"For" or "against" AOT—Are we asking the wrong question?

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Note: For those of you reading this post for the first time as a part of Friday Update, 7-10-15, know that the original post was written 4-29-15. We are featuring the original post again, as we have received a number of requests for some of the more popular background posts written about HR 3717 that are still relevant to current discussions about H.R. 2646.

Over the past year, the Children’s Mental Health Network has convened a series of dialogues in Washington, DC on Assisted Outpatient Treatment (AOT). AOT is one of the cornerstones (though only a small part) of the Helping Families in Mental Health Crisis Act. The bill didn't go anywhere in the last Congress, but any day now we should see the introduction of an updated version of the bill. No doubt, the new bill will once again, be the topic of intense conversation in mental health circles.

Why did the Children's Mental Health Network focus the dialogues on AOT?
Championed by Representative Tim Murphy (R, PA-18), the Helping All Families in Mental Health Crisis Act included two components that have dominated the conversation in mental health circles. Both the inclusion of AOT and a stinging critique of the role of SAMHSA in addressing the needs of the seriously mentally ill have led to divisive splits among advocates. Sadly, the important conversation about mental health reform has been narrowed to one of the appropriateness of a civil commitment process that already exists in 45 states and questions about the leadership and focus of the Substance Abuse and Mental Health Services Administration (SAMHSA).

Mixed in the fray last year was the introduction of the Strengthening Mental Health in Our Communities Act, which was viewed by many as a Democratic response to the Helping All Families in Mental Health Crisis Act. Championed by Rep. Ron Barber (D-Ariz.) the bill moved away from controversial recommendations (such as AOT) and took more of a prevention focus for treating mental illness.

Members of Congress who are drafting legislation this year in both the House and Senate deserve a more robust dialogue between advocates that goes beyond a "for" or "against" argument. If we are unable to address the complexity involved in comprehensive mental health reform, how can we expect members of Congress to do the same, or more important, to ever come to an agreement on something useful?

Start where the tension is greatest and the pain is deepest
We have a simple rule for our dialogues. We start where the tension is greatest, and the pain is deepest, in this case, the AOT debate. The dialogue series and our recent visit to a community that utilizes AOT is the first step in the Children’s Mental Health Networks’ ongoing effort to address this polarization among advocates.

Why a visit to observe the AOT process?
After our third dialogue session on AOT, it became evident that the next logical step in the process was to visit a community that utilized the AOT process in a way that Congressman Murphy would likely hold up as an example of excellence. I asked the Treatment Advocacy Center, the group most knowledgeable about how AOT is being utilized across the country, for a recommendation of a community that they would describe as a shining example of the use of AOT. It is important to note that the founder of the Treatment and Advocacy Center, E. Fuller Torrey, has been a vocal proponent of both the Murphy bill and AOT.

The Treatment and Advocacy Center referred me to the court of Judge Randy Rogers, probate judge for Butler County, Ohio, located in the city of Hamilton, Ohio. Judge Rogers, his team and community partners welcomed us to visit, observe their process and engage in dialogue.

The focus of the Children’s Mental Health Network on the visit to Butler County
Our purpose was to observe, listen and ask questions so that we could better understand how this one community utilizes AOT. None of the Network team gave advice or tried to promote a personally held position on AOT. We directed our questions toward what they saw as the keys to success in their approach to wrapping services and supports around individuals with serious mental illness who are going through civil commitment proceedings.

Recognizing that AOT is approached differently in communities across the nation, we were hopeful that we might be able to identify a few key elements that would help broaden the national dialogue on AOT beyond “for” or “against.”

Structure of the visit
We spent the morning in the courtroom, observing several updates with individuals under civil commitment. After the morning session, we held a roundtable discussion over lunch with representatives of the court, mental health, the local hospital and other community leaders. We then transitioned to a roundtable discussion with community providers, family members and advocates. Finally, we held a wrap-up discussion with Judge Rogers in the late afternoon.

Overall conclusion about AOT as utilized in Butler County, Ohio

It was enlightening to hear from the local participants in the dialogue as they reflected on how far they have come in their understanding of how to effectively use the AOT process. The road leading to where they are now was full of mistakes, but also enough success and strong leadership to keep them motivated to continue to improve.

Most striking was they way they talked about AOT. For them, it was very clear that the civil commitment component was the beginning part of a larger process to help individuals along the way to recovery. For this group of providers, family members, court officials and community leaders, the question is not “Are you for or against AOT”. The question is “Do we have sufficient services and supports around this individual to help them recover in the community? The actual civil commitment process and court follow-up is a critical component, but only one of many.

Broadening the understanding of the AOT process is important for readers to understand. If we want mental health reform, true mental health reform, we must get away from asking “for” or “against” questions. Instead of asking if someone is for or against AOT, the better question is “What does a community need to have in place to effectively protect and promote recovery for individuals with serious mental illness?” In Butler County, it requires a combination of services and supports, and for those who are most ill, a compassionate judicial system.

What makes the AOT process work in Butler County?
We spent much of our time on this visit asking participants in the dialogue to share with us what they saw as the key components of their success utilizing the AOT process. Their willingness to be candid about challenges and triumphs over many years of developing a process that seems to be working for them was both humbling and inspiring.

Courtroom leadership is knowledgeable about mental illness, emphasizes humanity and dignity in the courtroom, and exercises authority through love.

Judge Randy Rogers
Judge Rogers is an imposing figure. Six-foot 7 inches tall, a booming voice and a heart as big as Ohio. I am pretty sure that if you looked up the words “charismatic” and “sincerity” you would see a reference to Judge Rogers. The people around him idolize him. And it is not hard to see why. He is intensely focused on wrapping love and support around those who come before him in court, almost to the point of obsession.

Before court began on the morning of our visit, Judge Rogers spoke to us about his view of the responsibility of a probate judge, especially when invoking civil commitment proceedings. Judge Rogers said,  “When you place someone on a civil commitment you are responsible. You have a responsibility to know where they are and know what they are doing. It is not acceptable to not know where they are. When you take some of their civil liberties away from them, you owe them a higher level of care. The goal of civil commitment is for people to recover, get better and get off civil commitment. “

Commitment to humanity and dignity
Everyone we spoke with during the visit commented on how Judge Rogers exudes passion, love and care for the individuals who come into his courtroom. He, himself, referenced changes in his life 20 years ago that had an impact on who he is today and how he views those individuals involved with AOT. Judge Rogers bases his approach on the principle of Parens Patriae, which for him, translates to leading with authority through love. “You have to care for people in order to have the authority over them.”

Here is one example to give you an idea of his level of commitment to those coming before him in court. The judge is about six years away from retirement. In preparation for retirement, he has asked his assistant to go through the more than 1300 cases that have come into his courtroom during his long career on the bench. His assistant is finding these people, taking a picture and writing a brief bio of them. Why? So that when he retires, the next judge will have a folder, with a picture and brief synopsis to help humanize the process for both the judge and the individual appearing in court. They call this the “Red Book”, and Judge Rogers thinks it will take about two years to complete this project.

Magistrate Patricia Hider
On the day of our visit, Magistrate Patricia Hider was presiding over the court. Sitting in the courtroom watching the proceedings was unlike any courtroom experience I have ever witnessed. Magistrate Hider was intently invested in each and every person who stood before her. The magistrate's interviewing skills and respectful question probes were impressive to observe. She gave 100% of her attention and energy to the individual before her, their family members and providers in the room as she worked to understand how the individual was progressing. She was never condescending or abrupt, even with those who might not have been following their treatment plan.

Magistrate Hider told us that she learned her interviewing skills in her previous work as a negotiator in the private sector. After law school, she worked in patent law. From there, she had the fortune to stumble upon Judge Rogers. She had a case involving mental illness and was told to “talk to the judge who handled mental illness cases.” Both she and Judge Rogers had similar personal tragedies in their background, and just like that, she was home. “You go where you need to be, not where you think you will go”, she said.

Personal experience
In the dialogue that took place after the court session, Magistrate Hider said that for her, personal experience with a loved one with mental illness helped her be a better Magistrate. Her personal experience gave her a better sense of the pain the individuals standing before her and their family members were experiencing.

Education
Magistrate Hider told us that another key factor in her development early on in her career was Judge Rogers insistence that she brief all cases related to mental illness and observe the cases he was presiding over. “I wanted to write down personal comments about people so I could remember them”, she said. I didn’t want people ever to feel we had forgotten who they were.” Now that the “Red Book” is online, she has ready access to personalized information about individuals that come before her. One of the most compelling things Magistrate Hider said to us during the visit was, “When I first started doing these hearings I would always whisper to myself before coming into the courtroom -Do no harm.”

Nicholas Schrantz, Butler County Probate Court Monitor
Judge Rogers court has a full-time Probate Monitor dedicated to his courtroom. “Nick” brings to his job both an understanding of public mental health and how the judicial system works. His job is to coordinate care between the respondent, the treating agency, and all the other players (court, mental health board, group home, crisis team, family, payee, etc.). He emphasizes to the individual under civil commitment that their treating agency is the one that provides the care, and they need to focus their attention on that treatment relationship in order to one day be released from court supervision. By doing so, he keeps the focus on the treatment relationship, and this puts the court in the background until it is necessary. As a sign of shared commitment to ensuring the highest care possible for individuals involved with the probate court, Nick’s position is fully funded by the mental health board.

Understanding the responsibilities of the court and treatment providers
There was universal agreement in our dialogue that Nick played a critical role in the process. We repeatedly heard praise for Nick’s ability to navigate the wishes of the client and treatment providers with that of the court. “His ability to talk the language of the courtroom,” as one participant stated, “is invaluable to ensuring strong communication between the court, treatment providers, the individual under civil commitment, and family members.”

Evolution of the probate court in Butler County
In 1988, Ohio Governor Richard Celeste signed into law the Mental Health Act of 1988, in large part, to reduce the number of people in state psychiatric hospitals. The push to develop community-based services and supports was on. Butler County realized if hospital beds were being reduced; they needed to beef up their community-based services.

Over time, the Butler County community mental health board developed a wider array of services and supports to help individuals transition from hospital settings to community-based settings. They developed residential housing options and a mobile crisis team, which included a deputy sheriff as part of the team. They created a crisis hotline, ACT teams, a step-down program, and rehabilitation options, along with other ancillary services designed to wrap support around individuals with serious mental illness.

With a community of health care leaders invested in developing alternatives to hospitalization, Judge Rogers noticed that there was a clear process for addressing individuals with serious mental illness in the criminal justice system (forensic monitor), but nothing on the civil side.

Fourteen years ago, the judge sat down with the psychiatrist representing the mental health board and together, they began to think through how they could adapt the model used in criminal court for civil court.

They quickly realized the harsh reality that if they were to require a treating psychiatrist to attend every outpatient commitment hearing, it would be outrageously expensive and likely just not happen. They knew that whatever system they put in place would have to be based on trust between judicial officers, mental health providers and the individuals and family members involved in the court process.

Ongoing education between the judge and the lead psychiatrist
A critical part of their planning involved educating each other. Judge Rogers reached out to the Mental Health Board psychiatrist, Dr. Kenneth Tepe and said “teach me.” As Dr. Tepe said in our discussion, “I taught him about schizophrenia and he taught me about Parens Patriae.”

The influence of the drug court model
In addition to looking at the forensic model used by the state, Judge Rogers also borrowed heavily from the Drug Court model. Judge Rogers had experience running a drug court, and the principles were similar. “The way we were doing the community docket on civil commitments put me right into my drug court mode.”

Initial efforts were not successful
Former Magistrate not invested in mental illness issues

Participants in the dialogue said that the magistrate who preceded Magistrate Hider did not have a strong interest in individuals with mental illness and that this impacted the process. Magistrate Hider stressed that if a judicial officer is going to do this work it has “got to be something you can relate to. You need a magistrate who has both heart in it and an intellect and understanding of the individuals they are seeing.”

Former Probate Monitor focused only on treatment
Initially, another agency provided the case management role in the courtroom. It became evident that the case management role was perceived to be that of a mental health treatment case manager and as such, they just focused on treatment. There was not a strong emphasis on understanding and navigating the interface between mental health and the court. As one participant told us, “There has to be a level of respect for the situation the person is in. If you allow your client to go awol, you allow them the opportunity to jeopardize even more of their personal freedom than before.“

What changed?
Communication was poor between the court and mental health, and it did not appear that individuals under civil commitment were getting what they needed. Recognizing the problem, the contract for the Probate Monitor was moved from an agency that was 100% focused on mental health services to one that had more experience with the forensic and mental health setting. The ability for the court and the mental health provider to be able to understand each others role was critical to developing a strong working relationship.

With the change in agencies, Nick Schrantz, an individual with experience in both judicial and mental health settings, was hired as Probate Monitor. At the time, there was not a job description for the Probate Monitor, so the Judge and his team created one based heavily on Nick’s input.

The elements were quickly falling into place. A passionate judge; a new magistrate who was knowledgeable about mental illness and equally passionate; and a new probate monitor experienced in both judicial and mental health settings.

Additional critical elements in place today
Participants in the dialogue identified two key elements that were critical to being able to intervene effectively with individuals in crisis. The first was the development of a mobile crisis team that could respond quickly to individuals in need of help. The second important element was the passage of a law that gave authority for health officers to be able to write an “application of emergency admission." Ohio law permits a psychiatrist, licensed clinical psychiatrist, licensed physician, health officer, parole officer, police officer or sheriff to take a person into custody and transport to a hospital as long as they have a reasonable belief that the person is mentally ill subject to hospitalization by court order, and represents a substantial risk of physical harm to self or others.

According to Nick, for the civil commitment process to work, you need a probate monitor, residential placement options, a mobile crisis team, and hospital triage social workers at a minimum. He said, “People in the community who are in trouble must have someone to call and a mobile crisis team who can respond. If they drive themselves to the emergency room, ER staff need to be trained to know how to evaluate and get the individual seen by a physician instead of discharging them without an assessment. Without these options available, most people in mental health crisis would never get into the probate process.”

Fiscal incentives and cost savings
Representatives from the mental health board were clear in our discussion that the incentives offered by the state for community mental health boards who reduced hospital bed stays helped. Early on, they exceeded their use of budgeted hospital bed days and were required to pay back the state over six hundred thousand dollars. That got their attention, and they got serious about their initiative to build community resources. Just last year, representatives from the mental health board estimated that they saved over a million dollars by avoiding the use of hospitalization. According to the probate monitor, 83 % of the individuals under civil commitment don’t end up in a psychiatric hospital. The mental health center utilizes a variety of community-based settings, many which include medication administration with nurses staffed 24 hours a day.

However, the representatives from the mental health board offered a cautionary note. Funding for supporting processes like this and the ancillary supports that help make it work far exceed what Medicaid can provide. With state funds diminishing, the mental health board has to rely on local tax levies to help support the work being done. Currently,  there is not a funding structure in place to recoup savings from Medicaid and reprogram those dollars to be reinvested in efforts like this at the local level. Not all counties have been as fortunate as Butler County with local tax levy funding. Many mental health centers in Ohio do not have the budget to put things like this in place.

Probate process continually evolving
It is important to note that in this community, the probate process appears to be continually evolving. Judge Rogers approaches the civil commitment process used with individuals who have a serious mental illness with pride, humility and an overriding concern for the safety and well-being of the individuals appearing in his court.

During the dialogue, the judge was up front about the mistakes they have made along the way and how they have learned from them. He pointed out that they have spent the last ten years honing the role of the probate monitor, developing trust and clear communication with mental health and other providers. Over the past 10 years they have developed a series of written forms to help them track progress, which has led to increased confidence on the part of community providers that the court/mental health partnership can indeed work and be beneficial to individuals under civil commitment. His hope is that others can study their mistakes, how they overcame them and possibly apply lessons learned to their community.

The AOT process used in Butler County did not happen overnight. It took years of trial and error, led by a passionate judge who would not take no for an answer.

Concluding thoughts
I want to leave you with a few quotes from dialogue participants that inspired us all during our visit:

I hope this brief glimpse into one community’s approach to utilizing AOT helps broaden your understanding of the complexities involved in ensuring the protection of individuals with serious mental illness and assisting them to a place of recovery and wellness.

After our visit to Butler County, a reporter asked me, “So now that you have seen AOT, does it change your mind? Are you for or against AOT?” “Neither,” I said. “For or against is the wrong question. The question you should be asking is, ‘Does this community have in place what it needs to protect and promote recovery for individuals with serious mental illness?’ My answer to that question for Butler County, Ohio would be – ‘They are well on their way.’”

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network

 

The following people made up the Children's Mental Health Network site visit team:

Comments

  1. Brian Stettin, TAC's avatar
    Brian Stettin, TAC
    | Permalink
    As the guy at Treatment Advocacy Center who connected Scott with the Butler County AOT program, I found this post only somewhat gratifying.

    I applaud every member of the CMHN group for making the trip, and I'm thrilled that you got to see a great AOT program in action. Having been there myself in 2014, I can only echo Scott's observations, especially the parts about the heroic trio of Judge Rogers, Magistrate Hider and Nick Schrantz.

    But I must also admit I'm disappointed and puzzled by Scott's ultimate refusal to vote yea or nay on the AOT question. From my vantage point, it's a cop-out.

    At the end of the day, important policy choices are beckoning: Should laws authorizing AOT be enacted in the five states that still don't have them? Should more communities establish AOT programs in the many states where such laws are little used? If we don't answer these questions with "yes," we are effectively answering "no." There is no avoiding the question.

    I of course appreciate Scott's larger point about the many elements that make AOT effective in Butler County. No AOT advocate has suggested that placing folks under court order is a magic exilir that somehow covers up for gaps in critical services or a failure to engage patients in their own recovery. I would have no quibble at all if Scott had concluded that AOT is useful IF AND ONLY IF it is practiced by caring, attentive professionals and linked to meaningful supportive services.

    Here are the questions I had hoped the visit would answer for Scott and any other fence-sitters in the CMHN group:

    (1) For those who have demonstrated a lack of insight about their severe mental illness (i.e., the target population for AOT), does a court order and judge's involvement ADD VALUE to a decent package of services?

    (2) Does court-ordered treatment in any way conflict with the imperative to treat people with severe mental illness respectfully and compassionately, and engage them in their own recovery?

    These are the questions that the AOT debate boils down to. It is of course possible to offer people with SMI all of the good stuff that Scott admired in Butler County on a purely voluntary basis. For most people with SMI, that is undoubtedly good enough. But what about that small subset who meet AOT criteria -- who tend not to adhere to voluntary care, no matter how amply and kindly it is offered, because their illness prevents them from recognizing that they HAVE an illness? AOT supporters believe that for this subset, adding a court order to the mix is a difference-maker, whereas opponents view the court-order as an OBSTACLE to recovery.

    So how about it, Scott (and fellow travelers)? After visiting Butler County, where do you stand on AOT? Do AOT laws and good AOT programs serve the needs of their target population, or not?
  2. DJ Jaffe's avatar
    DJ Jaffe
    | Permalink
    I am glad you saw that AOT is not the horror some SAMHSA funded groups would have us believe. But the question, 'are you for it or against it' is a legitimate one. Of course, good AOT is better than bad AOT the same way good housing is better than bad housing, but both are better than no housing. And you miss a key benefit of AOT: it 'involuntarily commits' the system to provide care. The judges order applies to both the system, which is given responsibility to provide care, and the patient, who is given responsibility to accept it. Today, now, as I write, in the hear and now, the alternative to AOT is homelessness, jail, inpatient commitment and suicide. I'm FOR AOT. I thank you for coming a long way, but political correctness and fear of offending shouldn't trump helping real people in the hear and now.
  3. walt stawicki's avatar
    walt stawicki
    | Permalink
    thanks for a concrete example. I constantly rant against the philosophical arguments of "civil rights" advocates on this issue, who seem to think it is beyond the pall to use a carrot, let alone a stick or force or coercion...to get one into treatment. The phrase "die with their rights on" is now nearly 4 decades old and the battle still rages, people still die, free to roam the streets and be delusional there. such compassion! so thanks for an example of a place where AOT is working and people are happy with the results. I will be refering to this in the future.

    waltinseattle
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