Tuesday, August 2, 2011

What Should Kentucky Do? Suggestions for Amending KY's Mental Health Laws

"The Untapped Power of AOT in Kentucky"

Suggestions for Kentucky, on how to improves it's 'outpatient treatment law' from Brian Stettin, Policy Director of the Treatment Advocacy Center.

Click here to review notes from Brian's workshop held at the NAMI KY 2013 annual conference, on July 20. 2013. 



On July 30, 2011, approximately 150 mental health advocates, individual living with mental illness, their family members, mental health providers or law enforcement professionals attended workshops at the NAMI KY conference in Louisville, KY. One class helped members learned more about the current out-patient treatment laws and why the current law needs amending. The workshop concept was inspired by GG Burns, founder of "Change Mental Health Laws in Kentucky Project", (based on her personal struggles with a family member) and by a well known mental health professional, Ms. Rita Ruggles, MSW of Naples, Florida.

Ms. Ruggles, broke down a very complex subject into bite size pieces. Several family members in the audience reported they were unable to obtain medical attention for their loved ones, who suffered with psychotic episodes and lack the ability to agree to treatment on their own. Others reported they had never heard of the KRS 202(A). One NAMI affiliate leader spoke of not only was this law underutilized, it is sometimes NOT supported in many regions of the state, even when a very sick person finally receives AOT!

GG reported, "until KY’s Mental health laws are amended, services and treatment will continue to be unavailable for a small population of people who do not believe they are sick due to a symptom of their brain disease called
anosognosia". Consequently according to state data, this group is taking up too much of Kentucky's resources in the corrections, criminal justice and law enforcement budgets.

What Should Kentucky Do?

Click on 'How to Advocate for AOT in KY' Fact Sheet Here:

NAMI Kentucky Conference outline to "Closing the Loop" presentation
July 30th, 2011

By: Rita Ruggles, MSW
Clinical Director for the David Lawrence Center in Naples, Florida

GG Burns, Mental Health Advocate


Workshop Goals ... to

• Gain an understanding of the Assisted Outpatient Treatment.
• Gain an understanding of KRS 202A
• Gain an understanding of civil commitment criteria pursuant to Kentucky
Revised Statute ( KRS) 202A.
• Gain an understanding of other states civil commitment criteria.
• Gain an understanding of an agreed outpatient order and the stipulations outlined
in KRS 202A.
• Gain an understanding of the types of situations that warrant assisted outpatient
• Gain understanding of NAMIs efforts to advocate for clear language in the states statutes that address assisted outpatient treatment.

What is Assisted Outpatient Treatment?

• Assisted Outpatient Treatment (AOT), formerly known as involuntary outpatient commitment (IOC), allows courts to order certain individuals with brain disorders to comply with treatment while living in the community.

• Assisted Outpatient treatment was initially proposed in the early 1980's by families of individuals with the most serious mental illnesses as a way to help their loved ones. Individuals with disorders like schizophrenia often need medicines to enable them to control their own thoughts and behavior. But sometimes, they don't recognize they are ill ("Anosognosia") and therefore see no need to be in treatment.

• These individuals often decompensate; commit suicide; become homeless persons with mental illness; end up in jail; or, on rare occasions, are involved in acts of violence. Family members and caregivers were not allowed to intervene until 'after' the individual "became danger to self or others". Many felt the law should prevent dangerousness, rather than require it.

• Once the family member deteriorated to the point of dangerousness, the only thing police could do was involuntarily commit the individual to inpatient hospitalization.

• Families believed that committing someone to receive services on an outpatient basis was kinder, more humane and less expensive than inpatient. In addition, it could prevent the person from deteriorating in the first place.

AOT is NOT an alternative to voluntary services. It is a way to see that services get utilized by those who reject voluntary services and are likely to needlessly decompensate as a result.


Why Advocate for AOT?

• Assisted Outpatient Treatment is an important advance.

AOT allows individuals to be court-ordered into treatment without ordering them into a hospital. It is a less-restrictive, less-expensive, more humane form of 'commitment' than inpatient commitment.

• The criteria to place someone in assisted outpatient treatment are easier to meet than the "imminent dangerousness" standard often required for inpatient commitment. AOT allows someone to be ordered into treatment "to prevent a relapse which or deterioration which would likely result in serious harm to the patient or others." Prior law required 'dangerousness', Assisted Outpatient Treatment prevents it.

• The court order not only commits the patient to accept treatment, the court order also commits the mental health system to providing it. Prior to AOT, many treatment providers preferred to exclude the most seriously ill.


The PRO’s

While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate base their arguments on the quality of life and cost associated with untreated mental illness and "revolving door patients" who experience a cycle of hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment.

The CON’s

Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied. The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders.

The Outcomes

In 2005 and 2009, the New York Office of Mental Health conducted an outcomes study related to the provision of assisted outpatient treatment:

74 percent fewer experienced homelessness;
77 percent fewer experienced psychiatric hospitalization;
83 percent fewer experienced arrest; and
87 percent fewer experienced incarceration.

Efficacy of services provided under an assisted outpatient treatment orders

Comparing the experience of outpatient commitment recipients over the first six months of commitment to the same period immediately prior to commitment, the OMH study found:

• 55 percent fewer recipients engaged in suicide attempts or physical harm to self;
• 49 percent fewer abused alcohol;
• 48 percent fewer abused drugs;
• 47 percent fewer physically harmed others;
• 46 percent fewer damaged or destroyed property; and
• 43 percent fewer threatened physical harm to others.

Kentucky’s Civil Commitment Law

KRS 202A – A Work in Progress
• Major Amendments in the early 90s
I. The Criminalization of Mental Illness
• E. Fuller Torrey National Report
• Worst state in the nation designation
• Decriminalization Project (HB 207)

II. Task Force on Violence and Persons with Mental Illness

Recommendations for statutory language changes in both KRS 202A and KRS 504

Criteria for Involuntary Admission,
current KRS 202a reads that in order for a person to be involuntary committed to a hospital for up to 72 hours ...

  • Person has to have a mental illness; and Be expected to benefit from treatment; and Be a danger to self or others; and Hospitalization has to be the least restrictive environment.

Compare the wording in Florida' s Baker Act:
    A voluntary Baker Act admission occurs when a person 18 years of age or older, or a parent of a minor, applies for admission to a facility for observation, diagnosis, and treatment.
    An involuntary Baker Act admission occurs upon a finding by a court that (1) a person is mentally ill and, because of the mental illness, he/she has refused voluntary placement for treatment or is unable to determine whether placement is necessary; (2) he/she is incapable of living alone or with help, and without treatment is likely to suffer from neglect or refuse to care for him/herself, or there is a substantial likelihood in the near future that he/she will inflict serious bodily harm on him/herself/others as evidenced by recent behavior; and (3) all less restrictive treatment alternatives are not appropriate.

KRS 202 A/ KAR 908:209

Definitions: Criteria, Facility, Hospital

Three Pathways in …
(1.) 72 Hour Hold
(2.) 72 Hour Court Order
(3.) Warrantless Arrest

202A.081 Court-ordered community-based outpatient treatment.

(1) Following the preliminary hearing but prior to the completion of the final hearing, the court may order the person held in a hospital approved by the cabinet for such purpose for the committing judicial district, or released, upon application and agreement of the parties, for the purpose of community-based outpatient treatment. No person held under this section shall be held in jail unless criminal charges are also pending.

(2) A hospital shall discharge a patient there held and notify the court and attorneys of record if any authorized staff physician determines that the patient no longer meets the criteria for involuntary hospitalization.

(3) If a patient is discharged by the hospital pursuant to subsection (2) of this section, then the proceedings against the patient shall be dismissed.

(4) The release of the person pursuant to subsection (1) of this section for the purpose of community-based outpatient treatment does not terminate the proceedings against the person, and the court ordering such release may order the immediate holding of the person at any time with or without notice if the court believes from an affidavit filed with the court that it is to the best interest of the person or others that the person be held pending the final hearing, which shall be held within twenty-one (21) days of the person's further holding.

(5) If the person is released pursuant to subsection (1) of this section for the purpose of community-based outpatient treatment, the final hearing may be continued for a period not to exceed sixty (60) days if a provider of outpatient care accepts the respondent for specified outpatient treatment. Community-based outpatient treatment may be ordered for an additional period not to exceed sixty (60) days upon application and agreement of the parties.

504 Interface with KRS 202A

504 is the Kentucky law that addresses a persons criminal responsibility in criminal cases.
• Persons may be found competent to proceed, incompetent to proceed and restorable or incompetent to
proceed, not restorable.
• Kentucky Corrections Psychiatric Center in Lagrange is the state forensic facility. Forensic evaluators
are also available on an outpatient basis.
• Differentiate between competency and criminal responsibility.
• Competency - Ability to understand the charges and participate in their own defense
• Responsibility - Speaks to the individual’s state of mind at the time of the crime.

504.110 Alternative handling of defendant depending on whether he is competent or incompetent to stand trial.

(1) If the court finds the defendant incompetent to stand trial but there is a substantial probability he will attain competency in the foreseeable future, it shall commit the defendant to a treatment facility or a forensic psychiatric facility and order him to submit to treatment for sixty (60) days or until the psychologist or psychiatrist treating him finds him competent, whichever occurs first, except that if the defendant is charged with a felony, he shall be committed to a forensic psychiatric facility unless the secretary of the Cabinet for Health and Family Services or the secretary's designee determines that the defendant shall be treated in another Cabinet for Health and Family Services facility. Within ten (10) days of that time, the court shall hold another hearing to determine whether or not the defendant is competent to stand trial.
(2) If the court finds the defendant incompetent to stand trial but there is no substantial probability he will attain competency in the foreseeable future, it shall conduct an involuntary hospitalization proceeding under KRS Chapter 202A or 202B.
(3) If the court finds the defendant competent to stand trial, the court shall continue the proceedings against the defendant.


Closing the Loop Between KRS 202A and 504

• The problem for the Commonwealth arises when individuals are found incompetent to proceed yet may not meet the stringent criteria for civil commitment.
• Civil commitment criteria is different than criminal responsibility and competency therefore many individuals fall through the cracks in the system.
• This leads to multiple arrests, expensive court and law enforcement expenses, additional victims and a revolving door life for the individuals who are struggling with the mental illness and justice system involvement.
• The key to addressing this issue is an amendment of either KRS 504 and 202A that will require outpatient treatment in lieu of hospitalization or following hospitalization of a person with mental illness who are incompetent to proceed.


• Review the recommendations issued by the Task Force on Violence and Mental Illness issued in the late 90’s and re-issued by the Criminal Justice/Behavioral Health Interface work group of the HB 843 Commission.
• Assign a staff person within the Department to specialize in the states Civil Commitment Law and Forensics.
• Consult with Legislators interested in this issue. (Rep. Tom Burch). Prior draft language for amendments should be available.
• Form a state level policy group to build on the prior work and validate historical information and to work with a sponsor and their staff to design a bill for the 2012 session.

Kentucky needs to "rebalance" their properties.

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