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Treatment Advocacy Center Staff Testify on Assisted Outpatient Treatment

By Treatment Advocacy Center News

Treatment Advocacy Center’s Executive Director John Snook and Legislative and Policy Counsel Sabah Muhammad testified today, November 17, 2020, before the Pennsylvania House of Representatives Human Services Committee informational hearing on Assisted Outpatient Treatment. Pennsylvania passed its AOT law two years ago. Snook and Muhammad offered testimony in support of the implementation of AOT programs in order to prevent crisis and help Pennsylvanians with severe mental illness.

Below is the full text of their opening statements to the Committee:

Statement from John Snook:

Thank you Chairmen Murt, Cruz and members of the Human Services Committee for the opportunity to testify today.

My name is John Snook and I am honored to serve as the executive director of the Treatment Advocacy Center. I am a Pennsylvania native, having grown up in Mifflinburg. But most importantly, I am a family member of a loved one with severe mental illness that receives care within the Commonwealth.

It is for that reason I so appreciate the opportunity to discuss the opportunities that the use of assisted outpatient treatment (AOT) presents to help address the needs of Pennsylvanians with the most severe mental illness and prevent crisis.

COMMMUNITIES ARE IN CRISIS: Make no mistake, we are in the midst of a crisis. An estimated 8.3 million adults in the United States live with a severe mental illness (SMI). Approximately half go untreated every year.

The consequences of failing to care for the most severely ill are devastating and have significant implications for law enforcement, those with mental illness, their families and our communities. In Pennsylvania today, as in too many communities across the nation, those in need of mental illness care frequently only receive care once a crisis occurs that necessitates law enforcement involvement.

Though numbering somewhat fewer than 4 in every 100 adults in America, individuals with SMI account for no less than 1 in 10 calls for police service. Approximately one-third of individuals with SMI have their first contact with mental health treatment through a law enforcement encounter. Officers report resorting to “mercy bookings” (using low-level misdemeanor charges) to get individuals in psychiatric crisis off the street and into treatment.

Additionally, requiring law enforcement to respond to mental health crises raises a safety risk to both the officer and the individual in crisis. Our research shows that people with untreated mental illness are 16 times more likely to be killed during a police incident than for other civilians approached or stopped by officers. As we have seen in the aftermath of the death of Walter Wallace, such incidents, especially when involving the use of deadly force, can severely impact police-community relations.

Utilizing law enforcement to address what are medical crises also exacts massive, often unconsidered, costs for law enforcement and county budgets. Such encounters use at least 90% more resources than encounters not involving mental illness, even when statistically controlling for type of response.  A 2019 survey my organization conducted with the National Sheriffs Association on the role and impact on law enforcement of transporting individuals with SMI found that at least one-fifth of total law enforcement staff time was used to respond to and transport individuals with mental illness, at an estimated cost of $918 million. Law enforcement officers drove a total of 5,424,212 miles to transporting individuals with serious mental illness in 2017 — the equivalent of driving around the Earth’s equator more than 217 times. Officers transporting someone in crisis are forced to travel an average of five times farther to reach a medical facility than a jail. If officers do reach a medical facility, they wait significantly longer — almost 2.5 hours longer, per our survey results.

It is unsurprising then that jails have a steady churn of people with SMI coming through their doors. It is estimated that two million people with serious mental illness are booked into jails each year, part of a revolving door of criminalization, homelessness, and emergency department visits that too many Pennsylvanians fall victim to. As detailed by HHS Assistant Secretary for Mental Health Elinore McCance-Katz, mental health treatment standards that require crisis or violence also directly contribute to the criminalization of those with SMI.

Given those realities, my overarching recommendation for this Committee is to continue to support polices that allow a person with SMI who is in crisis to receive adequate mental health care without requiring law enforcement contact. Chief among those policies is the implementation of assisted outpatient treatment (AOT).

In 2018, this legislature unanimously passed amendments to the Commonwealth’s treatment law to add the use of AOT as an important tool in the toolbox for providers.  The use of AOT has been shown, both in practice and in study, to significantly benefit the most seriously ill who otherwise are not being effectively served by the system.

AOT IS A GROWING NATIONAL TREND: This legislature’s decision to support AOT puts Pennsylvania squarely within the mainstream and reflects a larger national tide supporting AOT’s use. For example:

• In 2019, the National Center for State Courts, the Conference of Chief Justices and the Conference of State Court Administrators launched a national initiative to address the criminalization of mental illness. They adopted six recommendations: expanding the use of AOT was number two. 
• The American Psychiatric Association launched a nationwide project to address severe mental illness, in coordination with the federal mental health agency SAMHSA. That project, known as SMIAdviser, included a full series of training and implementation modules to support the use and implementation of AOT.
• Communities across the nation, in red and blue states, joined Pennsylvania in establishing or increasing their use of AOT.
  • In California, the State Auditor’s analysis, “California Has Not Ensured That Individuals with Serious Mental Illnesses Receive Adequate Ongoing Care” specifically called for greater county AOT use, referring to the program as “an effective community‑based approach to mental health treatment to help prevent future involuntary holds and conservatorships. In response, the state legislature passed AB1976 to greatly strengthen the state’s AOT law with Governor Newsome’s support.
  • In New Mexico, the state legislature passed a near-unanimous AOT bill to improve the state’s effective program and further increase its implementation after seeing the initial success of the program in the state.
  • Similarly, Kentucky passed an update to support implementation of its AOT law, a change that led to the state winning a federal AOT grant.

• We also have now results detailing the impact of AOT from the first-round of federal AOT program grants. The federal government awarded four-year implementation grant to AOT programs from across the country to study its effectiveness and benefit to the most seriously ill. The results have been overwhelmingly positive. 
  • 44% decreases in incarceration rates;
  • 48.5% decreases in nights spent homeless;
  • 78% decline in psychiatric visits to emergency departments; and 
  • 85% decreases in inpatient hospitalizations.

But perhaps most importantly, participants in the program reported liking the services they received: 91.8% of participants agreed or strongly agreed with the statement “I liked the services I received here.”

• As a consequence of those reductions in the most expensive services, federal AOT participants Reno, Nevada and Baldwin County, Alabama both publicly reported more than $1M in savings after implementing the program.
  
  

AOT SAVES SYSTEMS MONEY: Opponents of the use of AOT have made a number of arguments for why communities should not implement this proven program. Chief among them is cost, based on a mistaken assumption that AOT serves a new population with new services.

It is important to recognize that AOT does not serve a new population, rather it provides consistent care for a population that is otherwise poorly served under the current system. Both research and practice shows us that this ultimately costs the system far more than incorporating AOT.

Under the current system, this population is typically the most difficult to serve, least likely to engage voluntarily by definition, and the most likely to be in contact with law enforcement. As a consequence, their experience is typified by disjointed care, repeated hospitalizations, repeated engagement with law enforcement and much worse overall treatment outcomes.

However, by and large, services for this population are eligible for Medicaid reimbursement and so there are not significant additional resource outlays necessary to provide care that meets AOT order requirements. Simply put, AOT combines the treatment an individual is already eligible for with a court order to help prioritize their needs within the treatment system. This combination effectively shifts the broken incentive structure that otherwise allows this population to fall through the cracks.

And as we have seen in both the federal AOT demonstration program and in communities across the country, effective AOT implementation can reduce cost outlays for the most expensive services (inpatient hospitalization, crisis response and emergency department use), ultimately saving resources that can be reinvested into the system for populations not in the AOT program.

Thank you for your time and attention. I appreciate the opportunity to highlight the opportunities that effective implementation of AOT presents for Pennsylvania communities.

I am available to answer any questions you may have.

Statement from Sabah Muhammad:

I appreciate the opportunity to submit testimony today. My name is Sabah Muhammad. Not only do I serve as Legislative and Policy Counsel with the Treatment Advocacy Center (TAC), I am a family member of a loved one diagnosed with paranoid schizophrenia.

The Treatment Advocacy Center is a national 501(c)3 nonprofit organization dedicated to eliminating legal and other barriers to the timely and effective treatment of severe mental illness. Treatment Advocacy Center promotes laws, policies and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder.

I would like to commend the legislature for passing AOT legislation. AOT is a vital and necessary step in decriminalization, crisis intervention and long-term well-being. However, the benefits of AOT, which can be lifesaving, offer no relief for Pennsylvania families without proper implementation. Pennsylvania passed the law, now it’s time to let the law work.

In my home state of Georgia, we have AOT legislation which is often underutilized. My loved one averaged about 3-4 arrest or involuntary commitments a year for ten years and was not once offered AOT. In Georgia a lack of AOT utilization and an imminent standard for dangerousness, led my loved one to cycle in and out of the civil and criminal justice systems untreated. This failing system of catch and release with no concern for breaking the cycle or offering access to long-term well-being caused my family and community to suffer many tragedies, all of them preventable. Pennsylvania, which also has an extremely high standard for emergency and impatient commitment, can avoid this pitfall by making AOT implementation a priority so that families are not required to suffer. As the Pennsylvania dangerousness standard is too high to prevent a crisis, AOT is the only law with the potential to offer treatment before tragedy, tragedies like the untimely death of Walter Wallace Jr.

Thank you for the opportunity to discuss the possibilities that the implementation and utilization of assisted outpatient treatment (AOT) presents to help address the needs of families like mine and other Pennsylvanians, who, instead of thriving in their daily lives have learned to merely navigate from crisis to crisis.

Criminalization

For families like mine, Walter Wallace Jr.’s untimely and tragic death is a daily worry. Individuals with severe mental illness are 16 times more likely to be killed during a police encounter. For families like mine criminalization is the status quo as evidenced by the 44 states, including Pennsylvania, that have more individuals with severe mental illness in jails than in a psychiatric hospital. With limited access to healthcare, long-term well-being and lawmakers who advocate on our behalf, families like mine are subject to regular interaction with law enforcement over what is ultimately a medical condition. The implementation of AOT can eliminate these barriers to treatment. Considering the extremely high standard for danger in Pennsylvania AOT implementation is vital to criminal justice reform and decriminalization of Pennsylvanians diagnosed with severe mental illness.

AOT and Dangerousness

The Treatment Advocacy Center has outlined lifesaving policy recommendations that would mitigate police interaction and allow treatment before tragedy. The policies I offer today are the same policies that caused me to reach out to Treatment Advocacy Center more than 8 years ago when my own loved one was in crisis.

Without proper implementation of AOT to assist with outpatient care and crisis intervention, the standard for involuntary commitment in Pennsylvania is extremely high and leads to tragedy. The best practice is to avoid an extremely high dangerousness standard and include the common forms of harm that families and loved ones face on a daily basis. These harms include a person’s untreated mental illness when it prevents them from securing the basic necessities of human survival such as food, clothing and shelter. Pennsylvania’s new AOT law offers care in the community and intervention before crisis and police interaction, with no need for an individual to become extremely dangerous.

Under Pennsylvania dangerousness law a factfinder must identify death, serious bodily harm or serious physical debilitation before intervention. Walter Wallace Jr. might not have met a tragic end if Pennsylvania law did not make death, serious bodily harm or serious physical debilitation the listed criterion for involuntary treatment and if AOT were being implement and utilized Mr. Wallace would have not been subjected to the extremely high requirements of that dangerousness standard. Ideally, as the newly passed and unused AOT law allows, Mr. Wallace would have had a legally appointed community-based support system ready to intervene before anyone was in danger of serious bodily harm or serious physical debilitation.

Pennsylvania’s grave disability standard requires an unreasonably high risk of harm. AOT can help to prevent the types of tragedies associated with extremely high risk of harm. That means for families like the Wallace family, failure to meet basic human needs would have been enough for treatment, not waiting impending death or debilitation. It means Mr. Wallace would have received help long before the people around him, including the police, had to fear for their lives before they could intervene. That point is clearly too late. Of the 8.1 million Americans diagnosed with severe mental illness approximately 3.9 million are untreated. The implementation of Pennsylvania’s new AOT law will help to mitigate the cycle of criminalization caused by untreated severe mental illness.

Treatment Before Tragedy Response

Families all around the country know the signs of approaching psychosis long before a loved one is in imminent harm. The signs are not controversial or hidden. Many states use multiple criterion to define dangerousness that prevents suffering instead of requiring it. Pennsylvania requires suffering. When the standard for danger is too high, when a parent must fear their loved one, instead of fearing for their loved one, before the court will consider involuntary treatment, AOT can be an important tool to fill this untenable space.

When the danger standard is high families are forced to include police officers as a part of their loved one’s continuum of care. Make no mistake, as the law stands, when danger must be imminent, when death is listed as a measurement for medical intervention, families are forced to look to criminalization as a means of default healthcare. Six states require imminence of harm to self or others to qualify for emergency evaluation and Pennsylvania is one of them.

Horrifically, we are sending police officers to carry out a job they were never meant to do. Mr. Wallace’s mother’s request was clear, he is having a mental health crisis, please send an ambulance. In 2013, when Mr. Wallace appeared in front of a judge and was ordered to undergo treatment for bipolar disorder Pennsylvania had a chance to put his long-term wellbeing first. Then, in 2013 Pennsylvania did not have a working AOT law. Pennsylvania has one now.

Right now, we are funding the criminalization of individuals diagnosed with severe mental illness then saying there is nothing left in the budget for prevention. We owe them more. We owe them a chance for AOT to offer treatment before tragedy, especially when the only other Pennsylvania standard requires police intervention when it’s too late.

Assisted Outpatient Treatment

Decriminalizing persons with severe mental illness requires providing treatment and support services to individuals in the community to prevent their entering into the criminal justice system at all, a core tenant to the Treatment Advocacy Center’s work. It requires laws that intervene before harm is imminent, before families are torn apart and lives are lost. States that utilized AOT as a part of their decriminalization model have found:

• 44% decreases in incarceration rates; 
• 48.5% decreases in nights spent homeless; 
• 78% decline in psychiatric visits to emergency departments; and 
• 85% decreases in inpatient hospitalizations.

Thank you for your time and attention. I appreciate the opportunity to highlight what implementation of AOT can do for Pennsylvania families and communities in need of early intervention, long term well-being and treatment before tragedy. 

 Watch their testimony, here.

For more information on Assisted Outpatient Treatment, visit our website, here.