It’s Time for Mental Health Advocates to Take Back Assisted Outpatient Treatment From Misguided Politicians

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Morning Zen Blog Post ~ Scott Bryant-Comstock ~ 

The month of June 2016 holds promise for being remembered as the time when “something” was done about mental health reform. The Senate is hard at work on crafting mental health legislation, and the House Energy and Commerce Committee has announced that Tim Murphy’s Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646) will rise again, apparently with a robust managers amendment to address some of the most problematic aspects of the bill.

One of the more ironic aspects of the protracted debate about what defines mental health reform is the discussion of Assisted Outpatient Treatment (AOT). Followers of congressional discussions of mental health reform will remember that since the early crafting of HR 3717, the precursor to the current HR 2646, AOT has been the tip of the spear for Tim Murphy’s campaign to get his bill passed.

Over the past few years, in stump speeches and editorials too numerous to count, the term AOT has become synonymous with mental health reform. Never mind the not insignificant fact that AOT is already on the books in 46 states or, even more telling, that I have yet to hear a politician articulate, with any sense of clarity or understanding, what is involved in the AOT process other than the civil commitment hearing component. Somehow, AOT has become the media darling for the “thing” that is going to prevent mass shootings and make us all safer from seriously mentally ill individuals determined to commit mass murder.

A few months ago I asked our research team to conduct an analysis of the news stories in support of HR 2646 listed on Representative Murphy’s website. Not surprisingly, the articles are filled with provocative and inflammatory language, graphic descriptions of violent incidents, and emotionally charged personal anecdotes. Headlines and articles contain references to "bloodiest rampages," "horror," "heinous crimes," "blood-curdling screams," "murderous assaults" and "apocalyptic assault." Authors have referred to seriously mentally ill individuals as "deranged," "frighteningly unstable," "shooters on the dishonor roll of evil," "a clear and severe risk to the public" and "a threat to society." Some headlines send the message that mental illness causes violence: "Floyd: Dallas police department attack highlights mental health needs," "New Mental Health Bill Could Prevent Mass Shootings," and "Efforts Underway To Prevent All Too Often Tragic Results Of Untreated Severe Mental Illness."

Despite the overwhelming statistics dispelling the idea that mentally ill individuals are inherently violent, the public buys into this notion in part because of the media's depiction of mental illness as a predicting factor of violent incidents such as mass shootings (Hoffner et al. 2015; Swanson et al. 2015).

Sadly, while many of the current 189 cosponsors of HR 2646 will admit that they understand that most seriously mentally ill are not violent, they continue to let the sensationalized misleading headlines in the media pairing violence and mental illness go unchallenged. The tacit approval of the guns, violence mental illness comparison is a disgrace, but then again, this is politics. 

The AOT divide - advocate against advocate 
It is important to understand that the narrative about AOT that drove much of the discussion in Congress the past two years during hearings on the Helping Families in Mental Health Crisis Act was narrowly defined, focusing primarily on the civil commitment procedure in a courtroom. Justifying the need for AOT, architects of the various versions of the Murphy bill undertook a systematic campaign to eviscerate the peer support recovery movement and SAMHSA. Nowhere was this campaign more evident than in some of the hearings held by the House Committee on Energy and Commerce, Subcommittee on Health. Advocates supportive of the most intensive treatment end of the AOT spectrum railed against advocates supportive of the peer-to-peer support community seeking alternatives to AOT. Another sad tragedy caused by misguided politicians trying to move forward with an ill-defined bill at all costs. 

Time for advocates on both sides of the AOT debate to band together 
For several years, the Children’s Mental Health Network has called for advocates on both sides of the AOT debate to come together to find ways to meet the needs of individuals with serious mental illness. With the recent announcement by SAMHSA of the Assisted Outpatient Treatment (AOT) Grant Program, advocates on both sides of the AOT debate have an important opportunity to work together to design an AOT process that incorporates the full breadth of community involvement.

The AOT pilot program was established by the Protecting Access to Medicare Act of 2014 (PAMA), Section 224, that was enacted into law on April 1, 2014 (Commonly known as the “Doc Fix” Bill). Rep. Tim Murphy (R-Pennsylvania) and Senator Debbie Stabenow (D-Michigan) are credited for getting the pilot program into the Doc Fix bill during the height of controversy around AOT being considered as part of HR 3717.

The description of the grant announcement includes language that states that "...grants will only be awarded to applicants operating in jurisdictions that have in place an existing, sufficient array of services for individuals with SMI such as Assertive Community Treatment (ACT), mobile crisis teams, supportive housing, supported employment, peer supports, case management, outpatient psychotherapy services, medication management, and trauma-informed care." 

Mental health advocates need to seize on the language in the grant announcement that provides an opportunity for states and communities to put together applications that reflect the full breadth of what is required to make the AOT process work. I know this may seem difficult for anti-AOT advocates, but now is the time to get involved in the design and delivery of these pilot projects. Leaving it up to politicians to define what AOT is will result in more of what we are currently seeing – a gross lack of understanding of the importance of the recovery community in treating and supporting individuals with serious mental illness.

I encourage you to read our review of a community implementing AOT so that you can have a better understanding of what is required to make the process work. Also, take a look at Dr. Dennis Embry’s article on the science behind the AOT process. The recovery community must work in close collaboration with the treatment community if the precious federal dollars devoted to this effort are to have any chance of success. A winning proposal will honor both the need for high-intensity services along with the need for peer-to-peer supports that are designed for and by individuals with a history of mental illness. 

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

Comments

  1. walter stawicki's avatar
    walter stawicki
    | Permalink
    aside with SAMHSA issues: "based on the dubious and entirely unsupported notion that common psychiatric conditions, such as depression and anxiety disorders, including phobias, result from blockages in energy fields. (Callahan also maintained that TFT can cure anxiety disorders in children, dogs and horses, often in a matter of minutes. At some point, he added malaria to his list of disorders treatable by TFT)."
    http://www.forbes.com/sites/sallysatel/2016/03/29/you-wont-believe-the-government-is-supporting-this-crackpot-mental-health-therapy/#4fe07c5d2773
  2. walter stawicki's avatar
    walter stawicki
    | Permalink
    having read:

    "Somehow, AOT has become the media darling for the “thing” that is going to prevent mass shootings and make us all safer from seriously mentally ill individuals determined to commit mass murder.""Headlines and articles contain references to "bloodiest rampages," "horror," "heinous crimes," "blood-curdling screams," "murderous assaults" and "apocalyptic assault." Authors have referred to seriously mentally ill individuals as "deranged," "frighteningly unstable," "shooters on the dishonor roll of evil," "a clear and severe risk to the public" and "a threat to society." Some headlines send the message that mental illness causes violence." This gets Scott rilled up. It gets most of us who support 2646 rilled up too. This bill was careful to get around "the gun question." It is the press that needs to use the blood sells angle. Furthermore, it is certain mainstream Democrats who wish to make reform be about "the gun issue." That really gets ME rilled up. So lets leave the politick of journalism aside please. It is not part of the solution, it is not in our control. It is not open to "evidence" anyway.

    "a systematic campaign to eviscerate the peer support recovery movement and SAMHSA." Being in conversations of bqackers, I think the peer support issue is not so simple an issue. There is a campaign to keep the hectoring, closed minded out of peer work. There is a campaign to haver only reasonably stable peers as a front line for those not yet stablized. The same voices see a big area for peers. But to let them replace psychiatrists, psychiatric nurses or psychologists? Lets return to barbers doing surgery? Is Dr. God perfect? of course not! is a peer (many do not want any "certification, btw)"specialist" perfect? same answer. Lets get on one side and decide how it will work. Who is ready and what they need to be able to do. At the less "professional" end, no one denies there is a place for hand holding, story sharing, help with emhancing trust in the recovery proccess and team, and a lot of companionship navigating "the System." (forms, apps, waiting rooms, dumb bureaucrats, housing searches, job searches...all the things that tax the best, all the things that mean finding how to get there, what to ask for...all which too many take for granted.)

    SAMHSA needs a treatise all its own. It has been seduced by agenda, not best policy as understood by either side of AOT or of Peer infighting, but agenda of philosophical politics, economics and greed. Yes, some will read that as "Big-Pharma. I will add "Big Alternative." I think a place we might all feel like "on the same side" is the current controversy over "Chronic Fatigue Syndrome" vs "Myalgic Encephalomyelitis" M.E. is championed not by psychiatrists, but by neurologists. CFS is backed by behavioral theorists who call their consumers malingerers, sluffs, who throw them out of tests after berating their bad attitude to the supposed cure. Here the anti-pills side is demonstrably discounting the lived experience, yet they are the talk therapist side more than the pharma side. These lines and the way we distinguish good guys from/among "mad doctors" needs a little more give and take on both sides. It needs examples, not flat accusations.."all of."them"..should be..." is not helpful.

    Transitional housing, that first step in re-entry...the same bed every night, where clothes are left, baths taken, phones are available, and the team can find people for checking in (the case mgr) or spending the day out and about with (the peer /personal support advisor). Politicians and top admin at the beancounting high bucks umbrella consortiums have decided 10,000 "permanently housed" sounds too good to look closer. It is a ladder to the top, all the way to the 30th floor. unfortunately there is no street level door. Like the "re-institutionalization" (aka jail not hospital) effect that was sold as "de-institutionalism" (aka free from the clutches)this new course for housing makes great news stories. Well, so do all those lurid shooting instances. Except now its fuzzy unicorn s and success being the sales point. look reader , no blood. bought and paid for by the good guys at... (really HUD bond financiers, trades union cheats and home depot wholesale division and backslapping politicians...with tax money at that!!!)

    Yes, we need perm housing. But we need transitional first, all the support money and good will can assemble...a bigger piece of the share than will come with such politico-economic charts guiding SAMHSA (the psyciatristless oversight and check writing agency, who uses tax money btw.)

    "only be awarded to applicants operating in jurisdictions that have in place an existing, sufficient array of services for individuals with SMI such as Assertive Community Treatment (ACT), mobile crisis teams, supportive housing, supported employment, peer supports, case management, outpatient psychotherapy services, medication management, and trauma-informed care." That's a great list as far as I am concerned. There are other good things in 2646 that are wider than the scope of this grant proposal. But the proposal is not a punative offering. It is 95% carrot, Unless you have a stake in protecting a broke system.

    Anyone want to talk views of AOT, the history, the evidence?
  3. walter stawicki's avatar
    walter stawicki
    | Permalink
    first: I have not read but the first two lines. Nothing is truer than we should not let politicians run medidcal policy. Yet this same SAMHSA? ZIP, Zero ,Nada
    NO med professionals in the wheelhouse. WHATEVER your beliefs, experiences or views...VOICE THEM!! The ship is clueless without it.
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