Let’s work together to finally stop public and private systems from denying care and forcing our loved ones to go from crisis to crisis

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Morning Zen Guest blogger ~ Debbie Plotnick

How did we ever get from “no one will be treated for mental illness against their will unless they are a danger to themselves or others” to “no one will get treatment for a mental illness unless they are a danger to themselves or others?” The only difference between the two parts of that sentence is the words “against their will.” This has caused many deeply caring families, and others of good conscience, to become so desperate as to place their hopes on passing laws that will only serve people after they’ve been repeatedly failed by the mental health system.

We all know that in most locales mental health services and supports are at best spotty, and even likely to be down-right terrible. Families are often driven to despair, unable to access mental health treatment at all until there is a crisis, or worse yet multiple crises. Even when services are in place for kids, parents are scared to death that the minute their child turns eighteen and they enter the so-called adult system everything will go away—or worse yet their child will reject help altogether. This is why some parents believe that enacting what has become known as AOT (assisted outpatient treatment) laws will help their kids.

AOT laws are very specific and have very strict criteria. That’s why even where such laws are on the books, and where they are implemented (meaning counties are willing to create the infrastructure to oversee them, and to provide the dollars to fund them), very few people are subject to these super-sized involuntary treatment orders. In the ongoing debate, we hear conflicting and confusing information. Forty-two states have involuntary outpatient commitment laws (IOC), but yet in many of them there are repeated attempts to pass AOT laws, usually advocated for by parents.

Under AOT provisions, a person can be committed to outpatient services for a period of six months. But before an individual, age eighteen or older, can become eligible for this extended community commitment, they have to (among other things) have been diagnosed as having a serious mental illness, to have had a least two prior incidents of involuntary hospitalization or imprisonment due to their mental illness in the previous thirty-six months, and be “unlikely” to accept voluntary treatment. The unlikely part is very hard to prove, mostly because—as desperate parents know—all too often there are hardly any services, let alone the continuum of services necessary to help keep people from cycling in and out of crises, that are available.

Research from the largest studies assessing two of the best known AOT type laws from New York and South Carolina showed that the mean age of those under AOT orders was 39 years and 37.9 years respectively. It also showed black people were five times as likely as whites to come under AOT orders. People coming under AOT orders are never kids or adolescents, and very rarely are they transitional age youth (between 18 and 26). The research does show that when these laws are in place and funded, then the people who have been failed many times by the system and then come under AOT orders do better than they did before. They have fewer hospitalizations, are less likely to be homeless than they were before, and they have fewer arrests and spend less time incarcerated. Research is also clear that these outcomes are highly correlated to the funding that brings care coordination and services to people who early on likely had been willing to accept help…but were let down—time and again.

The question that I ask myself, and I pose to other parents like me, who know what it is like to be willing to tie their kids up in a burlap sack and lock them in a closet—court order aside—are these the outcomes we want for our kids? Does it really make sense to put so much of our energy into advocating for laws which research predicts would only to apply to our kids once they’re approaching middle age and only after they have been hospitalized and arrested many, many times. Do we really want to pin our hopes on outcomes that don’t measure recovery, education and employment status, but which only strive for reductions in the number of times people end up homeless, hospitalized and jailed?

Many people, parents, legislators, even mental health professionals are confused by what the difference between regular involuntary outpatient commitment (IOC) and AOT. Let’s take a look at my home state of Pennsylvania as an example. Similar to most other state laws, Pennsylvania’s Mental Health Procedures Act has had IOC, which provides for inpatient or outpatient commitment, on its books since the 1970’s. Under its provisions, commitment can be either to inpatient or outpatient services. Commitments can be for 3, 30, 60, 90, or up to one-hundred and eighty days (six months). So, why are shot-term commitments hard to come by and long-term commitments rarely used? There are two reasons. First it’s always better (short or long) for the individual and their family if a person (adult or child) voluntarily engages in treatment and support services, and they are much more likely to do so when what is available feels helpful, safe and supportive. The second reason, which Pennsylvania also satisfies, is that if good services are in place, few people will need to be remanded to long-term involuntary commitment. Overall in the state there are good services and quite a few of what I call “pockets of excellence.” These are communities that offer really good services for children that wrap-around the child and their family. There is also recovery-focused outreach that successfully engages even people who are very reluctant to accept help. And the services for adults and kids include a wide array of peer services.

But still many people don’t get help. Some of it is because these pockets of excellence are just that, pockets. It is rare to find the continuum of services and supports needed to keep people employed, in school, housed, and to fully address all of their health needs, including substance use treatment. But to qualify for these most of these support services, when there are available, the individual usually has to be on Medicaid, and be served by the perpetually underfunded public systems. This is because until we had the new laws that are just coming into effect, such as the Affordable Care Act (ACA), the Mental Health Parity and Addiction Equity Act (MHPAEA), and Medicaid expansion (unfortunately not in all states), we had no mechanism for paying for, let alone growing, the availability of services. Now that we do have more financial avenues, it will still take some time and lots of effort to make sure that there is a continuum of collaborative care services. This means services and supports that serve young people and their families. This means serving people at every stage of life. This means treating and supporting the whole person—all their health needs, including substance use. These new laws have the means to allow families to finally get prevention services for family members at risk, providing early interventions and caring coordination. They can help us to, make use of evidence based practices, such as supported education, employment and housing, and for recovery to be everyone’s goal. But it will take work.

Let’s stop arguing over whether we need change existing state statutes from generic IOC laws to AOT laws. Let’s work together to finally stop public and private systems from denying care and forcing our loved ones to go from crisis to crisis. Let’s work together to ensure that our new laws help kids, families and adults at all ages and stages of illness to get to recovery and achieve the kinds of goals every parent really wants.

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debbieplotnickDebbie Plotnick, Senior Director of State Policy, Mental Health America, works with affiliates and state and local advocates on Medicaid, health reform, and state mental health programs and policies. She also coordinates the efforts of the Regional Policy Council, a ten person council of state affiliate policy leaders. Debbie also provides technical assistance to mental health advocates, participates in national mental health coalitions, and develops and disseminates policy information for affiliates, stakeholders, decision makers and the general public. She can also speak about community inclusion, evidence-based practices, and her own experiences with mental health challenges and as a family member. 

Comments

  1. George Patrin, MD/MHA, San Antonio, TX's avatar
    George Patrin, MD/MHA, San Antonio, TX
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    You're comment "It is rare to find the continuum of services and supports needed...to fully address all of their health needs... ." So true. And even if we get mental health professionals to begin providing continuous rather than episodic care, few are integrated with the client's primary care provider team, where holistic healthcare that includes behavioral health should begin and continue after seeing the specialist. Woe be to the citizen who is homeless for any variety of reasons, who is unlikely to have "healthcare insurance" coverage. There is no such thing as preventive or holistic healthcare for them.
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