Extended Interview: Mental Health Expert Explains Assertive Community Treatment
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SUSAN DENTZER: Let’s start off by talking about assertive community treatment. What is it?
ROBERT WEISMAN: Assertive community treatment is taking the mental health care to the individual that we’re serving. This differs from traditional care where someone would come in and receive their care in a clinic. They would come, see a doctor, a nurse, a therapist, get their medication, go to a group. But there are a group of individuals that don’t access that care, and for those individuals, assertive community treatment provides that necessary outreach so that they can get the treatment they need.
SUSAN DENTZER: And when we say forensic assertive community treatment, what are we talking about?
ROBERT WEISMAN: It’s also an outreach program, but it differs from traditional assertive community treatment in that we integrate or collaborate with the criminal justice system, whether that’s parole, probation, mandated care, or the court system. We communicate, collaborate for the care of the individual in the community.
SUSAN DENTZER: Let’s talk about why that’s necessary. In the big picture sense, what happens to people who are mentally ill that often entangles them in the criminal justice system?
ROBERT WEISMAN: By the nature of certain severe mental illnesses, let’s say schizophrenia, someone may lack the insight or the appreciation, or deny their illness and not show up to treatment. And what happens is they may be out in the streets not taking their treatment, getting involved with drugs and alcohol, and as a result what can happen is they may end up in petty crimes, or maybe even more serious crimes. They end up in the wrong place. Rather than receiving treatment, they get locked up.
Now, there are a certain portion of individuals that need that intensive care, and that’s what our program, Project Link, or that forensic assertive community treatment model does.
Project Link works with the criminal justice system, if you will, the three C’s. We’re the clinical care that works in collaboration with the criminal justice system, to help the client and the family to survive in the community.
'A mobile treatment team'
SUSAN DENTZER: A lot of these people do wind up in jails or in prisons, correct?
ROBERT WEISMAN: That's correct. As I said, as a result of sometimes just nuisance behavior, or petty theft, or loitering, individuals may end up in the criminal justice system--first in the jails, and if they have longer sentences, may end up in prison. And depending on individual studies, that number may reach anywhere between 6 to 15 or 20 percent of the population being mentally ill in jails and prisons these days.
SUSAN DENTZER: Okay, and a case in point was Byron [a member of Project Link]. Let's talk about his case for a moment. Tell me about Byron, starting from when he appeared to be exhibiting symptoms of paranoid schizophrenia in his late teens, and what has happened to him since.
ROBERT WEISMAN: Sure. Byron's been in Project Link now since the late 1990s, since our program was developed, and Byron's story is not unlike a lot of other folks that we serve. Byron started out as a healthy young male, had odd jobs, went to school, traveled with his family from Rochester to Connecticut, and came back.
Around the late teens, early adulthood he started expressing symptoms of his mental illness and that included hearing voices, being hostile, having paranoid delusions, and prior to even enrolling in our program, he had around 10 hospital admissions for his mental illness.
The ultimate instance where he ended up into our program was following a visit to Washington, DC. One day Byron decided that he himself wanted to speak with the President. He had this idea. He was able to take his son - he had a nine year old son at the time--remove him from his mother's custody, was able to obtain two bus tickets and go to the White House. He ultimately was apprehended by the Secret Service and locked up for attempting to move into the White House.
He was released the next day, and I might note that while he was locked up, he ended up getting in a fight, into a fist-fight with another inmate there. He was released the next day from jail, and in fact ended up back at the White House, and repeatedly had to be apprehended.
SUSAN DENTZER: And he told us the story today, his brother retrieved him, took him to Baltimore. He eventually is brought back to Rochester. What happened then?
ROBERT WEISMAN: He was brought back to Rochester and was hospitalized at our local Rochester Psychiatric Center. That's a state facility, a long-term psychiatric institution. He was stabilized on medication and then released into Project Link.
What that allowed us to do then was to follow Byron at his home. We worked with his family, we made sure his medications were delivered on a regular basis.
But that still didn't solve all the problems. What we had to do was make sure that Byron took his medication. And as I spoke about before, people with severe mental illness often deny that illness, and don't feel that they need the treatment that's offered to them. And in Byron's case, there have been lapses, and he has fallen sick as a result. He's ended up back in the hospital, he's ended up entangled with police, and has put himself and sometimes other people at risk as a result.
More recently, Byron was released from the hospital. As you saw today, he's taking his medication. He's accepting his illness, and he's accepting injectable treatment, which is not an easy hurdle to overcome.
We are aware, though, based on reality, that Byron may stop again. What our program can do differently, though, than traditional care is that we can see early emergence of symptoms, and then hopefully treat him rapidly, or take the necessary steps to protect him or others.
SUSAN DENTZER: Now let's talk a bit about how Project Link works. Who carries it out? When a person becomes involved in the program, whom does that person see from Project Link and on what kind of a basis?
ROBERT WEISMAN: Sure, what Project Link is, is an actual mobile treatment team. If you will, you understand the intensive care unit at any hospital, USA. It has a number of staff, much higher than the rest of the floors, for the number of patients it serves. It's intensive, it costs a lot of money, and it requires very competent people to work there.
Our program is, if you will, the mental health ICU in the community. We go out, see people frequently, have the numbers to do that, and the support to do that.
In Byron's case, we go visit him if necessary daily. If he's doing well, we may titrate that down and see him on a weekly basis.
As he came out of the hospital this time, he's taking his medication. He looks stable, but we're always aware of the next turn of events that can occur. And what's important about our program is that we're available to both him and his family, and to see if there is any emergence of symptoms before he gets in trouble, or someone like him gets in trouble.
SUSAN DENTZER: And even with this program, he still is not entanglement free vis-Ã -vis the criminal justice system. He still is having episodes and he's still not completely adherent to his medication. He's gone off on these periods where he hasn't been taking his medication. So let's talk about that, that even with all of this, the challenges remain.
ROBERT WEISMAN: The challenges remain for a specific population that we serve in Project Link. Project Link is not for every person with mental illness. It's for the most seriously ill who are not adherent to treatment, who don't show up to traditional care. Knowing Byron and others like him who do well when they're treated really offers us, I think, the benefit of being able to see him do well when we visit him.
If he were left to traditional care, he may not show up, he may not take his medication, he may end up in the throes of the criminal justice system, or worse. Byron can look intimidating when he's not under appropriate care, and under an untrained eye he may be challenged. Someone, including himself or others, can get hurt, and we've seen that in the past.
Our job both is to keep an eye on his care, but also public safety, but at the same time all of our work is about improving autonomy of the individuals we work with.
SUSAN DENTZER: How so?
ROBERT WEISMAN: If someone is able, as you saw with Byron, to take his treatment, to get a better understanding of his illness, and have a reasonable acceptance of our treatment, he may be able to step back into work, to follow up with group programming, and maybe even develop relationships and improve his relationships and care-taking ability with himself and his family.
A lifetime commitment
SUSAN DENTZER: Now, let's say something, because it's important for people to understand that it's not like you fix this, you cure the problem and the person is fine, that this is really a lifetime commitment for him and for you. [...] Do you ever succeed to the point that you could stop doing this for someone?
ROBERT WEISMAN: Unfortunately for severe mental illnesses, there are no cures that exist. But what we can do, is graduate our need of care or the delivery of care for those individuals who need it, rather than just assume one size fits all.
Byron will have mental illness for his whole life. Until we obtain a cure, he will still need our services, and hopefully will get a better understanding to stay on his treatment, and maybe transition to traditional services. The challenge is this is not just a mental health concern. This is a public health problem, and we need to continue to address that.
SUSAN DENTZER: Now, this program is not cheap. What does it cost?
ROBERT WEISMAN: It's difficult to ascertain what it costs, but we can add up all the costs of staffing, with wraparound funding, with insurance costs. We did a study looking at individuals over a year's period prior to entry into Project Link, and then the year after enrollment, and what we discovered is we were able to reduce their service utilization costs -- that's going to the hospital, arrests, jail and prison days -- by almost one-half for the year following enrollment.
So we know that this program costs money to run, but it also saves money as far as service utilization, and hopefully improves the community tenure of the folks we work with.
SUSAN DENTZER: Is it at least a break even situation, or is there a net additional cost to running this?
ROBERT WEISMAN: Well, there are additional costs, but again if you look at the comparison to an intensive care unit, let's say for a heart attack, or someone who has a stroke, that can run into the thousands of dollars per day. Being an inpatient for psychiatry can cost up to a thousand dollars a day, not including emergency room costs, not including the cost maybe of apprehending them and bringing them in with law enforcement, and also not including the considerable regression personally that can happen to somebody who is brought in under an arrest situation.
So it's really a losing situation both financially and personally if we can't help people in the community and prevent them from declining.
SUSAN DENTZER: Does society come out ahead with programs like these?
ROBERT WEISMAN: I think they do. Byron's a good example. You heard about his history, the potential risk for himself, to a ten year old boy. In this day and age with Homeland Security, someone walks into the White House with the wrong idea, tragedy can occur.
If we are able to treat them as they are in the community, for those who fall through the traditional care cracks, we may be able to prevent some of these tragic events that we've seen in the past.
Parallels to the Cho case
SUSAN DENTZER: Now let's talk about the parallels, if any, to the case of Cho. Here is a young man who is picked up because he's sending harassing e-mails to female students. He's referred into at least the campus police, possibly also the justice system. He ends up being ordered to get mandatory outpatient treatment, and nothing happens.
First of all, how might things have functioned differently for him had he been in a jurisdiction that had a program like this?
ROBERT WEISMAN: It's always difficult to tell if a program like Project Link could prevent every tragedy. What's important and what we've seen, though, since the inception of our program is that we've been able to work with very high risk individuals, at risk for criminal justice involvement, and work with their families to prevent some of these tragic events.
What we do, I think, [is] work with the clients, work with their families, and that we integrate with that the criminal justice piece, that conditional release, that mandated care. We communicate after releases of information have been signed, to make sure that person is leveraged into treatment rather than leveraged into the criminal justice system.
That may sound like we're soft on crime. This program is not about being soft on crime. It's about treating mental illness, and preventing bad outcomes as a result of untreated mental illness.
Our ability to communicate with those leveraging facilities allows us to keep people in treatment and hopefully better their lives as well as keep an eye on public safety.
SUSAN DENTZER: What are your thoughts about the Cho case? What should have happened?
ROBERT WEISMAN: It's a very complex case. There's been a lot written about it. I was unable to evaluate the individual involved, so I don't want to make an opinion about his diagnosis or what should have been done. But what needs to be done in all cases, whether it's like Cho or others, is to have that level of communication or collaboration -- the three C's again: the clinical care combined with the criminal justice system, to keep our clients and their family members safe and well in the community.
SUSAN DENTZER: Here in Rochester, Judge Marks, whom we're going to see today, would see a client like this, like Cho perhaps, and say that he is a danger to himself or others, and recommend him into this system. Walk us through the steps. Let's say the phone rings today and it's a person much like Cho, hauled before the judge. What happens?
ROBERT WEISMAN: Well, we look at our risk factors and we can talk more about that. The risk factors include being off treatment, being involved with drugs or alcohol, having a family history of illness, and maybe hanging around with the wrong crowd, access to weaponry, and maybe limited oversight or support.
These are some of the common denominators that we see that end people up in trouble, jail, prison, or in untoward behavior.
Our role is to, at first blush, when we get that referral, to start looking to see what are the supports and strengths that individual has, and what are the potential pitfalls that they may fall into. Working then with support services, talking with the judge about what is the best treatment plan, and also looking at what type of legal leverage or what we call therapeutic leverage can be meted out so that we can properly serve that individual, avoid an unnecessary incarceration, and avoid an unnecessary bad outcome.
SUSAN DENTZER: What I need you to do is connect the dots for me and sort of lay out almost like a diagram, because if you look at the diagram of what happened in Cho's case, everything goes right. It gets referred to the judge. The judge says he needs mandatory treatment, and then it stops. So tell me how all the dots get connected. What are the dots here and how do all the dots get connected?
ROBERT WEISMAN: If Judge Marks calls me, I'll pick up the phone, she'll give me the name of the individual who is in question, she'll hopefully have some form of diagnosis that we can start with, and then we'll screen that individual to make sure that we can provide the necessary care that he or she needs.
Then what we'll do is we'll set up a very immediate appointment to go out and outreach to that person. We may even see that person while they're in custody. They may be in jail. We'll do a jail visit. Our mobile treatment team, our mobile ICU will go out there, which includes myself, nurse practitioner, case advocates or case managers to assess and find out what would be the best treatment plan for him or her.
Then we would give that report back to the judge. The follow-up appointment would be made, and the judge would have a schedule that that person needs to come back, check in, have an advocate with him to describe whether or not he or she is following that proposed treatment, and then decisions are made in a fluid way.
Each visit may be different. Somebody may be on their medication and doing well, or as often happens, someone may be off their medication, using drugs or alcohol and ending up in trouble. And that legal leverage standing over them, although sometimes coercive, may prevent them from harming themselves, others, and having a quality of life that's impeded.
SUSAN DENTZER: Let's imagine for a moment that a program like this had been in place in the area surrounding Virginia Tech. What do you think could have been forestalled?
ROBERT WEISMAN: It's again tough to tell. What again this underscores -- the Cho case or any other case -- is the need for the criminal justice system or mandated treatment programs to be able to communicate with the clinicians to have that [...] care. Neither one of those programs, the criminal justice system or the mental health system, can deal with this alone. We need to work together in a treatment-focused manner, and also consider the individuals' rights, but also understand the limits of their illness and what that can mean to their outcome.
Steady funding needed
SUSAN DENTZER: When the federal report comes out in a couple of weeks and the state report will come out at some point in the indefinite future, what do you think should be in it vis-Ã -vis recommendations along the lines of this program?
ROBERT WEISMAN: Well, of course I would say we should have more of our programs. These programs are intensive, but Dr. Lamberti and I go around the country doing technical assistance work and consultation, and no matter big or small community, there is a need for these kind of programs where we can collaborate between the mental health system and the criminal justice system.
There are a number of clinical services available in the United States, especially for those with mental illness, and that serves a particular population. But those who are at high risk for potential decline, those who do not access care, or are demonstrating high-risk behaviors that are not serious enough to be in the hospital need programs such as Project Link that look at that forensic aspect to make sure that that communication doesn't get overstepped.
SUSAN DENTZER: And to the degree there are not these programs around the country, why is that?
ROBERT WEISMAN: It's hard to tell. Again, these programs cost money. I think there are more and more programs being developed, and we've done some research about that to look at them. A lot of these programs were developed out of grant funding, and grant funding has a beginning, a middle and an end. And when they end, it's all about what can we do, or what can programs do to sustain themselves, and that's often easier said than done.
We have clinicians running these programs, academicians, and not necessarily people who hold the purse strings to the funding streams, and it's important that we make sure that the clinical care is there, that collaboration is there, but also that there is sustainability for programs as they are developing these days.
SUSAN DENTZER: Which means money.
ROBERT WEISMAN: Which means money.
SUSAN DENTZER: A steady stream of funding.
ROBERT WEISMAN: A steady stream of funding, but also the competent care. It can't just go to any odd clinic. This is a special group of individuals who need this care, and it requires, like the intensive care unit, specially trained individuals to do that intensive work.