1/25🧵to share thoughts on last week’s @NYTimes story on Kendra’s Law + AOT in NYC, chronicling undeniable oversight failures over the yrs. Be assured, we won’t compound these tragedies by failing to draw lessons from them. But nor we will lose perspectiv.
nytimes.com/2023/12/21/nyr…
nytimes.com/2023/12/21/nyr…
2/25 The portrayal of a broken NYC AOT program is a distortion + a disservice to readers. A fairer, more measured story would make clear that whatever its flaws + resource challenges, AOT enhances public safety + has helped 1000s of vulnerable NYers gain a foothold on stability.
3/25 The impression of rampant dysfunction is built not on outright lies but on manipulative presentation of facts + omission of important explanations we shared w/the reporting team. To unwind it, let’s start w/the reported 380 violent acts by people under AOT over a 5-yr span.
4/25 By reporting this # in the midst of the very upsetting cases detailed, the story suggests that all 380 violent acts, like these cases, are attributable to process breakdowns. This is made explicit in the headline asserting that AOT “failed to prevent violence 100s of times.”
5/25 Reality check: W/this high-risk population, some violence will happen, even when everyone involved in AOT does exemplary work. NYT has no idea how many of the 380 sealed cases involved process breakdowns like those in the cases reported. To imply otherwise is irresponsible.
6/25 More egregiously, the story emphasizes the raw number of violent acts at the expense of critical context. To judge the OVERALL effectiveness of AOT, it surely matters how many violent acts the same population would be expected to commit had they not been in the program.
7/25 Obviously the number of violent acts an AOT program prevents is not knowable. But astonishingly, NYT waits until the 24th paragraph of the story to drop a highly pertinent detail, and even then doesn’t bother to explain its significance.
8/25 It turns out the 380 violent acts WERE COMMITTED BY LESS THAN 2 PERCENT OF THE PEOPLE IN THE PROGRAM! (19,000 over 5 yrs). 
9/25 Consider that in reverse: >98% of people under AOT in NYS over a 5-year period had no documented violent acts. In an alt universe w/fair reporting, THAT might have been the story! It confirms 2010 research from Columbia that NYC’s AOT program reduces risk of violence/crime.
11/25 Keep in mind that the very small subset of people with SMI who meet legal criteria for AOT are at higher risk of violence than the general population. 28% have previously been incarcerated. All struggle with SMI treatment adherence, a well-documented violence risk factor.
12/25 Here’s another critical data point dropped into the story without explanation of its meaning: NYT reports that “more than a third of the 380 violent acts took place in NYC.” They might have added here that over the last 5 yrs NYC has carried 45% of the statewide AOT cases.
13/25 That means NYC’s share of the violence is significantly lower than its share of the overall AOT volume. So in NYC, the percentage of AOT participants who commit violent acts is EVEN LOWER than 2%! It’s about 1.5%.
14/25 Yet another part of the story inadequately explained: It is presented as an example of the program’s dysfunction that 85% of participants brought to the hospital for evaluation after failing to adhere to their court-ordered treatment are found not to require inpatient care.
15/25 It sounds pathetic if you don’t know much about AOT. Here’s what the reporting team left out: An AOT hospital removal is fundamentally different from a hospital removal of someone not under court order to adhere to treatment, in both the legal criteria and the very purpose.
16/25 Ordinary removal requires evidence of danger to self/others. A clinician initiating it would naturally expect the hosp to confirm their assessment + admit the person for care. By contrast, AOT removal requires evidence the person is treatment non-adherent + MAY be a danger.
17/25 Typically we use AOT removal in a situation where the person is disengaged from treatment + their provider, and their current condition in UNKNOWN and cause for concern. The purposes of removal are to evaluate them, reconnect them w/treatment team + get them back on track.
18/25 So an AOT removal can have great value even when it doesn’t lead to hosp admission + it’s unreasonabl to expect most ppl to meet admission criteria in such murky situations. Not 2 say there aren’t blown calls sometimes in hosp evals (a larger issue we’re making headway on).
19/25 A final point. As I read the article, I kept hoping NYT would provide some balance by offering just one anecdote of a person who benefitted greatly from AOT. We get one in the end, but it’s mystifyingly presented as yet another example of an AOT failure.
20/25 The case of Samuel Junker in Westchester shows exactly how AOT works much more often than not.
21/25 Not only did AOT make a huge difference for Mr. Junker, but when the court order was due to expire, the W’chester program did exactly the right thing. They determined that he needed an additional period of AOT + petitioned the court to extend the order. So what went wrong?
22/25 The judge denied the petition, apparently unmoved by the testimony. That’s not a failure of AOT itself. Patient is constitutionally entitled to due process, and judges operate independently, as they must. Risk of bad decisions is a price we must pay to maintain rule of law.
23/25 In case this isn’t already clear: If NYT had documented mishandled AOT cases over the years WHILE ALSO recognizing the program’s overall effectiveness, I’d have no quibble + would appreciate the contribution to the discourse. Daylight is welcome + necessary, even if harsh.
24/25 And there’s no disputing that to reach its potential and fill current gaps, AOT needs more $$, more staffing, more supports to link ppl to, + wider professional understanding of the legal criteria to hospitalize patients in crisis. All larger needs that go way beyond AOT.
25/25 Thanks for reading this far, and happy holidays! Big plans for the year ahead for improvements across our system of care for folks w/SMI. AOT included.
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