AOT Implementation Training Treatment Advocacy Center What Is Assisted Outpatient Treatment (AOT)? What Is It? Why Do We Need It? AOT Implementation Training Baton Rouge, LA February 23, 2018 By: Brian Stettin Policy Director Treatment Advocacy Center treatmentadvocacycenter.org

Public Mental Health: Many Needs, No Single “Cure-All” More investment in community-based care (mobile crisis teams, crisis respite, et. al.) Inpatient psychiatric beds Recruit mental health professionals to underserved regions New law-enforcement / diversion strategies Address treatment non-engagement

Treatment Non-Engagement Too many with SMI caught in the “revolving doors” of the mental health and criminal justice systems

The Consequences of Non-Engagement: Violence and Crime People with SMI receiving treatment (the great majority) are NOT more dangerous than general population. UNTREATED people with SMI ARE more dangerous than general population. Untreated SMI estimated to be a factor in 10% of US homicides. More commonly, untreated SMI leads to assaults, property and drug crimes

The Consequences of Non-Engagement: Frequent Hospitalization People with SMI can only be kept in a hospital until stabilized. Non-engagement with outpatient treatment makes re-hospitalization inevitable. A vicious cycle. Each successive psychotic break puts recovery further out of reach.

The Consequences of Non-Engagement: Budgetary Impact Law enforcement, incarceration, and hospitalization are enormously expensive. Patients caught in the revolving door are stressing the CJ & MH systems beyond the breaking point.

Many reasons for non-engagement Inadequate community-based support Health insurance gaps Distance to provider / lack of transportation Substance abuse Side effects of medications Challenges with executive functioning Mistrust of doctors Anosognosia / lack of insight

A most challenging cause of non-engagement: a symptom of brain dysfunction known as … ANOSOGNOSIA

Anosognosia Lack of insight into one’s own illness. (inability to recognize illness in self) NOT denial Brain-based. Out of the individual’s control Makes non-adherence logical

Linking Anosognosia and Non-Adherence Psych. Services 2/06: Of 300 patients with non-adherence tracked, 32% found to lack insight. Those 32% had significantly longer non-adherent episodes, more likely to completely cease meds, have severe symptoms, be hospitalized

Bottom Line on Anosognosia If you build it … … SOME still won’t come!

AOT is … A strategy to address non-adherence A form of civil commitment A means of leveraging the power of courts to influence behavior

Why Does the Court Order Matter? As court orders go, AOT order is uniquely toothless: No contempt of court No automatic return to inpatient commitment No forcibly administered meds Fair to ask: what’s the point?

Point #1: “The Black Robe Effect” Judges naturally command respect as symbols of authority in our civic culture. The AOT judge must embrace the role of primary motivator. The black robe effect works on the treatment system too.

Point #2: Rapid Response to Non-Adherence Lack of punishment for non-adherence doesn’t mean lack of consequence

AOT “Program”? Where’s that in the law? Answer: nowhere Establishing a “program” means using the authority granted in the law to seek AOT, in a manner not contemplated by (but clearly consistent with) the law.

What is an AOT “program”? Organized practice of local mental health system, in conjunction with a single court docket, to: Proactively identify those meeting AOT criteria Petition for those patients to receive AOT Deliver TREATMENT, SERVICES and INTENSIVE CASE MGMT to AOT patients, ideally with specifically dedicated staff. Take swift CORRECTIVE ACTION when AOT patients become non-adherent Determine for each patient the point at which AOT is no longer needed.

AOT is not Mental Health Court Court’s authority is not predicated on the commission of crime. Must be heard in court with jurisdiction over civil commitments (specific court varies by state). No “sanctions” for violating the order. Should not require the individual’s voluntary choice to participate.

AOT is not just for those presently refusing treatment Legal criteria allow programs to choose patients based on history and fragility of condition, not immediate state of mind. Most natural point to start AOT is upon hospital discharge of a stabilized patient Starting AOT with positive outlook is optimal. “Voluntary” settlement agreements are fine, but …

Can AOT be truly “voluntary”? No. An AOT-appropriate patient should never be given the option to disengage. Any offer to avoid the court order should be made with mutual understanding that patient’s refusal will be followed by court petition.

Judicial involvement in every case Any settlement agreement should require court approval. Lack of need for a contested hearing is no reason to deny patient the benefits of interacting with the judge.

Periodic Status Conferences The best AOT judges check in regularly with the parties. Convene all around a table. Stresses that AOT is a reciprocal commitment, not one-sided. Regularly reinforces the “black robe effect” upon both sides.

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The 2016 Game-Changer: Federal Grant Money for New AOT Programs! $13.25M awarded to 17 sites 4 years of support expected DOJ funding on the horizon.

TAC is Here to Help Brian Stettin Policy Director 703-294-6007 stettinb@treatmentadvocacycenter.org Lisa Dailey Legislative & Policy Counsel 703-294-6004 daileyl@treatmentadvocacycenter.org