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Linda Rosenberg

Former President and CEO, National Council for Behavioral Health

Assisted Outpatient Treatment : We Can Do Better

December 11, 2013 | Uncategorized | Comments
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Practitioners, advocates, families, and individuals with mental illnesses: We all care very deeply about helping people. We dedicate our time to trying to figure out how to help people with mental illnesses to live well. This deep concern can sometimes lead to a clash in perspectives, most prominently in discussion of assisted outpatient treatment.

Last week, the Substance Abuse and Mental Health Services Administration (SAMHSA) hosted a seminar on Assisted Outpatient Treatment, including panelists representing academic, state, peer, and provider perspectives. Behavioral Healthcare magazine’s recent two-part series on assisted outpatient treatment also outlines the perspective from both sides of the debate.

Based on my experience, and again in hearing from the panelists on Monday’s seminar, despite our differing perspectives, we still have quite a bit of common ground. Leaders from all sides agree that:

  1. We need to have a real conversation on assisted outpatient treatment
    This is not a topic we can ignore. The reality is 45 states have assisted outpatient treatment laws. Thousands of individuals with mental illness are in assisted outpatient treatment programs. Public funds support these programs. But not all programs are created equal. Many do not do much to go beyond issuing a court order.

    According to research from Jeffrey Swanson at Duke University, the chief concerns of individuals with serious mental illnesses are avoiding re-hospitalization, avoiding problems with the law, attaining and keeping safe housing, and having access to care. While it is debated heavily within our field, the specific concerns around court-ordered care are lower relative to these primary concerns. But it does not make this a low priority for policymakers.

    SAMHSA is inviting further dialogue on the topic. Let’s make sure all views are brought to the table – respectfully. As SAMHSA Administrator Pam Hyde noted, it does a disservice to those we serve to see this only as forced treatment. Let’s engage in this debate, in a way that does not dismiss or oversimplify any of the perspectives.

  2. Assisted outpatient treatment can’t function without adequate services
    New York’s assisted outpatient treatment program, also known as Kendra’s Law, has the benefit of being the largest and most well-funded program of its kind. When I was with the New York Office of Mental Health, my responsibilities included helping to design and implement the state’s assisted outpatient treatment program, so I want to be clear about what from my experience makes the New York program unique.

    Each year, New York State allocates $32 million to the assisted outpatient treatment program, and $125 million into expanded and enhanced community services including supported housing, case management and assertive community treatment. Because it is the most comprehensive assisted outpatient treatment program in the US, New York’s program is frequently brought up as the prime example of effective assisted outpatient treatment, both during the seminar and in a recent study appearing in the American Journal of Psychiatry.

    The funding from the state goes toward resources and much-needed oversight. Some key elements established included very specific eligibility criteria for the program, and a matching program to connect services to need. The program was an opportunity to reach the individuals with the highest needs, and we found that this matching process was essential, just as all quality care should be individualized to the person’s goals and needs.

    Although the law exists for those with a court order, what the enhanced system really established was a single point of access where people could go (such as families, friends, and county officials) when they recognized that someone had a need for intensive services. Setting up this county-by-county system helps identify and respond to people who have high needs, very often without a court order.

    A strong network of community services is essential. There is no debating the streams that lead to care if the care is not available.

  3. Accountability is critical – for all
    Most importantly in New York State, we established a system of accountability, which set up program coordinators in each county, who monitor and follow up regularly to ensure individuals are getting the services they need. County directors are responsible for the program and the Commissioner of Mental Health has to approve all county programs. This chain of accountability means the program is regularly assessed and analyzed for efficacy.

    Marvin Swartz, a researcher from Duke University, believes accountability makes the difference in showing that assisted outpatient treatment specifically, and not just effective treatment, works. He noted that beyond the availability of services, the court order seems to have the effect of alerting the service system and the individual themselves of the high priority of the individual – leading to increased attention of their care.

    Chacku Mathai, an opponent of assisted outpatient treatment, disagreed with Swartz’s reasoning, but agreed that we need to hold ourselves accountable to getting people the care they need – when and where they need it.

    We all agree on accountability. We agree that getting people care is most likely when we have systems in place that match the most intensive services to those with the highest need and then monitor to ensure consumers and families are engaged and that the needed services are being delivered. And I would argue that with strong systems of accountability overseeing effective services we can avoid using the courts to do our work for us. It is our responsibility to engage and monitor the care of people with serious mental illness and it is our responsibility to work with their families, keeping connected with them throughout the engagement and treatment process.

  4. There’s still a lot we don’t know
    Swartz noted, “The question of if assisted outpatient treatment works is the wrong question – what we need to examine is when or why it works.”

    The outcome we do frequently focus on is reduced hospitalization, which in turn leads to decreased healthcare costs. The research is important, but often comes down to just looking at how effective services are, not as specifically to the conditions around the care which allow them to be effective.

    When assisted outpatient treatment shows positive outcomes, it is because it doesn’t look like forced treatment, but shows an array of supports for individuals – including housing, supported employment, available options for community based services and systems of accountability for service delivery. These are all areas we need to explore, and we need to discuss and collectively determine the research questions we’d like answered.

  5. We can do better
    Our ultimate solution in helping individuals is not through assisted outpatient treatment, but in finding ways to foster positive outcomes through building up the community supports necessary to help them. In finding ways to engage people in care. In holding ourselves accountable.

    The goal is that no one would experience the pain of mental illness or addiction. And if that is not yet possible, all individuals with mental illness should have the means, access and community supports to face their illness and work toward recovery in a manner of their choosing. We must have adequate funding and attention toward prevention and early intervention in every community. We must address the bias toward males of color that leads to their increased involvement in the most restrictive treatments including assisted outpatient treatment.

    The increasing use of the courts reflects not only the desire for simple answers to complex problems but reflects our failure to as a mental health community. We can do better. I’m reminded of the quote from President Kennedy, “If not us, who? If not now, when?”

I invite you to join the conversation.