Last month, the Department of Health and Human Services announced the Crisis Solutions Initiative, a new state effort aimed at addressing the failures of Gov. Easley’s 2001 mental health reforms. Following the announcement, the Civitas Institute called on the McCrory administration to get serious about severe mental illness. The first meeting of the Crisis Solutions Initiative was held this week. As coalition partners consider myriad issues in the mental health system, it’s time for some innovative responses.
North Carolina’s mental health system is strained to its breaking point. Inpatient resources for people in crisis are so scarce that it takes an average of three-and-a-half days to get admitted to a psychiatric facility. But the outpatient system is even worse: Few patients follow through with treatment after they are discharged from psychiatric hospitals. The result is a system that is constantly in a state of crisis. Scarce resources are wasted as people with severe mental illnesses are trapped in a destructive “revolving door” of hospitalization, discharge, regression, and hospitalization.
“Psychosis,” by Amber Osterhout
If the Crisis Solutions Coalition is serious about addressing this “revolving door,” they should start by looking at assisted outpatient treatment. Assisted outpatient treatment (AOT) is a court-ordered process used to prevent deterioration in someone who might become dangerous to themselves or others if untreated.
AOT works to interrupt the “revolving door” by directing care at individuals who repeatedly end up in the hospital, but refuse to adhere to treatment in an outpatient setting. This is quite common among people with severe mental illness: Approximately half of people with schizophrenia or bipolar disorder believe that they are not sick. To be clear, not all of these people are necessarily good candidates for assisted outpatient treatment. But when other forms of intervention fail, assisted outpatient treatment can provide a badly-needed safety net for the worst-off people.
Studies from Duke University and Columbia University (see sources below) have shown conclusively that assisted outpatient treatment is an evidence-based practice that improves outcomes, both for participants and for the public at large. AOT participants are less likely to be victims of crime. They are less likely to be violent. They are less likely to be incarcerated or hospitalized. At the same time, they are more likely to take their medication and more likely to be actively involved in the community.
Assisted outpatient treatment also saves taxpayers a great deal of money. A study of assisted outpatient treatment in New York found that
… the average annual cost per person declined substantially and consistently … In the New York City sample, average costs declined 50%, from about $105,000 to about $53,000 per person, and in the five-county sample, average costs declined 62%, from about $104,000 to about $39,000 per person.[i]
The evidence shows that assisted outpatient treatment can interrupt the “revolving door.” By ensuring continuous care after discharge from a hospital, people who previously would have slipped through the system are able to remain integrated in the community. Nonetheless, AOT has fierce critics. Opponents of assisted outpatient treatment argue that involuntary treatment is a violation of civil liberties. They argue that patients should be free to make decisions for themselves about their treatment. And in most cases, this is true. But in some cases, it is not at all clear that psychotic or delusional patients are in the best position to make those decisions. Michael Biasotti, a New York police chief and a staunch advocate of AOT, asked: “We’re so concerned about someone’s civil liberties – which, I agree – but at what point? At what point are you denying them their civil liberties by not bringing them back to reality?”
So-called “patient advocates” say that they want mentally ill people to have “self-determination” and receive treatment in the “least restrictive setting.” But as E. Fuller Torrey, a prominent schizophrenia researcher, has warned, this is not always possible:
“Self-determination” often means merely that the person has a choice of soup kitchens. The “least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror-filled existence plagued by both real and imaginary enemies.
For family members who watch their loved ones consumed by untreated mental illness, lofty talk of civil liberties rings hollow.
The arguments against assisted outpatient treatment are well-intentioned, but often they ignore the facts. Assisted outpatient treatment is an evidence-based practice that can save lives in North Carolina. It can serve as a badly-needed safety net in the state mental health system. Finally, it can reduce the strain on families, law enforcement, and the public health system.
If the administration is truly earnest about this new Crisis Solutions Initiative, they should start by taking a close look at assisted outpatient treatment.
Swanson, J.W., Van Dorn, R.A., Swartz, M.S., Robbins, P.C., Steadman, H.J., McGuire, T.G. & Monahan, J.T. (2013). The cost of assisted outpatient treatment: can it save states money? American Journal of Psychiatry 170, 1423-1432.
Van Dorn, R.A., Desmarais, S.L., Petrila, J., Haynes, D. & Singh, J.P. (2013). Effects of outpatient treatment on risk of arrest of adults with serious mental illness and associated costs. Psychiatric Services 64, 856-62.
Van Dorn, R.A., Swanson, J.W., Swartz, M.S., Wilder, C.M., Moser, L.L. Gilbert, A.R.,…Robbins, P.C. (2010). Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatric Services 61, 982-7.
Gilbert, A.R., Moser, L.L., Van Dorn, R.A., Swanson, J.W., Wilder, C.M., Robbins, P.C.,…Swartz, M.S. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61, 996-999.
Swartz, M.S., Swanson, J.W., Hiday, V.A., Wagner, H.R., Burns, B.J., Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52, 325-329.
Swartz, M.S., Wilder, C.M., Swanson, J.W., Van Dorn, R.A., Robbins, P.C., Steadman, H.J.,…Monahan, J. (2010). Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatric Services 61, 976-981.
New York State Office of Mental Health. (2005). Kendra’s law: final report on the status of assisted outpatient treatment.
The cost you site in your article are all extremely high.I suppose you are saying it is lower than paying what it cost to care for them in emergency room settings but those cost go mostly unpaid.Once you put the mentally ill in a controlled environment the cost are paid and by the taxpayer and the true cost including meds,housing,doctors,personal care,counseling,travel,meals,entertainment,education,vocational rehab in some instances will be many multiples of the numbers you state.The Disability Rights Law and its advocates have case law on their side that declare the state must provide independent housing and care which if thought out will cost the State enormous amounts of taxpayer money and in some cases put private citizens in communities at risk from those with psychotic episodes.I contend the best world was when those with mental illness were confined to assisted living facilities like the one the State closed in Candler,NC because it had too many residents with mental illness.The home specailized in the care of those with mental illness and did an outstanding job of caring for that population.The residents were happy,well adjusted,receiver their meds appropriately,doctor visits were scheduled and things ran smoothly.Until the Disability rights advocates had court rulings saying it was inappropriate for more than a certain number of those considered mentally ill to be housed with those just elderly.The home in question had about 80% mentally ill and could have just discharged the 20% deemed just elderly but that would not suffice in the States wisdom.In any event the cost to the State was app $1,700 per month per resident and I suspect before this all is settled the cost to the State will be in the neighborhood of $20,000 + per month to the State per month and very little will have changed to improve the circumstances of those with mental illness but the State will be much larger with larger buildings and more study commissions and reams of paper and documents about concern for the mentally ill.
Mr. Strum:
Thank you for your very insightful comment. Assisted outpatient treatment does not necessarily involve a “controlled environment” — it’s coordinated so that intensive services (e.g. assertive community treatment or intensive case management) revolve around the recipient. ACT teams, for example, make house calls. These ARE expensive services, but as the Duke and Columbia studies show, the cost is significantly less than the cost of a crisis-oriented system that puts strain on emergency departments and the criminal justice system.
I agree with you that the Olmstead settlement reached between the state and the federal government poses a number of problems. I’m familiar with the case you mentioned in Candler — by all accounts consumers and their families were very happy with those services, but overzealous interpretation of Olmstead caused the facility to shut down. Given the existing case law, I do not think that it is possible to re-institutionalize with the use of group homes.
I’m very interested in continuing this conversation, though. I read your comment on my other article with great interest, and I’d love to hear more about your experiences and insights. Please give me a call if you’d like to talk — our number here is 919 834 2099.
In the early 2000s in Fl., funding was cut for day treatment facilities. Folks would come from assisted living and had a very structured environment with med review once per week by the visiting psychiatrist. The thinking was to assimilate many of them into society and cut the Day Treatment programs. For some, this is not possible, as many came from a controlled mental health facility to assisted living, and this was a strain for them. These people are really ill with very little chance of rehabilitation. Several, once released into independent living over medicated to escape the pressure.
Our state must deal with this in a better way than relying on law enforcement and families for the seriously ill. It is not working, and they are caught in a revolving door at the emergency with a Sheriff often sitting with 7 patients. If needed, they must be admitted, yet there are not enough facilities or beds to help these people; so, they are released back to families. The cost to the taxpayer now in each county is astronomical, and the mentally ill are not getting the assisted treatment they desperately need. It is also straining local law enforcement. These people need structure and careful monitoring of meds. The way things are being handled, more will become a danger to others, and we will continue to see catastrophes such as Newtown. That mother begged for help to no avail. Do we really want to continue to blame irrelevant causes, when we have a broken mental health system?
Involuntary Outpatient Treatment: How Effective Is It?
A broad group of concerned stakeholders in North Carolina are currently meeting to consider how to reduce over-use of emergency departments and hospitals by citizens who have mental health needs. Already, many sensible and innovative ideas are coming forth. Our state should focus on efforts that reduce costs while managing crises and providing services in a manner that actually engages individuals in a way that sets them on a path toward mental health recovery. Sometimes this means hospitalization, but very often there are other services that are more suited to the individual’s need while being less costly. By improving efforts to support a person through improved care coordination, less intensive transitional supports just recently developed, and intensive longer-term (already existing) services, North Carolina can greatly reduce over-utilization of hospitals.
It is timely that our state is in the midst of a shift in the service culture from one that has focused on medication and paternalistic treatment approaches to one focused on engaging a person as having responsibility and voice in his services and ultimately in his recovery. This has important and very hopeful implications for our state’s public mental health system and those who use it. Furthermore, this challenges the necessity of forced outpatient treatment (Involuntary Outpatient Treatment).
Under Involuntary Outpatient Commitment, a person with a serious mental illness is mandated by the court to follow a specific treatment plan, usually requiring the person to take medication and sometimes directing where the person can live and their daily activities. Proponents of IOC claim that it is effective in reducing violent behavior, incarcerations, and hospitalizations among individuals with serious mental illnesses.2 However, the facts show that IOC by itself is not effective, has high costs with minimal returns, is not likely to reduce violent behavior, and that there are alternatives that are more effective and efficient. In sum, as Mental Health: A Report of the Surgeon General noted, “Almost all agree that coercion should not be a substitute for effective care that is sought voluntarily.”
Comprehensive services are effective, not IOC.
IOC has consistently been found to not be a substitute for comprehensive mental health services.3 In the late 1990s, Jeffrey W. Swanson, Ph.D., and colleagues conducted a field study in North Carolina that found that IOC can be effective only if combined with other intensive treatment. The authors concluded, “This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.”4 Proponents of IOC use the findings from the North Carolina study to claim that IOC is effective, but do not account for the additional resources put into the service delivery system in the form of increased funding for mental health services and supports. A second study, conducted in the mid-1990s at Bellevue Hospital in New York City, before Kendra’s Law was passed, found that, “[o]n all major outcome measures, no statistically significant differences were found between the two groups” (IOC and control groups).5,6
Another study, published in The Lancet on March 26, 2013, reported: “In well-coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.” And the RAND Corporation, which studied the implementation of IOC in eight states, found: “There is no evidence that a court order is necessary to achieve compliance and good outcomes,” and reported that the literature provides clear evidence that “alternative community-based mental health treatments can produce good outcomes for people with severe mental illness.”
New York’s Kendra’s Law is one of the better known state IOC statutes. In addition to mandating IOC for certain individuals with serious mental illnesses, it is significant that the law also provided for greatly increased funding for mental health programs. For example, the 2005-2006 Fiscal Year budget for Kendra’s Law operations was $32 million, and that same budget included an additional $125 million to expand case management services, to improve service access and utilization, and to increase the availability of other mental health services and supports.7
IOC has high costs with minimal returns.
IOC is a costly program that needs significant resources to have an impact. However, research has shown that, for the cost, there is minimal impact. It would take 27 IOC orders to prevent one instance of homelessness, 85 to prevent one (hospital) readmission, and 238 to prevent one arrest.8 Dr. Swanson of Duke University, who has studied Kendra’s Law extensively, told Behavioral Healthcare: “[P]eople who understand what outpatient commitment is would never say this is a violence prevention strategy.”
Other mental health interventions are more effective.
Research has shown that other interventions are a more efficient and effective use of resources than is IOC.8,9,10 In California, some counties already have in place proven voluntary treatment programs without the expense and coercion of court-ordered treatment. In Orange County, the Full Service Partnerships have reduced hospitalizations by 50%, incarcerations by 88% and homelessness by 70%. Assertive community treatment, in which multidisciplinary teams of highly trained mental health professionals provide community-based care, also has good outcomes for persons with serious mental illnesses.9 In addition, Dr. Joseph Parks, who has served as medical director for the Missouri Department of Mental Health for 20 years, recommends that resources should be spent on programs such as early identification and treatment of mental illnesses, including effective early treatment of psychotic illnesses such as schizophrenia.11
Given the limited impact of IOC when compared to the high cost, it is imperative that the resources of the United States be used to fund programs that have a positive and significant impact on improving the lives of persons with serious mental illnesses, and not on IOC.
Notes:
1. Some call this process Assisted Outpatient Treatment, but that terminology is not a proper reflection of the process, so this document uses the more accurate phrase “Involuntary Outpatient Commitment.”
2. Torrey, E Fuller. “Examining SAMHSA’s Role in Delivering Services to the Severely Mentally Ill.” Oversight and Investigations Subcommittee of the U.S. House of Representatives Committee on Energy and Commerce. Washington, D.C. May 22, 2013.
3. Swartz, M. and Swanson, J. 2004. Involuntary Outpatient Commitment, Community Treatment Orders, and Assisted Outpatient Treatment: What’s in the Data? Canadian Journal of Psychiatry. September, 2004.
4. Swartz, M, Swanson, J, Wagner, H, Burns, B, Hiday, V, Borum, R. 1999. Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings From a Randomized Trial With Severely Mentally Ill Individuals. American Journal of Psychiatry. 156(10): 1968-1975.
5. Steadman, H., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., and Robbins, P. 2001. Assessing the New York City Involuntary Outpatient Commitment Pilot Program. Psychiatric Services. 52(3): 330-336.
6. Outcome measures included re-hospitalization, arrest, quality of life, symptomatology, treatment compliance, and perceived level of coercion.
7. New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. Retrieved from http://bi.omh.ny.gov/aot/files/AOTFinal2005.pdf on November 26, 2013.
8. Kisely, S., Campbell, L., and Preston, N. 2009. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochran Database of Systematic Reviews.
9. Ridgely, M., Borum, R., and Petrila, J. 2001. The Effectiveness of Involuntary Outpatient Treatment: Empirical Evidence and the Experience of Eight States. RAND Institute for Civil Justice.
10. Dieterich, M., Irving, C., Park, B, and Marshall, M. Intensive case management for severe mental illness. Cochrane Database of Systematic Reviews 2010, Issue 3.
11. Parks, Joseph. “Examination of SAMHSA’s Role in Delivering Services to the Severely-Mentally Ill.” Oversight and Investigations Subcommittee of the U.S. House of Representatives Committee on Energy and Commerce. Washington, D.C. May 22, 2013.
In my very personal opinion this will drive people away from treatment. They will be to afraid to voluntarily seek treatment when they need it, if NC becomes a state that goes with this approach. This is definitely not a mental health consumer, or disability friendly process. It sends the wrong message to clients and the public, increases stigma and would instill fear in hundreds of thousands of clients across our nation that are in treatment regularly. It could be misused to do great harm to many, who have to tough enough life already, that are trying to fit in to a society that daily treats them as less than. Give them a HAND UP with Recovery Programs and Education about their illness and the importance of staying in treatment, not a LOCKDOWN.
One policeman gets scared and over-reacts to an individual in a psychotic state. Mobile crisis teams are no longer a team observing the best practice of having a mental health professional, nurse and peer support specialist on the team. Patients, frequently in a deep depression go to the ER only to be guarded by a member of sheriff’s department, handcuffed, sometimes shackled and to wait an average of 3 days for a much needed bed. It is not unusual for a young person having a first breakdown to wait two weeks tied to a guerny. Everywhere across the state clubhouses and psychosocialrehabilitation programs are closing. Those coming out of adult care homes lack a team of people to transition them into community life. Patients who do want mental health services may wait three months for an appointment while only being given two weeks worth of medication when they department the emergency department of our hospitals. Many hospitals that did have adult beds have transitioned to only geriatric beds. It is a system of violence and neglect.
I question thinking that forcing people involuntarily into this system is sound. Individuals I have known who were court ordered into treatment resent it, come to no insight, have no hope for a recovered future and throw their medicine away as soon as the court order is over. “No Force First” is becoming a best practice. Dr. Schwartz research was with individuals in an enhanced program of psychiatric treatment. Most mental patients have a history of trauma and need to be asked What Has Happened to You?” not “What is wrong with you now?” This takes a well trained team, individual therapy and careful medication regimen. If NC in a panic over costs, not lost lives and futures, institutes more outpatient commitment, beyond the programs that already exist in this state, it will be tragic.
Laurie,
Thank you for your detailed comment. I understand your concerns, and I will try to address them in this comment. You brought up a lot of points, but in the interests of brevity I will not be able to respond to all of them.
I completely agree with you that we should engage individuals in their recovery. The state should always seek the least restrictive option, and obviously it is always preferable to have people actively participating in their own treatment. That’s what the recovery model is about, after all – having optimism and encouraging consumers to take charge of their needs.
But the problem with the recovery model is that sometimes it fails. There is a small segment of the population for whom the recovery model will not work – in cases involving anosognosia, for example, where the individual does not even know that they are sick. No matter how many services are made available, or how many attempts are made to engage the person in treatment, some of these folks will not voluntarily do so. We’re seeing the results of that today – 16 percent of homeless adults have an untreated severe mental illness. Approximately 60 percent of local jail inmates have some mental illness. And of course, there is the “revolving door” of involuntary commitments and hospitalizations.
Assisted outpatient treatment is NOT the first option for people with severe mental illness. It’s not even the second or third option. It is the last resort when all else fails. It’s a safety net for the people who continually fall through the cracks of the recovery model. And the clinical results of AOT, contrary to some of the information you provided, are overwhelmingly beneficial.
You mentioned Dr. Swanson’s and Dr. Swartz’s work in your notes. Both Swanson and Swartz have published numerous papers that show that AOT, when paired with intensive outpatient services like ACT, produces results. You cited a number of studies in your notes, but most of those studies actually show that ACT has significant positive outcomes. Observational trials in New York and North Carolina, along with randomized controlled trials in North Carolina, show that assisted outpatient treatment reduces hospitalization, arrest, victimization, and violence. It also reduces cost, because although ACT services are indeed expensive, they are much less expensive than the combined effects of recidivism, trips through the criminal justice system, and other aftershocks of non-treatment.
As to the Bellevue study and the Lancet study – both of those studies had situations in which there was no judicial order for outpatient treatment. The treatment administered in both studies was not consistent with the model that assisted outpatient treatment uses.
Anyway, this response is getting quite long, so I will end soon. One last point: There is a lot of concern among some consumer advocates that assisted outpatient treatment is overly restrictive. But which is the more restrictive setting – is it court-ordered outpatient treatment, where a person can live in the community, free or more free from their psychosis? Or is it a homeless shelter, hospital bed, or jail cell? I submit to you that assisted outpatient is in fact far less restrictive than the system we have now.
How will court ordered compliance with outpatient treatment be helpful while there is continued reduction of providers in the community? The author posits “Few patients follow through with treatment after they are discharged,” refusal “to adhere to treatment in an outpatient setting,” and client difficulty with acknowledging their condition as correlated with the ‘revolving door’ but he does not discuss the provider purges that have occurred over the past few years. Focusing primarily on client resistance as causative is a very narrow, limited, and biased way of addressing the issue. There are significant systemic problems that are HIGHLY correlated with the ‘revolving door’ and unless there is an accessible and diverse provider network the effect of outpatient commitments will be negligible. I am not opposed to outpatient commitments (NOTE: adding the word ‘assisted’ makes it sound very friendly and positive but we can’t re-define away the fact that this is a legal action with consequences) but this is only one leg of an array of necessary interventions (and a stool cannot stand on only one leg).
Over time, thousands of qualified and dedicated providers have voluntarily opted out of being Direct Enrolled Medicaid providers or were forced out by subjective audits and subjective choices by the LME/MCO’s concerning who will be granted a contract and who won’t be granted a contract. The first wave of provider purges was the implementation of CABHA. The next wave was the state wide implementation of 1915 b/c. Now, there is a push for Requests for Proposals (RFP’s) which will further trim the tree. Clients have been repetitively ‘bounced’ from one provider to the next – disruption in the continuity of care contributes to the risk of relapse. An outpatient commitment can be beneficial if it adds a layer of support and monitoring but court pressure and monitoring will be ineffective if a client is on a clinic’s waiting list, is scheduled for their first appointment weeks after a hospital discharge, has to wait for an authorization, has a delay in treatment due to the intake and Clinical Assessment being scheduled sequentially (as opposed to being scheduled conjointly), and has a delay of treatment waiting for the Person Centered Plan to be approved.
I recall one study (I can’t seem to locate it right now) on outpatient commitments where the author discussed in the Conclusion section how the availability of resources and rapid and responsive treatment may be a stronger dependent variable than just the outpatient commitment in and of itself.
At the CIT conference held in February of 2013, there was a review of the Waiver implementation. On one of the Power Point slides it described one of the ‘benefits’ as it “Can create a smaller, more identifiable, more professional, sustainable and stable Provider Network.” At this point, it is no mystery that the reduction of the provider network is intentional. In my private practice, when I terminated my contract with one of the LME/MCO’s, I had to call the Contracting Department to get clarification on the instructions – there was a typo on the instruction letter. During the phone call, the person said “…I’m sorry for the typo…I have been so busy lately…I am receiving 3 or 4 requests from providers to drop out of the network per day.” 3 or 4 per day? WOW!!!! I can go on and on about the dissolving of resources and the move away from small and medium sized providers and towards the larger agencies, but suffice to say that this is a central issue. The activation of an outpatient commitment process will be a lot of effort that LOOKS like something is being done but when in reality it will have minimal productive impact if the availability of services is not addressed.
I support the initiative to target this issue. I caution the committee from relying on outpatient commitments and ignoring the systemic problem of reduced providers and services.
Geoffrey,
Thank you for your thoughtful and detailed comment. I think you’re absolutely right – the lack of providers, along with the fragmentation and instability of services, is a key part of the problem. When NC had county mental health services, there were case managers whose job it was to monitor clients and make sure that they weren’t falling through the cracks. That went by the wayside, as did the “one-stop shops” that would have psychiatric services, pharmacies, labs, and other necessary services all on site. Today, a person with severe mental illness is expected to do everything for themselves. If they don’t have a car, they might spend all day on a bus going back and forth across town to pick up medications, attend appointments, get blood drawn, etc. So even if you have someone who is fully willing to get treatment, the system makes it very difficult to actually follow through.
I am not proposing the expansion of assisted outpatient treatment as a quick fix for the mental health system as a whole. It won’t work that way because it isn’t designed to work that way. But assisted outpatient treatment can ensure that a small, targeted group that historically has been unable to get services (due to anosognosia, for example) is able to get treatment. This group may be small, but it is extremely expensive and has terrible clinical outcomes as a result of recidivism, incarceration, etc.
You’re also right on the mark when you say that AOT must be accompanied by appropriate services. Studies on AOT highlight this point emphatically. In New York, Kendra’s Law (their outpatient commitment statute) also included $100 million to build an infrastructure of services that could support AOT. Assisted outpatient treatment works hand-in-hand with assertive community treatment (ACT), the “gold standard” of outpatient services. If you don’t have ACT teams, then a piece of paper telling you to go see an ACT team isn’t going to do very much. I should have mentioned this point in the original article, but I was afraid it was getting too long.
Anyway, thank you again for your comment. And thank you for your work as (I surmise) a provider. If you’d like to talk more sometime please feel free to send me an email at Lee.Brett@nccivitas.org or call me at 919-834-2099.
Mr. Brett:
Thanks for responding to my article. Involuntary Outpatient Commitment (please don’t use the inaccurate euphemism “assisted outpatient treatment” –assistance is synonymous with welcomed help, and not with force. You are talking about forcing treatment by law and involving law enforcement systems, etc.).
The part that is assistive is the aspect of individually focused, genuinely welcoming relational approaches that help people become truly engaged in the treatment processes. If we get to a place where public systems offer this, then THERE is the solution.
In fact, the compulsory aspect creates natural resistance which does not promote a person determining he can re-build his life. The difficulty is that there is so much more to helping citizens beyond the pill. Yet so much of the emphasis of forced treatment is on medications. Until society moves away such severe stigma, we continue to consider policing and force–which is antithetical to life CHOICES and recovery.
I have studied all these issues as a psychiatric nurse, as a parent of an individual who has struggled with severe illness and as a person who herself has a diagnosis. I am a well-known and (mostly, I think) respected advocate for people with psychiatric and other disabilities. I follow the national thinking on such issues as Involuntary Outpatient Commitment. And I understand systems. I believe that respecting each citizen with the rights of full citizen ship is always one of the first steps toward civil and productive solutions.
I support the comments of Laurie Coker, Pat McGinnis and Bonnie Schell. I would add that I believe the criteria used to determine whether someone can be committed on an outpatient basis are often much less stringent, and less objective, than inpatient commitment criteria (which usually involve deciding whether someone is an imminent danger to self or others). Therefore, far more people can be subjected to IOC. The advocacy community of individuals with lived experience of a mental health condition are united in their opposition to outpatient commitment, which invades people’s everyday lives and only results in more coercion and in the draining of vital resources that could be much better spent on enhanced community-based services and supports, such as employment and housing programs. In addition, outpatient commitment statutes are not widely viewed as helpful in the public mental health system. Of the states that have such a statute, many rarely use it, according to a survey by the National Association of State Mental Health Program Directors.