Monday, July 12, 2010

Assisted Outpatient Treatment Program for Mentally Ill vs. Jail

Assistance to the Incarcerated Mentally Ill (AIMI)
Shackled Feet of  Mental Patient - AIMI

John M Grohol, PsyD, reports that mentally ill offenders who went through Minnesota's mental health court received a 20 to 25 percent improvement in offender outcomes. Although any decrease in imprisonment of the country's most vulnerable citizens is valuable to the mentally ill, their families, and taxpayers, the rate of improvement could easily and inexpensively triple if mentally ill offenders were placed in Assisted Outpatient Treatment programs (AOTs). AOTs combine subsistence assistance with mandatory psychiatric treatment. AOT program participants in New York received better between 85% and 97% reduction in their rates of arrest, hospitalization, homelessness, and incarceration. Enforced treatment makes the difference.

Mental patients often stop taking their meds and keeping psychiatric appointments soon after prison or hospital release due to a condition called "anosognosia" that makes it impossible for them to know that they are sick. Discontinuation of psychiatric treatment frequently causes these persons to lapse back into psychosis and eventually break the law. New York AOT program participants' 90% decrease in homelessness, arrests, hospitalizations, and incarcerations compared their experiences three years prior to program participation shows clearly that WE ALREADY HAVE THE ANSWER.

It is only common sense that if a person is mentally deficient, he is unlikely to make wise decisions about mental health care, especially during a psychotic episode. It is wrong to leave it up to sick people whether to treat or not, especially those exiting prisons and mental institutions. This issue needs to be addressed before more soldiers suffering from PTSD transition back home to civilian life. A study of the Balkan Wars soldiers showed that around 54% had some level of PTSD. People who have been trained to kill when they feel threatened will soon fill our cities, and some are soldiers who have been stressed beyond their limits of endurance like Sgt. John Russel. It is wrong to put any of our sick citizens in the position of going untreated and eventually be jailed for crimes and/or wandering homeless because they don't have the mental stability to seek help. Acute mental patients are even more likely to be hurt themselves than to hurt others, and many die during arrest attempts or by suicide. The reduction in arrests and recidivism among AOT program participants demonstrates plainly that the communities were safer because of the program. AOTs can end the madness.

In addition to being highly effective at restoring mentally dysfunctional persons to a wholesome existence and increasing community safety evidenced by fewer arrests, AOT program participation is far cheaper than incarceration. Each inmate in the general prison population costs taxpayers up to $50,000 per year per prisoner plus an additional $100,000 annually for each chronically ill prisoner who receives special housing, trained guards, and regular treatment. These hefty prison fees come after the cost of police services, attorney fees, and court costs. Since AOT programs reduce recidivism by up to 90%, billions of dollars could be saved off the nation's prison budget by releasing mentally ill persons from prisons and hospitals only under court ordered participation in an AOT program.

Court ordered AOT participation for mentally ill persons released from inpatient facilities and prisons (at least during parole or probation) would relieve them of a responsibility that most chronic mental patients are unable to handle reasonably: their mental health care. Rigid requirements in most states prevent enforced treatment unless mentally ill persons are immediately dangerous to themselves or others. Therefore, the released mental patients' families are not allowed to enforce their treatment, and anosgnosia prevents psychiatric patients from seeking or agreeing to psychiatric services, especially during a psychotic episode when help is most needed. Na Yong Pak is a 32-year-old woman who was released from a mental health facility in Georgia last year despite her family's protests. She is a schizophrenic patient with violent tendencies. Within 12 days of hospital release, Na Yong quit taking her meds (or never started after release from the mental hospital) and set her mother on fire, burning her to death. See this family's tragic story here:

There has been ZERO reduction in costs to taxpayers resulting from closing hospitals and reducing mental health services in the communities. In fact, a significant cost increase resulted from shifting sick people to the prison system. The mentally ill are not being incarcerated rather than treated in order to save money or save sick people from institutionalization. The difference is who gets paid - private prison profiteers rather than hospitals and outpatient treatment providers.

Methods and reasons for decriminalizing mental illness are examined in the article HUMAN RIGHTS FOR PRISONERS MARCH, as well as reasons why AOTs are not more broadly applied despite being a less expensive, highly effective, lifesaving approach to dealing with mentally illness, particularly for those exiting prisons and hospitals. See the article at this link:

Comment continues after Dr. Grohol’s article and an excerpt from the Philadelphia Inquirer. Dr. Grohol is the CEO and founder of Psych Central. He has been writing about online behavior, mental health and psychology issues, and the intersection of technology and psychology since 1992. The Philadelphia Inquirer published an editorial in favor of AOTs being more widely used in March 2009. It is the first mainstream news source to publish an editorial in support of AOTs replacing imprisonment for mental patients. Notice was published by Treatment Advocacy Center (TAC) at this link:

Imprisoning People with Mental Illness
by John M Grohol, PsyD
July 18, 2009

People with mental illness are increasingly ending up being imprisoned, rather than in the mental health care system where many of them belong. With the down economy, states and counties — who are primarily responsible for the health of the indigent — cut social services first. And with most public psychiatric hospitals long-since closed, people who have a mental disorder end up being warehoused not in hospitals, but in prisons.

Yes, we succeeded in closing down the state mental hospitals. But we moved the population not to outpatient facilities, but to our prisons.

Now, finally, people are realizing the short-sightedness of locking people with mental illness up, as the spiraling prison costs of doing so become a burden to cash-strapped local governments.

In Philadelphia, a new mental health court has just started, meant to divert people away from prison and into mental health treatment. By doing so, the hope is that they can reduce the incidence of mental illness within prisons, and provide better care for people with a mental disorder in the process.

The new court is part of an approach called “sequential interception,” which includes programs designed to intervene so that people with mental illness don’t get caught up in the criminal justice system - or even killed by it. [...]

The court and the CIT are responses to a complex problem that began decades ago when the closing of state hospitals released mentally ill people into the community without adequate support or services.

Decades later, the high numbers of mentally ill people occupying prisons - some reports put the number at 30 percent of the inmate population - suggests that in too many cases, prisons have replaced state hospitals.

Imagine that — up to 30 percent of prisoners could have a treatable mental disorder. And guess what kind of mental health care most prison systems offer? Limited, if any (federal prisons tend to do a better job in this area than state-run prisons, but none come close to offering the kinds of services one would typically find in their local community).

Human Rights Watch has called out the U.S. prison system for its warehousing of the mentally ill and giving them inadequate care:

In 1998, the Bureau of Justice Statistics reported there were an estimated 283,000 prison and jail inmates who suffered from mental health problems. That number is now estimated to be 1.25 million. The rate of reported mental health disorders in the state prison population is five times greater (56.2 percent) than in the general adult population (11 percent).

Women prisoners have an even higher rate of mental health problems than men: almost three quarters (73 percent) of all women in state prison have mental health problems, compared to 55 percent of men.

“While the number of mentally ill inmates surges, prisons remain dangerous and damaging places for them,” said Jamie Fellner, director of Human Rights Watch’s U.S. Program and co-author of a 2003 report, “Ill-Equipped: U.S. Prisons and Offenders with Mental Illness.” “Prisons are woefully ill-equipped for their current role as the nation’s primary mental health facilities.”

Prison systems are horrifying places to be in the first place. They are even more so for someone who is suffering from schizophrenia or bipolar disorder and doesn’t have access to standard treatments for them. The previous Human Rights Watch report noted:

Inmates with mental illness are often punished for their symptoms. Being disruptive, refusing to obey orders, and engaging in acts of self-mutilation and attempted suicide can all result in punitive action. As a result, the report noted, prisoners with mental illness often have extensive disciplinary histories.

Frequently, the prisoners end up in isolation units. “In the most extreme cases, conditions are truly horrific,” the report stated, adding:

Mentally ill prisoners locked in segregation with no treatment at all; confined in filthy and beastly hot cells; left for days covered in feces they have smeared over their bodies; taunted, abused, or ignored by prison staff; given so little water during summer heat waves that they drink from their toilet bowls. … Suicidal prisoners are left naked and unattended for days on end in barren, cold observation cells. Poorly trained correctional officers have accidentally asphyxiated mentally ill prisoners whom they were trying to restrain.

These are conditions one would expect in a third-world country. Not in the U.S. And not for people who are often most in need of compassion and care.

What research is there to show such mental health courts help? On Friday, a study was released that showed a 20 to 25 percent improvement in offender outcomes under the mental health court system in Minnesota. Dr. Grohol's article is at this link:


Philadelphia Inquirer on Assisted Outpatient Treatment Programs
March 30, 2009


Court-ordered outpatient treatment for the mentally ill is effective for the individual and less expensive for the state. But in Pennsylvania, it's rarely used.

That's because the state's outdated 1976 mental-health law requires ill people to be a "clear and present danger" to themselves or others before a judge can order them to get treatment.

By the time people with mental illness deteriorate to that point, outpatient services are often not appropriate. They usually end up hospitalized.

If such people receive community-based treatment before they deteriorate too far, the results are positive. But people with mental illness often don't recognize they need help, and won't agree to treatment voluntarily. Forty-two states have some form of assisted outpatient treatment for the mentally ill. And a bill pending in the state Senate would bring Pennsylvania up to date in providing round-the-clock outpatient services. (The New Jersey Senate is also considering similar legislation).

Sponsored by Sen. Stewart Greenleaf (R., Montgomery, Bucks), SB 251 would allow judges to order outpatient mental-health treatment for people involuntarily for up to six months. It would apply only to patients who have been hospitalized at least twice within the previous three years, or have been involved in a serious violent incident within the past four years.

The new standard would be a "likelihood" of danger for receiving treatment involuntarily. The bill provides for a court hearing and legal representation for the mentally ill person. (See the link above for full article.)




Imprisonment of the mentally ill has to do with prison profiteering by sacrificing the weakest members of our society. Criminalizing mental illness benefits prison profiteers, like excessive sentencing, denial of DNA testing rights, denial of new trials with substantial evidence of doubt, mandatory three-strikes laws, and many wrongful convictions, which result most often from inadequate defense by public defenders.

Some believe that public defenders offices have limited resources because of the lack of capital. The opposite is true. Every inmate, whether innocent or guilty, costs taxpayers around $50,000 per year to incarcerate, an amount which varies by state. Providing poor legal defense actually costs taxpayers more money than providing adequate defense, as it frequently results in innocent people being sentenced to expensive prison terms or offenders being sentenced to excessive terms of incarceration. A 30-year-old man who is sentenced to life in prison costs taxpayers around $3.5 million dollars if he lives to his full life expectancy. That amount can more than double if the inmate is or becomes chronically mentally or physically ill. Therefore, public defenders' lack of adequate resources results in unjustified human suffering and substantial avoidable expense to taxpayers even if just one wrongful conviction or overlong prison sentence occurs.

Most instances of imprisoning mental patients are violations against their civil rights, because so many of them lacked an understanding of their Miranda rights (giving accused persons the right to remain silent with the understanding that what they say during police interviews can and will be used against them). Acute mental patients also usually lack the ability to contribute to their own defense at trial. Na Yong Pak's brother reported that after she burned their mother to death within 12 days of release from the mental hospital, Na Yong had no idea whatsoever why she was in prison. What good is it that taxpayers spend millions of dollars "punishing" people like Na Yong? Acute mental patients like Na Yong recognize that they are being punished by imprisonment and often tortured by solitary confinement while cold and naked in small isolation cells, but many of them have no idea why they are made to suffer.

Prisons are called "correctional institutions," and the primary objective is punishment for wrongdoing. Prisons are also supposed to be rehabilitation facilities, even though precious little is done to rehabilitate inmates. Acute mental illness cannot be "corrected" by punishing sick people; neither can mental illness be "rehabilitated." It is a chronic health condition and must be treated, not punished. The victims of the devastating illness need care, like victims of heart disease, diabetes, or any other chronic illness. The cost of treating mental illness in outpatients under an AOT program which combines subsistence assistance with mandatory psychiatric treatment costs substantially less than the average cost of $3.5 million required for lifetime imprisonment after expensive trials that sick people may not even understand.

Nationwide application of Kendra's Law for non-violent mentally ill offenders and hospitalization for violent sick people would save billions annually off America's prison budget and restore 1.25 million Americans to a more wholesome existence. AOT programs have the capacity to facilitate moving many mentally ill offenders from being a taxpayer burden to becoming taxpayers, themselves.


WHATEVER THE PROBLEM, CHECK AND SEE WHO PROFITS, whether it is a matter of war and peace; poor prison rehab programs; withholding treatment from the mentally ill unless they have the wherewithal to seek psychiatric services (reserving them for prison); environmental injustice; equipping all police officers with Tasers that they should recognize as being less lethal, not "non-lethal"; inadequate public school education (keeping people ignorant); ousting God from public everything (so the Government will be the highest authority in the minds of the people), the proposal of forcing all U.S. citizens to choose between accepting a potentially harmful or deadly H1N1 vaccine or be incarcerated in FEMA camps, etc. Someone profits from every social problem.

Work by this author written to bring Assistance to the Incarcerated Mentally Ill include:





Mary Neal


  1. I'm very confused about this term "anosognosia." My experience with mental health has been this:

    I suffered through 2 90-day periods of outpatient commitment. From my files that my lawyer had, I saw that I had been diagnosed with a condition that the mental health professionals had never bothered to share with me. How could I have known what I was sick with if they refused to share it with me?

    BTW, I would have totally agreed with this diagnosis. It actually astounded me that they had figured it out.

    Like I said, it was for 2 90-day periods, but I kept coming back to the shrink for a while after that because I liked to see him squirm and lose his poker face.

    That's been 14 years ago. I have been drug free and stayed out of trouble ever since, no thanks to mental health treatment.

  2. Tony, you are one of the 97% of those with a MI diagnoses that would never need AOT. Not everyone with MI has anosognosia. Your story is an example that some people with a MI diagnoses can have one of two episodes and never experience symptoms again. I hope you remain healthy and are never hospitalized again. Thanks for sharing, ggb