Institutionalization for St. Lawrence County's mentally ill increasingly means jail rather than a hospital bed [Watertown Daily Times, N.Y. :: ]
(Watertown Daily Times (NY) Via Acquire Media NewsEdge) June 29--Nineteen-year-old Justin M. of Ogdensburg said he was "just hanging out with the wrong people" when he got into trouble with the law in 2011 and 2012.
But bad associations weren't the only underlying reason for his criminality.
Justin, who wanted to keep his last name private due to three felonies on his record, has a mental illness. He's been involved in assisted outpatient treatment for one year and lives at Northwood Manor, a community residence at St. Lawrence Psychiatric Center.
"I don't like taking my medication," he said. "It dazes me out."
AOT is a court order under the state's Kendra's Law for people with mental illness who have a history of hospitalizations, violence or non-compliane with taking medication, to participate in an individualized treatment plan specific to their needs.
In compliance with his AOT, Justin sees doctors on a regular basis, takes four different medications and goes to Step-by-Step Inc., a drop-in center for people who have mental illness or addiction problems. He has stayed out of trouble for the last two years.
Justin said he expects to be on the AOT for at least one more year. The program is designed to help him and people like him from having repeat hospitalizations or landing in jail because of an unchecked mental illness.
AOT was not a factor for Terry L. Bercume, 49, of Massena, who was placed on one year of interim probation in March following his incarceration last year.
He was charged with second-degree assault after attacking Massena village police who were at his residence responding to a mental health complaint June 7, 2013.
Mr. Bercume allegedly punched one of the officers and cut the other with a knife.
Mr. Bercume was represented by St. Lawrence County Public Defender Stephen D. Button, who stated that his client had a history of mental illness and non-compliance with medication.
If Mr. Bercume's interim probation is unsuccessful, St. Lawrence County Judge Jerome J. Richards, Mr. Button and District Attorney Mary E. Rain agreed that he will face seven years in prison.
Attempts to reach Mr. Bercume to see how he's doing were unsuccessful, but his story is by no means unique when it comes to St. Lawrence County's criminal justice system.
"Based on what I've seen, there has been what appears to be an increasing amount of people with mental illness in the justice system," Mr. Button said.
One in every 6,200 people is court-ordered to participate in a treatment plan in New York state, according to statistics listed on the state Office of Mental Health website.
In St. Lawrence County, however, there is one person in Assisted Outpatient Treatment for every 12,470 people in the county, about half of the state's average use of AOT.
BARRIERS to court assistance
St. Lawrence County Community Services Director Angela M. Doe said there could be a number of reasons why the county uses court-ordered treatment less than other areas of the state, despite increasing reports of those who have run-ins with the law as a result of mental illness.
"As providers, we're very conscious of the benefit of AOT. What we have to ensure, though, is that, despite an individual's mental illness, they meet criteria for AOT because what we don't want to do is violate their rights," she said. "While the Community Services board continues to work on improving our continuum of care, geography and other barriers for folks getting linked with services sometimes serves as an opportunity for them not being referred to AOT."
Ms. Doe said that to be eligible for an AOT program, people must first meet a set of specific criteria, including an age of at least 18, a history of non-adherence with treatment and a record of hospitalizations, violence or arrests.
"Those AOT regulations include more than just non-medication compliance," she said. "There is value and notable success for our clients who are deemed appropriate by the courts to be involved in an AOT program. They are enrolled in treatment and in need of treatment, and despite hospitalization and safe discharge planning they don't remain in treatment."
Ms. Doe said that another dilemma for getting clients into an AOT program is the strict criteria that a person must meet.
Determination of whether a person is eligible for AOT is a conversation for Single Point of Access, a group of multiple treatment providers in the county representing three disability groups -- mental health, substance abuse and developmental disabilities.
"The purpose of that committee is to talk about these high-risk, high-need clients and to identify them and to evaluate the services that they need and to monitor their success or lack of success in compliance to those services," Ms. Doe said. "If they're struggling and AOT is potentially an option, then that's where we talk about those things."
TREATMENT BEHIND BARS
St. Lawrence County Sheriff Kevin M. Wells said that on average, about one-third of the jail population receives forensic mental health treatment.
Currently, there are about 35 people in custody with a mental health diagnosis who are provided with treatment options including assessments, supportive counseling, medication, education and medication monitoring, symptom management and referrals to outpatient providers.
"We have encountered several cases where inmates have entered this facility and we felt hospitalization would have been more appropriate," Sheriff Wells said in a statement. "We have never encountered an individual here that was on an AOT because they would most likely be admitted to a psychiatric hospital for a 72-hour observation, so it is possible that an AOT could or would reduce the number of people in jail."
Probation Director Timothy P. LePage said that while he's not sure if an increase in AOT usage would decrease the jail population, any kind of treatment would at least postpone people with mental illness from having run-ins with the law.
"Jail time is not going to help them with any kind of illness, whether it be mental health or a drug addiction or anything like that," he said. "Jail is punishment; it's not treatment."
Mr. LePage said that if the county has someone on probation who is a concern, the Probation Department will make a referral for an evaluation. After the evaluation is conducted, the department then follows any recommendations from Community Services.
If those recommendations include an AOT program, it's Probation's job to enforce treatment, Mr. LePage said.
He said that if a person does not comply, Probation would file a violation with the court.
"The court would have two options: to decide whether it's imminent enough to where the need to mandate them to go, or to send them to jail if they don't have enough to force them to stay in treatment," he said.
Mr. LePage said that with continuous budget cuts, it's more difficult to get clients evaluations and treatment as fast as they'd like.
He said, however, that the evaluation process has sped up over the past two years. Referrals used to have to wait a few weeks to be evaluated, but now most clients are evaluated within 24 hours of their referral.
Ms. Doe said before screening for an AOT, Community Services would rather tap less-restrictive treatments for its clients, such as outpatient care and interventions with psychiatrists and clinical practitioners.
"AOT is an opportunity for us to take a look at their history and the opportunities for recovery that they've had and note that because of the symptoms of their condition, those least restrictive levels of care haven't proven successful," she said. "Then we'd be at a place where their behaviors have gotten to a level where there is potentially a dangerousness to their behaviors by not taking their medications. Their symptoms get worse and, unfortunately, as a result, many of them wind up in the criminal justice system."
A PLACE TO GO
Step-by-Step Inc. in Ogdensburg is one of those least restrictive levels of care. It's a place those with mental health or addiction issues can go for peer support and to be comfortable in the community, according to Executive Director David A. Bayne.
"It's much like a neighborhood center in the sense that people can drop in and aren't required to stay," he said. "They can come for five minutes or for the whole day."
Mr. Bayne said that while the facility doesn't provide clinical services, it does provide self-help and support.
Throughout the day Step-by-Step has different support programs in which people choose whether to participate. It also has community integration programs where they take clients shopping or to farmers markets.
"Not everyone takes their cholesterol medicine or blood pressure medicine, so how do we find the middle ground?" Mr. Bayne said. "What is the quality of recovery if we take away choice and force people to do things that they might not want to do?"
Mr. Bayne said that while AOTs can potentially provide safety for the individual and the community, there is still a question of how long a person should undergo court-ordered treatment.
"Do we give them AOTs for the rest of their lives? Because a lot of folks who are in the system know how and what to say and how to act until that one day when probation or the AOT runs out," he said. "The day after is when the rubber hits the road."
ROAD TO RECOVERY
Carla M. Nunes of Ogdensburg celebrated on June 22 her fourth anniversary of being out of the hospital.
"I've been hospitalized many times," she said. "I've actually been in 13 hospitals."
Ms. Nunes was diagnosed with schizophrenia and was in and out of hospitals for years.
"I went through really difficult times. It felt like I was in hell," she said. "But now I when I think back, that was just my delusions and my hallucinations. They told me to cut my limbs and my hands off and cut out my face."
Ms. Nunes said she used to call the voices in her head her "demons in the closet."
Once when she was at Kingsboro Psychiatric Center in New York City, she fought with a nurse over taking her medication.
"I thought my voices told me she was calling me stupid and that she's just trying to kill me," she said.
Ms. Nunes said she beat up the nurse so badly that the nurse had to be treated in an intensive care unit.
"When he saw me, my doctor said, 'Don't you ever pull a stunt like that again or you'll be in big trouble and go to jail,'" she said. "So I thought about that."
Ms. Nunes said that voluntary compliance to her medication along with working with the staff at Step-by-Step and doctors and nurses have helped to keep her out of the hospital.
"I was usually compliant taking my meds," she said. "Sometimes I suffered so badly that I just would ask for PRNs or to go to the quiet room as my coping skill and scream out my torments. I felt tormented, but now I look back on those days and I don't think I was ever very tormented at all. I think it's just the fact that I was so sick at the time that it appeared to me as though I was being constantly tormented."
After being discharged from a hospital four years ago, Ms. Nunes went to live at Northwood Manor, a community residence at St. Lawrence Psychiatric Center. She has since moved to United Helpers Gateway Apartments, which is supportive housing in Ogdensburg.
Ms. Nunes visits her doctors at the Ogdensburg Wellness Center twice a week and said she's working on year five of being out of the hospital.
GAPS IN CARE
Brian M. Stettin, policy director at the Treatment Advocacy Center in Arlington Va., an organization that advocates broader use of AOT, said that once a person has repeat hospitalizations, is prone to violence or has had multiple run-ins with law enforcement, "generally, the time to try a less-restrictive alternative has passed."
Mr. Stettin said AOTs need to be considered and integrated as part of discharge planning from hospitals and jails.
"Obviously, not everybody in the jail who is receiving forensic mental health services is going to meet the AOT criteria," he said. "Certainly the people who are hospitalized repeatedly should be considered."
He said AOT programs are more effective when used before a crime has been committed.
"It's about helping these people live fuller lives and remain safe in the community," he said.
Mr. Stettin said that if someone is "on the radar" of the county's mental health providers due to repeat hospitalizations or other mental health-related incidents, an AOT program should be considered. He said an AOT program would mandate a treatment plan and potentially prevent that individual from committing a crime or being arrested due to actions related to the individual's mental illness.
"Not everybody who needs AOT is out committing crimes," Mr. Stettin said.
He said the people who should be "on the radar" of the county's mental health office are "people who are caught in the revolving door of the mental health system."
Mr. Stettin said that many people go to hospitals for mental health treatment, are stabilized, receive medication and are released. He said that many of the patients don't stay on the medications once they are released because for some of them, an aspect of their mental illness is being unaware of their condition and the ramifications of not taking their medication. Because many patients don't stay on their medication, Mr. Stettin said they have repeat hospitalizations.
"The best way for us to ensure that our clients don't have repeat, unnecessary psychiatric hospitalizations is for us to work in collaboration with the state to ensure that we have a robust continuum of care in our county," Ms. Doe said.
She said the county uses short-term inpatient psychiatric stabilization, usually hospitalization, and people whose symptoms don't improve with short-term treatment are referred to the St. Lawrence Psychiatric Center, which is for longer-term inpatient psychiatric needs at an intermediate level of care.
Ms. Doe said there should be more options in between short-term stabilization and the longer inpatient treatment.
"The community-based services that we have in St. Lawrence County, although they do a wonderful job taking care of our clients, have notable gaps in treatment," she said.
She said the county doesn't have day treatment programs.
"While the New York state Office of Mental Health has been wonderfully accommodating to talk to us about how we can look at the services in the community and establish those levels of care, until we're able to truly do that we're going to have folks that may need a 'PROS' program, but they're receiving more intensive treatment on an outpatient basis. And if that doesn't meet their needs, then we have repeat hospitalizations."
Personalized Recovery Oriented Services, or "PROS," has four components: community rehabilitation and support, intensive rehabilitation, ongoing rehabilitation and support and clinical treatment. The closest "PROS" program to the north country is in Plattsburgh, but Ms. Doe said Community Services wants to establish one in the county to fill in some of the gaps in care. She said having more and better outpatient programs in the county will "lessen the opportunity for them to be arrested and our biggest institutions become our jails."
The PROS program, she said, is designed for patients to be exposed to a recovery model.
"A recovery model means that our patients don't just receive medications for their mental health condition and everything gets better but also they receive peer-to-peer support," she said. "They have the opportunity to increase their coping skills in the community, their vocational skills and educational skills. All of those opportunities, coupled with medication compliance, mental health therapy and sometimes an AOT, serve as our patients being successful in the community."
It would serve as a more intensive level of care for more persistently mentally ill clients and keep them from falling through the gap, having repeat hospitalizations or ending up in the justice system.
Ms. Doe said the PROS program would add to the county's existing continuum of care, which consists of outpatient treatment, AOTs and inpatient psychiatric hospitalization.
Ms. Doe said that although the county's average use of AOTs is half of the state's average, individuals are using AOTs more. She also said the providers and SPOA committee and the community services board are in ongoing conversations about using AOTs more.
Until then, however, mentally ill people still face uncertain prospects, left on their own to navigate gaps in a community-based care system and the choice between treatment and institutionalization. For some, institutionalization will not mean a hospital stay. It will mean treatment behind bars.
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