Friday, December 27, 2013

Assisted Outpatient Treatment?

Happy Holidays, everyone.  Blogging has been a little slow here at Shrink Rap as the Shrink Rappers overdose on cookies and get caught up in all the usual holiday stresses that get to everyone.
I've heard rumors that in the coming 2014 Legislative Session in Maryland a bill may be proposed to make Assisted Outpatient Treatment (AOT) part of the landscape.  As it stands now, we are one of the few states that does not have AOT, or forced treatment, for outpatients, outside of the forensic system for those on conditional release after having committed a crime (often a violent crime).

Since Maryland doesn't have AOT, I have no experience with it.  Perhaps it's a good idea; I don't believe it's humane to leave people living in the filth and cold on the streets if they have a psychotic illness that could be treated.  But I'm also well aware that treatment has side effects for some, and limited efficacy for others, and I worry that forcing people to get care in an already strained system is not the same as forcing them to get thoughtful, individualized care, with a spectrum of treatments being offered.  

So I'm staying out of the discussion at this point, as all I can say is that I don't know what the right thing is to do. I do know that people have strong opinions.  

If you live in a state with Assisted Outpatient Treatment, and you've been a part of the program, then I"d love to hear your comments.  If you have a family member who gets AOT, or are a doctor involved with such treatment, then I'd love to hear your opinion as.  If you've never personally been involved with forced outpatient care, even if you've been involved with forced hospitalization, then I'd like to ask you to hold your opinions for now.  I really  would like to hear from the direct recipients of these treatments.

Thanks so much!


Joel Hassman, MD said...

Yeah, well, why don't you want to hear from providers who are forced to take on these patients, without one second of input to the judge that presenting "treatment" as part of a judicial proceeding that instead presents the interaction as "punitive" is important to hear, and not solely what these clueless and insulated forensic mental health providers who only work in court rooms recommend without equally not talking to us providers out there in the trenches as well?! A run on sentence, goes along with the run on dumps we have been taking for decades!

I just don't get a clueless and equally reckless system by the judicial branch, who I respect and appreciate their frustrations and concerns they may actually have people in front of the bench who are truly mentally ill, but, who the hell are they to tell me to do what a conditional release document says without asking me my f----g opinion about the referral!

Oh, remember, I am the one taking care of these people, not the judge, who issues a verdict and then goes home for six months plus and has no contact with this person he/she orders to come and see me for care. By the way, who also expects me to be a proverbial add on probation officer to report compliance issues!! Give me a f----g break, and I use the curse word to reflect my incredibly outraged feeling of these referrals FOR DECADES NOW without never talking to a judge before the opinion for care is made.

Mental health care in the settings I have worked in is voluntary, and these patients have to have some interest in wanting to help themselves. Frankly, if this bulls--t knee jerk reaction to isolated but unfortunately repeated incidents of shootings by most likely seriously ill people is going to be handled by a new and irresponsibly term like "Assisted Outpatient Treatment" (and what a load of crap that phrase is for what the treatment intervention really involves), well, see how long providers stay in clinics that the state continues to decimate with their intrusions and irresponsible edicts on providers.

Hey, guess what you might see by 2016, PCPs having to work as "Med evaluators" for mental health clinics, because psychiatrists as a whole will say in so many words to state run clinics, "F--k you, I don't need this bulls--t!"

Again, as I write at my site, take a stand against tolerating incompetence and irresponsibility around you, it has to end!!!

Oh, and check out what John Grohol wrote on this same subject yesterday, at this link:

Yes, you'll note I commented there too!

Oh, also, ask your your forensic colleague about that innocuous ruling by a judge in North Texas last week allowing a 16 year old to be freed on probation after killing 4 people while driving, drunk with a BAC of 0.24 on the defense of "Affluenza".

Wow, how many people will catch this over the winter!?

Think he will be court ordered for mental health care too!?!?

Does my sarcasm come out in the simple print here?!?!

Yeah, try such an attitude in court, can you say "charged with contempt" faster than the judge will bang that gavel?? Guess what, judges don't want to hear the truth when it doesn't coincide with the court's agenda, not responsible verdicts!!! And I have been on there, charged with contempt, for advocating responsibly for a patient, so think about that before you write a rebuttal!!! Yeah, the topic touches a nerve here!

Happy New Year, lookin' forward to it!

Anonymous said...


I hope I am not violating your request by posting a link to an inpatient mental health worker who is against ACT. If I am, feel free to delete my post.


Dinah said...

Joel, I want to hear from people with direct experience, and you live in Maryland where we don't (yet) have AOT. Your sarcasm does come through, but it's not nearly as troublesome as your anger.

AA: Thanks for the link. I wasn't sure of Mr. Keyes role, but one of the commenters, the mom in Oregon, was what I was looking for.

Voluntary patients fill these scripts all the time. I'm guessing that a fair number of people on the streets would like to fill them, but have no means to do so.

And I'm all for Housing First. I don't see what good you can do anyone who is sleeping on the streets or is too fearful to go to a shelter.

Liz said...

i'm not exactly your target responder, and feel free to delete this if you feel that is best... for the first time in two years or so, two months ago i engaged in a relatively severe self harm act. rather than going to the emergency department to seek treatment, i bandaged myself up as well as i could and hoped for the best-- the prospect of forced treatment of any kind was untenable to me, and the only way i knew at that point in time to avoid forced hospitalization or aot (in particular, being forcibly medicated) was to avoid seeking medical treatment of any kind. this thankfully ended up being a good decision. i physically healed well and i have restarted therapy with a psy d student. but stuff like aot WILL prevent some people from seeking help... it did so with me.

Joel Hassman, MD said...

I am sorry to be angry, I guess watching Community Mental Health Clinics erode into Dependency Centers is something we should all just shrug our shoulders and simply utter, "that's just the way it is".

I'm sure when the next colleague is brutalized or murdered by a disgruntled Assisted Outpatient Treatment referral, then we will debate the appropriateness of this plan unilaterally forced on providers.

That is the nature of this society, true? I really think you should include comments from providers who work in the trenches as well, it makes for a more complete dialogue, but, just my opinion.

Anyone offended by the content or tone of my earlier comment, my apologies offered sincerely, but, do you want providers just to go through the motions, or, show some honest feeling at times?

This plan is wrong, again, just my opinion.

Dinah said...

I do want opinions from clinicians in the trenches! But I want them from people with experience and stories to tell, not theories that people referred to AOT will kill the referring professionals.

Borderline said...

I have a feeling you are talking about adults (I had AOT as a minor), so I won't get into too much detail...and I kinda don't wanna argue with potentially burnt out angry providers.

With that said, I would like to apologize to the pdoc world for not always having been the best patient. I think forced treatment, even on an outpatient basis, creates hostility and I think it generally makes care worse (especially when the patient has no choice in provider). I can understand why working with difficult kids or adults who don't want help and have severe psych issues would be growling.

Never had forced treatment as an adult, and that probably has it's own set of issues.

This was just my experience, but when treatment was enforced, I noticed that the provider was more likely to make really inappropriate comments. They would scowl, sneer, and bully. And it was always when a parent wasn't present. They would change their tone and be more professional when an adult was in the room. I always thought that part was weird. Pdocs usually saw me with a parent and they were just borderline annoying and acting like they didn't really wanna be there. If it was a therapist, they typically saw me alone, they could get VERY nasty. I don't even want to repeat some of the stuff that would fly out of their mouths.

I knew one kid who I swear said the therapist called him a stupid fuck. The kid said he cried and the therapist freaked out and apologized.

I think they were all just really burnt out from working with messed up kids.

Anonymous said...

Several years ago, I remember reading about Gabriel Hadd who fled Michigan to avoid AOT.

I would love to hear his story. I cannot imagine what he went through. Shameful.

Anonymous said...

Here's Australia's version of AOT. The videos aren't exactly a ringing endorsement of forced outpatient treatment. It seems to only be increasing this gentleman's fear and anger.

Joel Hassman, MD said...

I have written a post about this topic tonight, feel free to read it if interested, so not to disrupt this thread. I have no problem with anyone's feedback if offered at that post.

Rereading my comment at the top here, yes, I was harsh and again apologize for words used, but, not for the general content. Hope the thread hereon is valuable for all.

Anonymous said...

My son had his first psychotic break in his senior year of high school. We spent his first year of psychosis in disbelief, as there was no conclusive diagnosis. We really didn't know where to turn for help. Therapists are not trained in serious mental illness. Psychiatrists tend to not accept insurance. My insurance was useless in obtaining help, so we limped along using outpatient treatment that basically did not help. So my son went untreated for two years, then we managed to get him help in L.A.s full service partnership transitional age youth program. He went back to school, they graduated him. He relapsed. Long story short the next year he was on drugs, got arrested, spent 4 months in jail. Now as a condition of his release he is back in treatment. MUCH better!!!!!!!!!!!

Anonymous said...

It would be good to hear the son's opinion of the forced treatment to see if he agrees with his parent's assessment.


Anonymous said...

Hi Dinah! Found this via a friend on facebook. I have an adult child who is severely mentally ill. We live in a state with very good AOT laws. It is very difficult to place someone on AOT, the court system does a very good job of vetting and must include consideration of history, psychiatrists' evaluation, eye witness accounts, etc. Also, they almost always allow patients to go off court order after first six months/year and patients have a process to appeal. It is against the law to petition someone for involuntary treatment under false pretense. Our child would not be alive without it. He was almost placed in state hospital as he was so unstable and did not respond to traditional treatments. He was very dangerous to self and others. Now he is able to have a somewhat normal life with good supports and assistance. He does not have to live in state hosp., prison or streets. And most important, he is not dead. It saved his life. He still does not have insight, he has a hard time understanding how sick he is. He is still delusional, but is learning to cope better with assistance/counseling.

Dinah said...

Anons with children on AOT: Thank you for sharing your stories. What state?

Borderline: if you were involuntarily treated as a minor against your parents' wishes, that is involuntary treatment. If your parents wanted this, it's simply Childhood. We do all sorts of things to minors against their will from the moment of birth on.

Dr. H: as you've pointed out, Maryland does have 'conditional release' -- required treatment for those who've been found not criminally responsible because of their illness. I've treated a few people over the years who had spent years in a forensic facility for murder and were then released to the community with requirements for ongoing treatment for several years. It wasn't a problem, but I suppose some people rail against treatment more than others. I'm not sure what else society should do with someone who is psychotic, kills a stranger, then recovers with medications. But I do believe that after someone has committed a violent crime, it's not as stomach-turning to force treatment.

Anonymous said...

I don't want to share state. You would be surprised how much "hate" we can get from anti~psych movement folks and want to protect my son. I will add that every year a person on involuntary treatment gets to have a hearing. My son declined his right for the hearing and accepted being on involuntary treatment this year. They had never heard of anyone doing that. I think deep down he knows he needs to be on AOT and trusts us.

Borderline said...

There was some coercion. I was a minor, so I don't know anything. Frankly, I don't want to know all the details. Traumatized enough. But my surviving parent has said that if would be considered"child neglect" if he did not comply with getting me treatment and charges could be pressed. I do have a vivid memory of the outpatient treatment facility pushing to have me put in a residential setting. My parent was highly uncomfortable. They pushed it later on the phone and I could hear. My parent blew up, and I never saw that before with treatment workers. He accused them of being ineffective and he no longer wanted them treating me. He got me treatment elsewhere and put me on home hospital.

I rarely saw this parent have a spine, and it was one of the few brave things I saw him do.

My surviving parent claims there was highly pressured, and he would not have put me on as many drugs, especially risky ones, if there had not been that kind of pressure.

Borderline said...

I meant, "Don't know everything"

Joel Hassman, MD said...

Dinah, I think you are missing the point, whether it is a small and possibly insignificant portion of the population getting court ordered to treatment, or in my opinion a growing legion in my various travels as a temp these past 4 years, criminals are playing "the nut game" to avoid jail.

All it takes is one time for a person to act out once he/she senses "the jig is up" and may be exposed for either being a fake or just violating the terms by their entrenched attitude of uncooperation. The damage could be irrevocable. I have seen this in state hospitals that have better systems to minimize harm for staff!

We as providers have the right to trump what the courts or forensic colleagues say prior to the patient coming to the clinic. But, it doesn't play out that way, eh? I am genuinely watching out for people who are prey for simply providing empathy and compassion for the antisocial.

Case by case basis to decide this process for involuntary care, which is what it is. By the way, you should read the comments by Claire at my post about this topic, I think she wrote very honest, inspiring perspectives. I advised her to share it here.

Happy New Year, maybe the year of autonomy and independence?!

PsychPractice said...

My AOT experience is limited to running an inpatient unit in NYC for two years. During that time, I put several patients into AOT. I left that job in 2006, and things may have changed since then.
In theory, there's something to be said for AOT. But I found it frustrating. It was a lot of effort to get someone into it-paperwork, court, and so on. The way it worked in NY then was that if you got someone into AOT, they were required to take their meds and follow up with treatment. A case worker would come to the home regularly and check that this was happening. If the caseworker started to suspect that the patient was not complying with treatment, and was getting delusional or depressed or manic or disorganized, etc, then the patient could be forcibly brought to a psych ER for evaluation.
Note: the patient could not be forcibly admitted to a psychiatric unit. Or even realistically forced to take meds.
I don't know how it works in other states, or if it's even the same in NY now. But the system I dealt with had no teeth. Treatment was never truly "forced". And while I agree that there are tremendous problems with forced treatment, if someone is in AOT, they should at least get the treatment they're supposed to get.
What I'm saying is, if you're going to force someone to get treatment for his own good, then force him, and make sure the treatment happens. Otherwise you've lost the only real benefit of the program.

Anonymous said...

Maybe it comes with being a single female living in a big city, but I cannot think of anything scarier than someone busting in my house and taking me by force. Scary, scary, scary.


Dinah said...

Here is an article in the Baltimore Sun on the topic:,0,3608071.story?fb_action_ids=10201652110920870&fb_action_types=og.recommends&fb_source=aggregation&fb_aggregation_id=288381481237582

Anonymous said...

Just curious if there is any data on how many patient avoid the AOT order by leaving the state?


Unknown said...

Here in NY there are specifications that need to be met before someone qualifies for AOT. Someone needs to be admitted 2-3 times in a short period of time. One admission or two admission in a years time does not qualify someone for AOT status. I deal with clients on AOT frequently and my opinion is rather mixed when it comes to this. Yes, it does help some, but it also places people who really do not benefit from the AOT status. Some people are placed on AOT because the system does not know what else to do with them. Sad, but true.