At the end of November, the Children's Mental Health Network convened a group of mental health advocates in the conference room of Minority Whip Steny Hoyer for the third of three dialogues on Assisted Outpatient Treatment (AOT). The AOT issue is one component of the Helping Families in Mental Health Crisis Act and has been a lightning rod for controversy. Championed by Representative Tim Murphy (R, PA-18), the proposed bill has dominated the conversation in mental health circles over the past year, leading to divisive splits among advocates about what should be included in a comprehensive mental health reform bill. The bill (HR 3717) didn't go anywhere in the last Congress, but support is growing with members of Congress.
Congressman Murphy announced this week that he would be reintroducing the Helping Families in Mental Health Crisis Act, in the new Congress. If his energy level is the same as last year, and we are gonna guess it is (we've seen his Fitbit wristband), then you are gonna want to hold on to your hats - mental health reform will be an active topic in Congress and behavioral health advocacy circles. For stimulating the conversation about mental health reform, we are most grateful to the Congressman, but with that gratefulness comes a heavy responsibility for us as mental health advocates to double and triple our efforts at dialogue with each other to ensure that Congressman Murphy and members of Congress get all of the information they need to write a comprehensive bill that will help fix the broken mental health service delivery system in America.
- You can watch Congressman Murphy's floor speech from earlier this week, where he announced his plans to reintroduce the Helping Families in Mental Health Crisis Act, at the end of this blog post.
If you are new to the conversation we have been holding for the past year on Assisted Outpatient Treatment, get up to speed by reading the background here. Otherwise, continue reading to learn the results of the third dialogue and next steps for the Network as we continue to bear witness to developments in mental health reform in America.
Dialogue series on AOT - moving forward with concrete action steps
The third of three dialogues on Assisted Outpatient Treatment, like the others before it, brought together families, advocates, research scientists and great legal minds representing positions across the spectrum of the AOT debate. For some involved in the conversation, it was a chance to put a face to a name of others, who until this meeting, they may have only known through editorials and blog posts. I am happy to report that we found many areas of agreement. However, don’t get too comfortable, Network faithful, we have much work to do!
The most important agreed-upon takeaway from the AOT dialogue in late November is that for the AOT process to work there has to be an array of outpatient treatment options available. Implementation varies widely across the 45 states that currently have AOT laws. Advocates for and against AOT share a mutual desire for expanded community-based services for individuals with severe mental illness. In order to ensure we know how best to inform expression of this need and which implementation strategies work best, the CMHNetwork will undertake two major steps:
Action Step #1. Participants in the AOT dialogue series will visit a community actively using AOT to understand better how the process works from the perspective of judges, providers, family members and individuals who have been on the receiving end. The focus of the visit will include a review of the entire service array - from high to low intensity.
Action Step #2. The Network will conduct a survey of the states who have AOT processes in place to gain a clearer understanding of the various approaches to AOT being utilized, the services and supports accessed, and how states and communities define the elements of a successful AOT process.
It's all about the “T” in AOT
A key focus at this dialogue was on the importance of the treatment plan, which needs to be sound and achievable in order to drive the AOT process forward. This seemingly small, and maybe even obvious, point provides us a shared foundation to focus the conversation where it needs to be when talking about mental health reform, and possibly most important – understanding the critical interconnectedness between a process like AOT and the community-based services and supports that need to be at the ready for the process to work.
Action Step #1: We’re goin’ on a field trip!
We have spent three sessions “talking” about AOT. Now it is time for those who have been participating in the dialogues to observe the process, speak to the judges, families, young adults and providers who have gone through the process, so we can better understand the dynamics at play and what services providers find to be most effective. Our strong hunch is that it is much more than just a hospital bed, but we need to find out. Most important, dialogue participants will do this together, so that we can process what we have seen and heard, not in isolation from each other, but together.
We will convene our field trip in February with a visit to a community that utilizes the AOT process. I have asked Brian Stettin of the Treatment Advocacy Center (TAC) to identify a community that most accurately fits the design of the AOT process being promoted by TAC and referenced by Congressman Murphy as part of his platform promoting the passage of HR 3717. During this community visit, we will observe an AOT hearing, interview the judge and other justice and mental health officials about the process we have just seen, meet with family members involved, and interview individuals who have actually gone through the AOT process so we can hear first-hand, about the process and accompanying successes and challenges involved.
As part of the visit to this community, we will also be looking at the array of community-based services and supports available to individuals with serious mental illness. Whether you agree with AOT or not, what I think we can agree on is that a process such as AOT cannot be successful without an appropriate array of services and supports available in the community. There are AOT laws in at least 45 states. As we learned at the second dialogue, the AOT process is widely variable in how it is used, depending on specific state and local requirements. I want to stress that the community chosen for the visit will not be chosen because it has a "perfect" mental health delivery system. I think we can all agree that, unfortunately, a perfect mental health delivery system does not exist. What we are looking for is a community that is actively trying to build AOT into their process for meeting the needs of individuals with serious mental illness. That is our starting point.
The AOT dialogue is the doorway we must walk through to move to a broader conversation about meaningful mental health reform. I have yet to talk with a provider who thought that hospitalization was all that was needed for a person with serious mental illness. You can’t just have AOT (whether you are for or against it) if you don’t have the necessary services and supports available in the community.
Review of AOT laws in America
When mental health center directors tell me off the record that the problem with AOT is that they don’t have the funding for the services necessary to make the AOT process useful, I know we are placing focus where it is needed to broaden the conversation about meaningful mental health reform.This is an important theme, Network faithful. It is important for all of us to make the connection between a process (AOT) that by design, requires intensive outpatient treatment, with what the field recommends as successful approaches to meeting the needs of individuals with serious mental illness. One of the frequent remarks that I hear from mental health providers is that while it may be well and good for a judge to “require” treatment, if there are no treatment options available, it doesn’t do much good, and potentially leads to the concern expressed by community support advocates that decisions will be made that lead to an increase in hospitalization or residential care, instead of a more community-supported treatment focus. This is a classic chicken and egg conundrum, and the AOT debate is wedged squarely in the middle of this conundrum.
AOT advocates we speak with say that they want those community supports and see AOT as a way to ensure individuals get into a pipeline of care instead of ineffective and unacceptable options, with the glaring example being the skyrocketing rate of mentally ill in jails and prisons across America.
Advocates firmly opposed to AOT talk about never wanting to “force” someone into treatment that could likely result in hospitalization of some type, but should instead focus on increasing the array of self-directed community-based services and supports that have empirical evidence showing their success with young adults with serious mental illness.
Both sides are looking for similar outcomes – just approaching the challenge from different perspectives. When we talk with experts in the field about this, we invariably come away with an agreement on the following point – no one wants to force anyone to do anything. Ideally, we want a service delivery system that has a robust community component as well as the intensive services necessary for the small percentage of individuals who need them.
Action Step #2: The Children’s Mental Health Network will be conducting a survey this year of the states that currently have AOT laws on the books.
It's about time we understand how states and local communities are using AOT, if they use it at all. In spite of the ongoing national discussion about whether AOT is good or not, we really don't have a clear sense of what it looks like across the country, what services are involved, and how effective it is. Moreover, for those states and communities that either do or don't embrace it, we want to know why. Conducting this type of survey is hugely ambitious, and we will be reaching out to national partners to help facilitate this undertaking.
The Children's Mental Health Network will continue the dialogue series with a particular focus on the Helping Families in Mental Health Crisis Act
2015 promises to be a busy year for the Children’s Mental Health Network as we continue our unrelenting focus on bearing witness to research, policy and practice developments in children’s mental health. We are planning to facilitate a minimum of three dialogues focusing on key issues identified in the Helping Families in Mental Health Crisis Act.
Dialogue topics chosen for 2015 are:
- HIPAA reform
The Helping Families in Mental Health Crisis Act calls for reform of the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) to increase family access to information and eliminate barriers to communication between families and providers.
- IMD exclusion
The Helping Families in Mental Health Crisis Act calls for permitting federal Medicaid dollars to be used to pay for acute inpatient psychiatric treatment by creating an exception to the current Institutions for Mental Diseases (IMD) exclusion in Medicaid.
- Re-appropriation of the SAMHSA budget
One of the more controversial components of the Helping Families in Mental Health Crisis Act is the call for a re-appropriation of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) budget to increase support for programs designed to help those with the most severe cases of mental illness.
Gonna be a fun year, Network faithful. We will update you on the dates and locations of the dialogues. We are most hopeful that the generosity extended to us by members of Congress in allowing our dialogues to take place in the House Office Buildings will continue. If a congressional staff member gets just one idea that can help bolster legislation designed to improve services and supports for individuals with mental illness and their families, then it is worth it. We think it is. Let your representatives in the House know that you think it is worth it as well.
Keep those cards, letters, and donations, coming! We are gonna need all the support we can get!
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President & CEO
Children's Mental Health Network
November 21, 2014 ~ Dialogue Participants ~ Front row, left to right: Bethany Lilly, Bazelon Center for Mental Health Law; Shibli Nomani, Asra Nomani, Treatment Before Tragedy; Maria Silva, Allegheny Family Network; Lisa Lambert, Parent Professional Advocacy League; Debbie Plotnick, Mental Health America. Back row, left to right: Dennis Embry, Paxis Institute; Scott Bryant-Comstock, Children's Mental Health Network; Brian Stettin, Treatment Advocacy Center; Ron Honberg, National Alliance on Mental Illness; Mary Jacksteit, Creating Community Solutions.