? When was the first time?

If you’re not careful, you can actually end up asking questions into infinity, because clients and everyone else tends to really enjoy when someone sincerely asks them questions about themselves. Stay tuned for a post on setting boundaries on your allotted time and everything else in a future post.

Also, don’t forget the other “A”

The above does not include the trigger or as Albert Ellis stated it “activating event.” The questions above will become less random and purely reactive to the client’s responses as you organize them around triggering events, people, situations, activities, and places.

Albert Ellis, who established Rational Emotive Behavior Therapy, had his own ABC’s which can be similarly helpful if you’re first trying to wrap your head around how to provide therapy: A for Adversity or Activating event, B for Belief about the Adversity, and C for Consequences.

I know and am comfortable with my ABCs: What next?

A previous mentor once suggested picking a “home” theory and/or technique to fall back on when you’re not sure where to start. Different theories and techniques are certainly more effective with different client populations, so there’s nothing wrong with being a bit eclectic, but as a therapist you will be working with people who are their most overwhelmed, anxious confused, angry or sad. It’s likely you won’t always know where to start or what to say. This makes sense, because it’s likely for many new to therapy that they don’t know what the “right” thing to say is either, and they’re the premier expert on themselves.

There are many options with which to start:

  • Cognitive behavioral therapy forms (rational emotive behavioral therapy, trauma focused CBT, etc.)
  • Motivational interviewing
  • Psychodynamic/psychoanalytic (many models including brief psychodynamic therapy)
  • Solution-Focused Therapy

Once you have decided what theory and intervention you want or need to start with, seek certified training. Some of the links above will take you official training for each style, which will ensure you are actually getting the training that has been studied to be effective for that style.

It is great and best practice to do the full training and receive certification in whatever theory’s intervention you select, and if that’s an option you should certainly do it. Many therapy programs do not reimburse your extensive training in a therapy discipline. If that’s the case, and you can afford a three day, single day, or couple hour training in an intervention style, you may be able to use techniques, if not the entire intervention. You could use open-ended questions, affirmations, reflective listening and summaries, but not be implementing the actual Motivational Interviewing intervention.

Therapy 101

Posts in the Therapy 101 series focus on tips, tricks, and tools that can help get you started as a social worker practicing as a therapist. They do not necessarily make one more qualified, a licensed, clinical therapist, and does not provide specific intervention training or information.

This series is not intended as an endorsement of practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

03e612d2278922f2b443a8e2fa8de71e

3 Things to Know When Working With LGBT Clients

On June 26, 2015, the Supreme Court ruled that all couples, regardless of gender, have a constitutional right to marry the person they love. After the ruling was announced, states across the nation were forced to drop their bans on same-sex marriage allowing loving gay, lesbian, bisexual, and transgender couples the right to marry.

The ruling marks a significant advancement for the rights of LGBT individuals, who have faced a long history of discrimination and oppression. While the ruling is a monumental victory for the rights of LGBT Americans, our LGBT brothers and sisters face challenges that extend far beyond the right to marriage.

lgbtqhomeless1_400_393_90When working with individuals in the LGBT community, we must acknowledge the ways in which societal and social influence, oppression, and discrimination impact these clients as well as the communities we serve. As social workers, we have an obligation to be culturally competent and sensitive to the unique needs of our clients.

To do so effectively, we must first understand some of the significant psychosocial stressors that may impact members of the LGBT community.

Discriminatory Policy

While LGBT individuals now have the right to marry the person they love, only 22 states in the nation protect the LGBT community from employment discrimination. This means that in over half of our nation’s states, a person could be denied employment or fired from their job for identifying as LGBT. For LGBT individuals working in these states, such policies can prevent individuals from feeling comfortable in the workplace for fear of being fired. Uncertain job stability coupled with the stress of hiding one’s identity in the workplace can lead to a variety of negative effects, such as low job satisfaction or even depression and anxiety.

Knowing the policies of your state and how these policies impact the LGBT community can help you better assess the role discrimination may be playing in the lives of your LGBT client(s). Having a good understanding of these policies also allows you to engage in meaningful conversation with clients, the community, and other stakeholders about how to best facilitate change to such policies.

Violence

Individuals within the LGBT community are at a significantly higher risk for violence. Though individuals identifying as LGBT account for only 3.8% of the U.S. population, they are the victims in 21% of reported hate crimes. Sexual violence is also a very real threat to those in the LGBT community. According to a startling report by the Centers for Disease Control and Prevention (CDC), 46.4% of lesbian women, 74.9% of bisexual women, 40.2% of gay men, and 47.4% of bisexual men report being victims of sexual violence.

As social workers, it’s not uncommon for clients to seek our help in working through issues related to sexual or physical violence and intimate partner violence. Because of the high rates of these occurrences within the LGBT community, assessing clients for a history of sexual and physical violence as well as domestic violence are critical components of a thorough assessment. Using treatment approaches that take into account the experiences of the LGBT community will enhance the therapeutic milieu for your clients and help foster healing.

Mental Health

Individuals identifying with the LGBT community have significantly higher rates of mental health conditions, substance use disorders, and suicide attempts. According to the National Alliance on Mental Illness (NAMI) , LGBT men and women have a 2.5 times higher rate of mental illness or substance abuse than the heterosexual population. The types of mental health conditions impacting this population also differ. Gay and bisexual men are more likely to experience major depression and panic disorder than heterosexual men. Lesbian and bisexual women are more than 3 times as likely to experience generalized anxiety disorder.

In addition, the CDC reports that LGBT youth are more than twice as likely to attempt suicide than their heterosexual peers, with as many as 25% of transgendered youth attempting suicide. This is often due, in part, to the higher rates of bullying, physical and sexual violence, and social isolation experienced within this population.

Social workers need to be aware of the disparities in mental health and substance use disorders among the LGBT population so that proper assessment and intervention can take place. Ongoing screening for suicidal ideation or behavior is also of significance, especially for LGBT youth.

As the largest providers of mental health services in the nation, social workers frequently work with individuals across the various spectrums of diversity. This requires us to be skilled in understanding how discrimination, oppression, and public policy all play roles in the lives of our clients. While this may not always be easy, by tapping into your inherent skills as a social worker you can be a champion for your LGBT clients. If you feel overwhelmed by these complexities or find it difficult to understand issues surrounding the LGBT population, start by being a genuine, accepting presence for all your clients. After all, it’s all about love, isn’t it?

Mental Health Advocacy Must Remain A Top Priority

Heading

As of 2013, May is officially mental health month which was set in motion by President Obama, and it has made a huge impact in only a couple of years. This movement has caused other public figures to jump on board to help raise awareness to combat the stigmas associated with seeking treatment. Advocating for mental health awareness is a mindset that we all should aspire to follow.

Although mental health awareness month is officially over, we must be diligent throughout the year in creating awareness on mental illness. Mental health stigmas are a real problem, and they still exist all over the world. In America alone, there are about 8 million people suffering from severe mental illnesses and only around half of those are treated.

But why should we fight these mental health stigmas?

Fear of discrimination and the attached stigmas often keep sufferers and their families from facing their mental health problems. This deters them from seeking help, which is very problematic. Mental health is just as important as physical health.  Additionally, access to mental health treatment and insurance coverage can also be a barrier to seeking treatment. Mental health treatment should be viewed similarly to how physical ailments are addressed because the two are often times entwined.

Fortunately, as awareness of mental health issues spreads and stigmas recede, more and more medical professionals are choosing careers in mental health. We are learning more about the benefits of helping people care for their mental health, including longer life expectancy, increased productivity, improved financial stability, and happier personal lives. As a result, public and private organizations are recognizing the importance of providing access to affordable mental health care. In the U.S., this progress is evident in the inclusion of mental health care coverage requirements in the Affordable Care Act. Read More

What can we do to combat these backwards beliefs?

Simply put, we need to advocate for change. If someone refers to a person with a mental illness as ‘crazy’ or ‘insane’ it is completely justifiable to point out that it is not alright to use such shaming language. It is important to question how using those kinds of harsh words can segue into negativity and generalizations that are frankly not true.

Online communities such as BringChange2Mind and StigmaFighters offer those struggling with mental problems a judgment-free outlet for taking the steps towards acceptance of themselves and overall wellness. Although May is over, advocating for mental health equality must remain a top priority. We all deserve to live happily and feel healthy.

Be a voice of reason by advocating mental health all year-long and you will make the world a much better place for literally millions.

Wake Up Politicians, American Families Need Your Help With Mental Illness

The National Alliance on Mental Illness[i] reports that one in four adults have a mental illness. Take pause for one second of your day today to raise your eyes from your smart phone to look around you. See that woman over there? She’s one…keep it going. Count four people. Are they standing, sitting, or walking by you? STOP at four. Yes, one of those, yes…61.5 million Americans have a bout of mental illness of some form or another in a given year. One-half of all chronic mental illness begins by the age of 14 with three-quarters by age 24.  The number four person you counted, how old do you think they are?
1 in 4 logo news

The CDC[ii] reported in 2013 that an estimated 13 –20 percent of children living in the United States which is 1 out of 5 children experience a mental disorder every year. Next time you are in a grocery store, department store or movie theatre, look up and count again. One small child hounding his mom for popcorn.

Another running circles around his father while he tries to reign him in. Three. Four and a fifth, a nine-year old staring blankly into space as those around her engaged in friendly chatter. One of those children is suffering with mental illness. And although an estimated $247 billion is spent each year on childhood mental disorders, they are increasing and more than 50% of those children’s illness are not being addressed.

These statistics break my heart. My family experienced mental illness without resources in spades. I know we are not isolated or rare, however, and that is even harder to swallow than the outcome of what happened behind the front gate of my white picket fence.

Families all over the country are being told to call the police, restrain their children, and medicate in their living rooms with the likes of prescription drugs that were once only common in state-run mental health facilities.  Until a child cries that someone is hurting them or hurts or worse, kills others, there is barely a framework of support for the family – often left with the finger of blame pointing straight in their direction.

Are they victims? The jury is out. The more important truth is that no one is taking responsibility for there being a bare bones band-aid to support families raising the 20% of children that will become the 25% of adults with mental illness, if they survive their own battle towards self-destruction. More than 90% of suicides occur in those that have had mental disorders.[iii]

In October of 1980, then outgoing President Jimmy Carter signed the Mental Health Systems Act[iv], which had proposed to continue the federal community mental health centers program, although with some additional state involvement. Just a month later as Ronald Reagan on the heels of taking the presidency and probably before he’d even spent his first weekend in the white house no less read the entire Carter Mental Health Commission file, Reagan dumped the Mental Health Systems act and the appropriated funding to support the state’s programs was immediately blocked.

In this legacy of shame and disregard for the American people, President Reagan never understood mental illness. It wasn’t for lack of exposure as it was reported that several of his own family members suffered from various levels of mental illness. Rather, it was more ignorance and a sheer lack of interest in identifying ways to approach and care for those struggling with it. In the end, much of the out-picturing of that move towards sweeping the issue under the rug became clear as homelessness of the mentally ill soared.

No longer were there facilities or programs to support the growing need. No longer were there appropriations to develop new strategies or research to address the increasing incidents of mental illness. Board and care homes and state hospitals across the nation were bolted and to this day sit like empty horror houses, the haunting echoes of those that once sought care there now only ghosts in the halls.

It’s been a long 34 years since those first days when the shuttering of those services pushed so many back into the streets, homes, schools and of course jails. It wasn’t too long before everyone realized that deinstitutionalization of patients from state mental hospitals was a huge mistake. Crime and homicide doubled and tripled and the percentage of inmates with mental illness increased threefold if not more. And yet, nothing short of band aids were applied on the gaping wound not being addressed. Those band aids aren’t covering the wounds in families in this country. The statistics are undeniable. Mental illness doesn’t just crop up in the adult population, it often begins as young as five years old and there are so few resources for families who are parenting these children it’s ridiculous.

It’s been said that the definition of insanity is doing the same thing over and over again expecting a different outcome. Where does change begin? It begins with each of us. Speaking our mind, advocating for those who cannot advocate for themselves and making noise about the inequalities of support services for invisible disabilities. Eradicating the stigma surrounding the need for the services might just be the first step of many, but until we take the first step, we’re not being accountable to the needs of so many. Look around. Count to four. Know the strength in numbers. If two or even three in four stand up for the rights of one in four, change happens – for all of us.[i] National Alliance on Mental Illness, http://www.nami.org/factsheets/mentalillness_factsheet.pdf

[ii] 3/13 -Centers for Disease Control and Prevention (CDC), Mental Health Surveillance Among Children —United States, 2005–2011
[iii] National Alliance on Mental Illness, http://www.nami.org/factsheets/mentalillness_factsheet.pdf
[iv] Mental Health Systems Act of 1980- http://www.presidency.ucsb.edu/ws/?pid=45228

Mental Illness in ABC’s Black Box

ABC's Black Box
ABC’s Black Box

ABC’s Black Box premiered on April 24th with Kelly Reilly as the main character. Reilly plays Dr. Catherine Black, a brilliant neurologist, who suffers from bipolar disorder which is a chronic mental illness involving periods of mania and depression. The illness can have elated impacts on one’s mood, energy levels, and decision-making.

Those with this disorder are distinguished based on their intense highs and lows. Riley’s character is shown through the manic and depressive episodes of the illness throughout the show. The show refers to the brain as the black box, and Dr. Catherine Black is known as the curer of all neurological disorders while disregarding and hiding her own mental illness.

Catherine Black’s manic episodes conveniently occur when she’s away from work and the demands of the job. This show has brought on much controversy based on its portrayal of mental illness. Some questions I had while watching the show are:

  1. Is this a glamorized representation of mental illness?
  2. How accurate is the portrayal of Bipolar disorder?
  3. Can someone be in a 2-year relationship and hide their bipolar disorder from their partner?
  4. How can a neuroscientist hide their mental illness in the workplace without compromising their patients?

The creator of the show, Amy Holden Jones, grew up with a first hand witness to bipolar disorder. Her father was diagnosed with the illness and experienced the associated stigmas. When asked what sparked her inspiration for the show she answered:

“I’ve always wanted to get into the world of the brain, having personally lived in a family dealing with mental illness for a long time—I was 43 when my father finally died. In my era, with my father, there was so much secrecy. I never even had a conversation with him about his illness. We would live through his episodes and we’d never talk about them. He was very brilliant, high-achieving, worked 24/7 when he was younger. Then he had his first big breakdown at around 40.  He finally began taking lithium and it made such a difference in our lives—but there are a lot of things I don’t understand. Looking back, I assume he had something like high-cycling mania. When I read Kay Jamison’s An Unquiet Mind, I suspected maybe he sometimes stopped taking his medication. And I know, as a doctor, he often experimented with self-medicating.

In Kay’s book, I saw someone that had a full life, success and had mental illness. Black Box is not a show about bipolar; I only saw it as an opportunity to have a character that lived with it who had a full and interesting life. Because of my father, I did an enormous amount of reading about the brain always, people like VS Ramachandran, Steven Pinker, and Oliver Sacks, who was a big influence. What I took in most of all is that behavior is not the result of how your mother raised you, but the biology of brain you are born with. Our brains our built by our genes, just like our hair and our eyes and everything else. Read Full Article

Nami GBCan: Providing Support, Education, and Advocacy for those in Recovery

Nami GBCAN brings meaning, hope, and life to the word recovery. While in recovery for my own mental illness I was on an overwhelming search. I didn’t know what I was searching for until I landed on Nami GBCAN. The National Alliance on Mental Illness Greater Boston Consumer Advocacy Network is made up of a group of peers who serve as advocates to those with mental illness. Nami GBCAN stood out to me because just as I am, they are dedicated to eliminating the stigma and discrimination associated with mental illness.

nami
Nami GBCan Walk- Facebook

Howard Trachtman, the founder of Nami GBCAN is a leader in the mental health field who uses his lived experience as a tool to help others on the road to recovery. Advocacy is another huge part of their mission.

Some of the issues they have fought for include housing, homelessness, veteran support, restraint and elimination. I asked the staff of Nami GBCAN what does being a part of this group mean to them and this is what they said:

I get to listen to others and help individuals with issues they are struggling with. For one day a week, sometimes two, I feel like a professional I used to be.

To me NAMI GBCAN means being able to connect with people who understand where I am coming from. GBCAN makes me feel like my skills and abilities are valued and useful.

NAMI GBCAN gives me hope. The people that I have connected with here brings to life the idea that “recovery is real

I am proud that I have been able to mentor people to work in human services.  Being active in NAMI GBCAN has helped me feel like I have made a difference.

When I’m around peers at the NAMI GBCAN, the stigma of my illness is somewhat lifted and it allows me talk freely with no clouds over my head.

If you’re in the Boston area join the GBCAN as we take on the Nami Walk on Saturday May 10th, 2014 at the DCR’s Artesani Park along the Charles River.

Recidivism: Reducing Non-Compliance or Victim Blaming?

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.

Exit mobile version