Assertive Community Treatment

Evidence-based Practice or Managed Recovery

Sandra Johnson

• Publisher: Taylor & Francis
• Year: 2017
• Print ISBN: 9781138507449
• eBook ISBN: 9781351297462
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Political History & Theory
• Index: Politics & International Relations

The twenty-first century has witnessed an explosion in studies on comparative health studies, but mental health remains virtually ignored. Unlike the well researched topic of health policy, there is a gap in the marketplace covering mental health policy and health care policymaking. This book fills that gap; it is a comparative analysis of the implementation of Assertive Community Treatment (ACT), an evidence-based practice employed in two states that promises to empower the well-being of individuals suffering from mental illness.

Assertive Community Treatment specifically examines the tension separating the notion of client recovery and evidence-based programs. Johnson challenges the assumption that practitioners should rely on evidence-based practices to close the gap between scientific knowledge and practice. She argues that in an era of managed care, this encourages state mental health administrators to adopt policies that are overly focused on outcomes. Programs that can measure the outcomes of care provided, and evidence-based practices, have become central aspects of the quality care agenda.

This study traces the role of policy entrepreneurs throughout the Assertive Community Treatment policymaking process. By differentiating mental health in general, qualitative research increases the chances of observing similarities and differences in outcomes. Johnson explains why the ACT model was adopted and implemented. She concludes that there is a clear monopoly by medical researchers and scientists within Assertive Community Treatment research, and as a result, too much emphasis is placed on the roles of policy entrepreneurs as the main innovators in the agenda and policy formulation stages. Johnson presents a strong argument for more innovation in the implementation stage.

IV

The Role of the State Office of Mental Health in the Adoption and Implementation of Assertive Community Treatment in New York

On January 3, 1999, Kendra Webdale, a 32-year-old journalist and photographer, was pushed in front of a New York City N train at the 23rd Street subway station by Andrew Goldstein, 29, a young man who suffered from schizophrenia. Goldstein, who had a documented history of assaults and failed medication regimens, had repeatedly sought treatment prior to the killing, only to be denied. Goldstein was later convicted of second-degree murder in March of 2000.

Webdale’s death inspired a massive public outcry resulting in the passage of “Kendra’s Law.” This law established a procedure for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment. The law is set forth in §9.60 of New York State’s Mental Hygiene Law (MHL). The death of Kendra Webdale set the political agenda by forcing New York State government decision makers to acknowledge a social problem it could no longer ignore. Webdale’s death forced New York State government decision makers, namely Governor George Pataki, the Office of Mental Health, and Attorney General Eliot Spitzer, to acknowledge that mentally ill individuals had been “falling through the cracks” in New York State’s mental health system long before Webdale’s death.

Webdale’s death, in addition to two similar events involving mentally ill individuals in the spring of 1999—the police shooting of Charles Stevens, a man with a history of untreated mental illness who threatened passengers with a sword on the Long Island Railroad, and Julio Perez, an untreated person with schizophrenia who pushed a man onto the subway tracks in New York City—provided an opportunity for mental health advocacy groups to define how the existing mental health policy had miserably failed Andrew Goldstein, the young man responsible for Webdale’s death.

In response to these tragedies, New York’s Attorney General Eliot Spitzer proposed Assisted Outpatient Treatment (AOT) and Governor Pataki signed Kendra’s Law in August of the same year. Commenting that “it is clear that the law must be changed to protect both the public and the mentally ill from danger,” Spitzer consulted with advocacy groups, in particular the Treatment Advocacy Center of Arlington, Virginia, while crafting his AOT proposal.¹ Set forth in Article 9.60 of the Mental Hygiene Law, Kendra’s Law establishes a procedure for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment.² As part of Kendra’s Law, the bill requires that each assisted outpatient be assigned to a case manager or ACT³ team to provide regular contact with the patient to ensure that the patient receives necessary services and care.

The Office of Mental Health’s desire “to focus on quality and to introduce evidence-based practices”⁴ coincided with the death of Kendra Webdale. This political desire to increase community-based and outpatient programs opened a space for New York State’s Office of Mental Health to expand ACT programs statewide in conformity with evidence-based practices and develop program and fiscal regulations supported by Medicaid. After senior officials from New York State’s Office of Mental Health initiated contact with a nationwide study promoting the use of six evidence-based practices, of which ACT was one, New York began its Winds of Change initiative, declaring that “evidence-based practices are the way to go from now on for mental health services.”⁵

The language of Kendra’s Law focused on increasing the number of severely mentally ill that would be assigned to AOT and be forced to accept treatment. Under the law, each assisted outpatient becomes an obligation of the local and state governments, which are responsible for the client regardless of the limited budgetary resources allocated. Although this enormous infusion of money for ACT and case managers helped improve the state’s mental health infrastructure, it failed to provide the counties, the local government units, with any additional money to implement and monitor cases in compliance with AOT regulations. Thus, this underfunded mandate simultaneously jeopardizes New York’s community mental health system and contradicts the voluntary philosophy supporting ACT, which originally was not created to be a monitoring service. Rather, it was designed to work with people with schizophrenia and engage clients on a voluntary basis.

The Origins of Assisted Outpatient Treatment in New York

In the summer of 1999, NAMI–New York State,⁶ representing 58 affiliate organizations with more than 5,000 members throughout the state, was lamenting the lack of mental health services available for the severely mentally ill after the death of Kendra Webdale. In January of 1999, Webdale was killed in a New York City subway by a person suffering from paranoid schizophrenia, Andrew Goldstein, who had voluntarily committed himself for all 14 of his previous hospitalizations but had been unable to find the proper treatment for his deteriorating condition.⁷

As indicated in the chapter’s introduction, services included in the treatment plan must include either case management or ACT services to provide care coordination. The original ACT model was designed principally to work with people with schizophrenia and persons with severe illnesses who had had frequent relapses and hospitalizations and/or found it difficult to maintain recovery treatment activities. It was not created to be a monitoring service, but Kendra’s Law established a procedure for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment. Succinctly put, ACT is an evidence-based treatment approach, while AOT is court-ordered treatment.⁸

Within the evidence-based practice literature, ACT programs are widely accepted as the “gold-standard” of treatment for persons with severe mental illness who are frequent users of inpatient psychiatric care and emergency psychiatric services. However, there is little information about the effectiveness of ACT in providing care for patients who have been court-ordered to receive treatment as a “jail diversion program.”⁹

AOT was first proposed in New York in 1989 as a way to assist individuals who suffered because their illness prevented them from accepting treatment. For almost ten years, mental health advocates, including NAMI-New York State and the Treatment Advocacy Center,¹⁰ strongly lobbied legislators, encouraging the state to pass an assisted outpatient treatment law. By the mid 1990s, significant attention in the media focused more and more on the problem of “revolving door” patients, those who are non-adherent to medications and treatment and high users of psychiatric services. With NAMI-NYS reporting in 2002 that 10,000¹¹ persons with serious mental illness were incarcerated in New York’s jails and prisons, 3,000 mentally ill inmates on Rikers Island alone,¹² the New York City jail remains, in effect, the state’s largest psychiatric facility. Not surprisingly, revolving door patients also tend to have frequent contact with other community services and agencies such as the police, courts, jails, prisons, and emergency medical facilities.

Outpatient commitment was first proposed in 1989 but was strongly opposed by civil liberties and consumer advocacy groups. Only after a series of deaths in 1995 and 1996 at the hands of individuals with histories of mental illness did the New York legislature acknowledge the need for assisted outpatient treatment. In 1994, the New York State Legislature amended the Mental Hygiene Law to create a three-year pilot program to study the effectiveness of implementing involuntary outpatient mental health treatment throughout the state.

The current Assisted Outpatient Program builds on the Bellevue Involuntary Outpatient Commitment Pilot Program (Section 9.61 of the New York State Mental Hygiene Law), established by Chapter 560 of the Session Laws of 1994. The legislature followed with a three-year statutory authorization for the Bellevue Pilot Program, which commenced in July of 1995 and allowed the institutionalization of participants in the program under certain criteria should the participants fail to comply with their treatment plans.¹³

In December of 1998, Policy Research Associates,¹⁴ funded by federal and state agencies, national organizations, and foundations advancing the field of mental health services research, presented a study of the Bellevue pilot to the New York City Department of Mental Health. While admitting that the data were not statistically significant, the research suggested patients under outpatient commitment spent fewer days in the hospital than patients who had equally enhanced outpatient services without court orders. Although the report¹⁵ specified that patients involved in the study benefited from the enhanced coordination, the report also indicated that “the court order itself had no discernible added value in producing better outcomes.” In addition, the court order had no impact on participation in treatment, level of functioning, recurrence of symptoms, frequency of hospitalization, or frequency of arrest. The report indicated that coordinated outpatient services reduced the frequency of hospitalization for people who received such services, whether they were subject to the court order or not.

The Bellevue Project was scheduled to end in June of 1999 but with the death of Kendra Webdale in January of 1999, Governor Pataki was immediately forced to find a solution to the apparent mental health system crisis. Service providers and high ranking state officials alike acknowledged that Pataki’s response was largely “motivated by security” concerns,¹⁶ especially after the incidents involving persons with histories of untreated mental illness in the months following Webdale’s death. One New York City non-profit executive director familiar with the Bellevue Project and its “statistically insignificant” data explained that the trial conducted at Bellevue by Policy Research Associates had found that “whether the person was assigned to assisted outpatient treatment or case management had no impact on the outcome of the client.” In fact, the relationship with the case manager made the difference. However, this source indicated that the changes to the law were “headline driven.”

As one senior OMH researcher explained, following Webdale’s death there was a “notion that people are falling through the cracks” and the state needed to address the problem. Despite the significant research findings from the Bellevue Pilot Project suggesting that court orders are ineffective, the New York State Legislature enacted Kendra’s Law (S 5762) by an overwhelming majority (Senate 49-2, Assembly 142-4), making New York the 41st state with an assisted outpatient treatment program.

Assisted Outpatient Treatment’s Legislative Battle

AOT was supported by such advocacy groups as the Alliance for the Mentally Ill of New York State, the New York State Association of Chiefs of Police, the Greater New York Hospital Association, the New York State Public Employees Federation, American Psychiatric Association Task Force on Involuntary Commitment to Outpatient Treatment, Visiting Nurses Service, Bellevue Hospital Center, New York Treatment Advocacy Coalition, National Sheriffs’ Association, and the National Alliance for the Mentally Ill. In all, 25 religious, legal, and advocacy groups opposed the law, citing the criminalization of the mentally ill.

In August of 1999, Governor Pataki signed a version of Kendra’s Law that was opposed by only six legislators. Of the two senators and four assemblymen who voted against the law, all were Democrats except one, Assemblyman Robert C. Wertz, a Republican from Nissequogue. Commenting in the legislative testimony, Democratic Assemblyman Sullivan (D) stressed the following concerning Kendra’s Law:

[It is] an empty milk carton. It says milk on the outside. It says 2% butterfat, half gallon…but when you open up the milk carton and you look inside, there’s no milk…It’s a program without any funding to pay anybody, and that solves the political program, “What are you doing about this?” “Well, we passed Kendra’s Law.” It solves the political problem, but it does not solve the problem for the people who are going to be affected by this problem.¹⁷

Mental health advocates were divided over Kendra’s Law. Critics pointed out that involuntary commitment would not have helped Andrew Goldstein because he had repeatedly sought treatment on a voluntary basis before the attack on Webdale, but was turned away by the state’s underfunded mental health system. Assemblyman McEneny also questioned the bill’s political intent, pointing out that “the irony is that in the case of the mentally ill individuals who brought about these two tragedies…these were not individuals who were refusing medical treatment; to the contrary, they were individuals who were seeking treatment for their mental illness.” Although Assemblyman McEneny ultimately voted to support the legislation, McEneny added that they had “welched on the Community Reinvestment Act” by pursuing deinstitutionalization to save money and sending “mentally ill people without support back to their families and their communities” without focusing resources for their assistance. The results were individuals left to fend for themselves, the private not-for-profits being “overextended, and local governments spending public dollars” while the legislators failed to address the problem.¹⁸

Assemblyman Wertz also noted that the bill violated the civil rights of the mentally ill and mandated “that the person who is working on a treatment plan and is advising and taking care of the mentally ill person ‘rats out’ the person who is mentally ill,” destroying clients’ trust for those giving them assistance and making a person receiving mental health care in the state of New York a potential criminal.¹⁹ In a letter addressed to Mental Health Commissioner James Stone, Charles T. Capanzano, director of Cortland County Community Services, also expressed profound apprehension concerning the bill’s technical, fiscal, and philosophical foundations:

This law reduces trust in the Public Mental...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Tables
• Acknowledgments
• I. Assertive Community Treatment: Evidence-Based Practice or Managed Recovery?
• II. Medical Elites and Evidence-Based Practices: Yesterday and Today
• III. Process of Innovation: Theoretical Perspectives
• IV. The Role of the State Office of Mental Health in the Adoption and Implementation of Assertive Community Treatment in New York
• V. NAMI-Oklahoma’s Role in the Adoption and Expansion of Assertive Community Treatment in Oklahoma
• VI. How Model Fidelity, Medicaid, and Legislative Ambiguity Influence Inconsistent Policy Outcomes in New York and Oklahoma
• VII. Street-Level Entrepreneurs: Promoting Recovery despite Political and Economic Challenges
• Appendix: Methods
• Bibliography
• Index