calm down

When my mother was dying from cancer in 2008, my dad told me that there were 22 others living on Trailwood Avenue who were positive for some type of cancer concurrently. “There’s a lawsuit,” I told my dad. We were driving and it was warm outside and the air smells like Central California does in the Fall. Fog, basically.  There is no mystery that most probably embedded land subdivisions were watered by wells driven by the local growers and irrigation seepage will occur. Their water is screwed, no less. Now more than ever with the heat that will not stop and wells are drying. People are stealing their neighbor’s water in California.

My mother died in ’08 and my only sibling died from cancer at 53 years old in ’12 (also in November).

And so at my age, I have superseded the mortality for both, my biofamily and that of the <25 year early morbidity for people living with an SPMI who have received continuous US Community Public Mental Health services for at least 25 -30 years.

Which is worse? Cancer or the US Public Community Mental Health System? I’m laughing because I’m really not joking.

This writing’s intent is to at least touch upon the notion of how disease, chronic illnesses and malhealth – when not self-managed or self-cared for – will manifest physically and you will die sooner than later, probably.

Things to practice then:

  • Mindfulness.
  • Intentionality.
  • Carefully discerning that which takes your concern(s).
  • Be Kind to yourself and to others.
  • Love.
  • Be loved.
  • Adore.
  • Be adored.
  • Get that energy of others that is hurtful away from you.
  • Work your body out.
  • Practice Releasing.
  • Live gentler.
  • Walk with all of your senses as often as you can.
  • Get REM Sleep.
  • It’s okay to let yourself dream.
  • Walk in water.
  • Talk with your best friend.
  • Live.
  • Breathe.
  • Learn.
  • Teach.
  • The day is short. The night is shorter. Mind your time.
  • Harm no others.
  • Protect yourself and what’s yours.
  • Run. Run. Run.
  • Strength.
  • Power.
  • Know that you are immortal.

 

 

 

 

 

 

 

 

 

 

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piano solo

“Give me the simple life…”

I must learn how to live again.

My surroundings meld to gray. Ignore the brilliance of the oranges, the reds, purple, tallowed yellows. They do not exist any longer. May my visual acuity turn bland.

Let my energy focus on turning off life force. I must not linger, too long, over music, my love, my Beloved. They cannot breathe where they used to prevent rain.

The rain outside seeping in and whimpering now where it used to be full-on blue rain no longer. No longer. The sumptuousness of the wet and her smell of the rain no longer exists.

Since the moment of bliss, the thrilling kiss, heaven has shut her door on me for romance on the menu. There is no longer the slide slide slide pushiness of sex to wound through afternoons. That part of me is dead.

Day in. Day out.

Gershwin’s horns and the strings meeting at crescendo mean nothing to me anymore.

It came out of my mouth quickly and without thinking yesterday and it was the opening of a door, “Mary is dead…” and my friend and I both were frozen, grimacing and nodding.

I will promise you nothing and promise myself everything for now on.

The next three months are an end of a season.

I will, I must make the lap to Christmas Eve. Marker

Hello to a death march of trudgery, of plannedness, for wellness to persevere, to a life where nothing at all else marks me, ever again. Never again. Never again. She has killed me already many deaths daily, night sweating into obliviousness, holding on for footing.

The pain and the harm experienced is grievous. Were I to hold unlimited capital, I would correct the crime breaking another’s Beloved heart, but I instead do not.

That I lack a tribe, a community, a family, a prompter, I task, now.

 

 

the tempest

where is my Queen Leah now

carrie-fisher-2

i am forsaken

it is possible that the stars and moon and shapes of the world are behind the pine trees and the old oak in vines and the dogwoods are sleeping in the dark too

somebody let off a stream of fireworks sizzling and popping that stopped at the ground fast with reverb

yosemite

the air in atlanta in august smells like smoke and truck exhaust

it whips at the back of your throat when you inhale it

i am forsaken

after the knowing and lovely loving, there is but a draught of familiarity

of cold

my skin and my mind does touch off rapid fire memories and it’s war again

a high wire of white and silver ring high like lightning and thunder

it roars

my body scan depicts a swollen mind and my cave is empty and cock hard

pablo 3

 

 

The Right to Die With Dignity

The Right to Die With Dignity

Jennifer Maria Padron, M.Ed, CPS, PhDc Public Health & Amanda Barnabe

We are US Peers and we are Peers in everything that Peerness implies from State (Georgia, Maryland, Texas) certification. Acting in a healer saint wrap around service advocate activist give back to the community type of social supportive role, Peer supports and professional adherence accounting for personal-responsibility rings true. As well, we hold fast (in sum) to all federal Certified Peer Specialist SAMSHA related principles and codes.

We work pro bono or on average for >$12/hr as a Certified Peer Specialist in both public and private behavioral health systems of care for US Mental Health (MH), Substance Use (SUD) and now are in support of any individual experiencing criminal justice intersected challenges and where behind locked doors robbed of hope, we have insured that the Forensic Peer Recovery Specialist Endorsement and Certification is your brand new best friend in the State of Maryland.

We are unapologetic queers, submersed in this revolution of peer developed and implemented advancements battling a dark history of psychiatric practices.

We are practiced as a Certified Peer Specialist in the frontier, in rural and urban environments of the US.

We are trained, practiced and tried first responders and we are respected in 24/7/364 mobile crisis intervention (MH/SUD) and/or emergency response in rural and metropolitan environments where the demographics are broadly suicide or homicide or sometimes both.

We are the other and we know it.

We’re the damned.

We are the nonconforming square pegs, metropolitan, gender queer, gender fluid, gender non-conforming non-Judeo Christian, women of color with a disabling previous diagnosis of serious persistent mental illness.

We live lives in recovery as tortured psychiatric survivors who have survived to now.

We are more than our diagnosis.

We are more than our sexual identity.

We don’t buy-in to mental health or mental illness or the disease model or the medical model.

We get it and expect more.

If you can, then do. If you can’t, step aside for us to get ‘er done.

In the Winter of 2012 I (Padron, 2012) was impressed with five completions.

The State of Texas Department of State Health Services and Mental Health America of Texas Suicide Prevention point of contacts dealing with suicide education and prevention contacted me to ask me if I knew the details on the 5 completions from suicide of peers. I was aghast. Yes, I knew them. I know them. Their thinking was that they had a cluster on their hands. I hung up. I deleted their emails. I did not return their calls. I did not accept their calls.

Death and dying from our own hands is not a new feature to this (dis)ease. There is one death by suicide in the US every 12.3 minutes and every 30 seconds globally.

We are of the opinion today that should a person desire to die, then that is their right. At the moment there is anything sembling a Plan, there is nothing you or I can say to another person truly to “save” that life. It is one’s right inasmuch and as stigmatizing that suicide and mental illness is punitive, deadly even, it is in our experience that quite simply what works is to simply sit and listen with the individual in distress, in turmoil and emotional, physical, spiritual pain.

Inasmuch as the impulse derides or appears to lack any commonsensical logical thinking at the moment or eclipse of completing – saying simply, I love you or I would miss you terribly helps both people at the crux of a suicidal intervention back to center. Mixed episodes for those diagnosed with Bipolar 1 disorders tend to be at greatest risk.

Now, we ask you why then when, why, how and where does our dying and planning one’s death, and/or even by talking about it between ourselves, with others (e.g., lover, friend, family, providers) is this act formally considered a new feature and the not so (un)symptomatic of the clinically depressed, the bipolar disorders, the schizophrenia spectrum disorders, or anxiety/panic and/or the personality disorders?

The 25 year, on average, mortality rates of individuals living with a serious persistent mental illness number in the hundreds of thousands today (NASMHPD, 2007). It is my community’s genocide.

Why shouldn’t we count pharmaceutical and population’s genocide to psychiatric diagnosis and assuming my logic is correct then, why is Suicidal Completion numbers so shocking to you?

Many friends and colleagues are lost to dying from physically based illnesses such as cancer, heart attacks, congestive heart failure, stroke, car accidents, drownings and the like and more from suicidal completion. What is the difference between my dying from 30 years of consuming psychotropic prescriptions killing me slowly, like rat poison, with its’ long term effects causing pre-diabetic ailments, exhaustion, mind numbing grips of lack of passionate living, obesity, high blood pressure, cognitive impairment, or taking my life as juxtaposed with dying from a socially acceptable debilitating disease?

For selfish reasons alone, as a Certified Peer Specialist (Georgia, Maryland, Texas) we are rather directed by SAMHSA and national Core Competencies to provide Hope via all fashionable ventures in the name of Recovery. My story will not save anyone. My Hope and Story certainly cannot and will not save another person from completing. We’ve tried. We’ve lost too many. That we’re still walking, breathing, bitching and pissed off says it all. We are invincible. With at least ten (10) combined failed attempts, we conclude that we are unkillable. We are immortal.

We are Spiritually led to the opinion that the right to die a good death in dignity is an inherent privilege and may very well be perhaps the only thing which we retain control over, truly. There is one death by suicide in the US every 12.3 minutes and every 30 seconds globally. Individuals are killing ourselves off, completing, because living a life with a diagnosed serious persistent mental illness equates to being held in shackles by the current US antiquated, creaking, leaking mental health system built from a history of asylum, of involuntary commitment, of psychoactive medication dosing, chemical restraints and the dichotomy of failed medical healthcare professionals and vulnerable mental health consumers.

We are privy to terrible drownings and more divergent choices of suicidal completion (e.g., hanging, guns, auto, motorcycle, biking, cliff/bridge jumping, belts, poison, od’s, auto erotic asphyxiation). The US Community Public Mental Health system is in the business of Death and we are Agents of it, then.

We see no difference between dying from a terminal Stage IV invasive physical disease or the fact that 45 combined years of consuming psychotropic prescriptions is killing our bodies like mercury poisoning, with presumptive and eventual long term effects causing diabetic related ailments, exhaustion, mind numbing grips of lack of passionate living, obesity, disjointed involuntary movements, high blood pressure, cognitive impairment.

The right to die a good death in dignity is an inherent privilege and may very well be perhaps the only thing which we retain control over, truly.

Rate of Queer suicide attempts (%) (Trevor Foundation and Williams Institute 2016)

  • According to surveys, 4.6 percent of the overall U.S. population has self-reported a suicide attempt, with that number climbing to between 10 and 20 percent for lesbian, gay or bisexual respondents. By comparison, 41 percent of trans or gender non-conforming people surveyed have attempted suicide.
  • The most recent, comprehensive data on suicide attempts was gathered by The Williams Institute, in collaboration with the American Foundation for Suicide Prevention. Its report, Suicide Attempts Among Transgender and Gender Non-Conforming Adults, analyzed responses from 6,456 self-identified transgender and gender non-conforming adults (18+) who took part in the U.S. National Transgender Discrimination Survey.
  • Beyond the overall number of suicide attempts, the rates are consistently high from respondents ages 18 to 65, when they begin to recede. Trans men are the most impacted, with 46 percent reporting an attempt in their lifetime. Trans women are close behind at 42 percent, and female-assigned cross-dressers report rates of 44 percent.
  • Rates of transgender and gender non-confirming suicide attempts by age (%) (Source 2016).
  • Rates of transgender and gender non-confirming suicide attempts by gender identity (%) (Source 2016).
  • Race and ethnicity also play a role. More than half of all American Indian, Alaska Natives and mixed-race/ethnicity respondents have attempted to take their own lives, and the figures aren’t much better for the black (45 percent) and Latino (44 percent) trans communities. Even those with the lowest rates—Asian or Pacific Islander and white respondents—are still almost nine times higher than the national average.

Queer adolescents are more likely to be involuntarily committed to a long term mental health facility where they are subjected to being forcibly medicated with powerful psychotropic drugs, and archaic treatments such as aversion therapy, sensory deprivation, rotational therapy, ECT, restraint isolation and other inhumane practices. Homosexuality was removed from the DSM in 1973 but we are still persecuted, tortured and psychically damaged in our community’s youth.

SAMHSA’s efforts and initiative to increase the numbers of “saved” lives from suicide is telling. People are killing themselves out of presumably apparent poverty, experienced trauma, loss, grief, hate crimes, living shelterlessly, living disenfranchised and marginalized, from battling in combat and seeing it full front and center or from being out and out and exhaustively beaten to a pulp by our mental health system.

In SAMHSA’s and the Alliance for Suicide Prevention (2012) paper and study, “National Strategy for Suicide Prevention: How You Can Play a Role in Preventing Suicide,” they comprehensively detail the following facts:

  • Suicide is the 10th leading cause of death in the United States, claiming more than twice as many lives each year as homicides. i
  • On average, more than 33,000 Americans died each year between 2001 and 2009 as a result of suicide—more than 1 person every 12.5 minutes. ii
  • More than 8 million adults reported having serious suicidal thoughts in the past year, 2.5 million people reported making a suicide plan in the past year, and 1.1 million reported a suicide attempt in the past year. iii
  • Nearly 16 percent of students in grades 9 to 12 report having seriously considered suicide, and
  • 8 percent report having attempted suicide once or more in the past 12 months. iv

Although suicide can affect anyone, the following populations are known to have an increased risk for “suicidal” behaviors:

  • Individuals with mental and/or substance use disorders;
  • Individuals bereaved by suicide;
  • Individuals in justice and child welfare settings;
  • Individuals who engage in non-suicidal self-injury;
  • Individuals who have attempted suicide;
  • Individuals with medical conditions;
  • Individuals who are lesbian, gay, bisexual, or transgender (LGBT);
  • American Indians/Alaska Natives;
  • Members of the Armed Forces and veterans;
  • Males in midlife; and
  • Older

Further, in SAMSHA’s Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018. (HHS Publication No. (PEP) 14-LEADCHANGE2. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.) they speak to creating, “… a framework and process for identifying, developing, and implementing strategies to yield specific outcomes and ultimately influence system change” (p. 6). SAMHSA’s Strategic Initiative (SI #3, pp. 19-22) describes Disparities fall-out:

“Trauma, violence, and involvement with the criminal justice system disproportionately affect individuals, families, and communities of color, including indigenous and native populations. Racial, ethnic, sexual, and gender minority individuals experience trauma not just as individuals, but often also in the context of historical, intergenerational, or community trauma, which further compounds the effects of specific traumatic events. Mass trauma, such as natural disasters, often leave these communities underserved, unserved, or cut off from recovery resources. These communities are overrepresented in the justice system, are provided less opportunities for diversion from the system, and often move deeper into a system that itself is traumatizing and not geared toward recovery for people with mental or substance use disorders. For some people in these communities, the justice system becomes the de facto behavioral health system.”

For hundreds upon thousands of individuals living within the spiritual and emotional day to day anguish compounds and builds traumatizing distress. For individuals living with dual diagnosis and/or co-occurring physical health issues, how does recovery and hope really save us from the very “medicinal” prescriptive medications which are killing us slowly, bit by bit, day after day? They will not and they won’t help. We have accepted that we are dying a fast death biochemically due to extraneous debilitating side effects from 45 years of combined clinically invasive medication with concurrent treatment adherence at the hands of psychiatric staff nationwide. Our vital body organs are damaged, disease inflicted. We show premature damaged sugared blood coursing our veins blurring vision. Increasing terrible physical pain, aching and tenderness with effected cognition and comprehensibility is affected. We are already dying and we welcome relief.

Our argument rests in the very simple understanding that there is no difference between physical or psychiatric illness. That the body inherently breaks down and dies is tantamount to one’s humanity towards longevity of eternal life of one’s mind, heart and spirit. The daily poisoning of one’s body daily with antipsychotics, antidepressants, mood stabilizers from big pharma (e.g., Eli Lilly, Astrazeneca, Bristol Myers Squibb) weighs heavily on increasing opportunity for physical structural breaking down due to consistent poisonous or negligible medication dosing.

Symptoms to many of these very prescriptive psychiatric solutions is increased suicidal ideation which may or may not lead to death of the body. Given the presumptive mutual agreement between provider and acknowledging non-revocability to remaining truly self-informed, then contractually, we retain a right to die a physical death. We choose not to accept that which is de facto from a failed behavioral health and public community mental health system within the United States, or being jailed physically, and to be scapegoated publically and personally.

To die in dignity means that you must acknowledge and accept a daily walk with Death.  “Die Wise: A Manifesto for Soul and Spirit” Author Stephen Jenkinson, a Death Doula, a man busy in the death industry speaks to one’s right to die wisely. No judgment. There is just honoring the individual’s right to choose how to, when to and where.

  • Centers for Disease Control and Prevention. Fatal Injury Data, 2009. Web-based Injury Statistics Query and Reporting System. Available at http://www.cdc.gov/injury/wisqars/fatal.html. Accessed January 12,
  • Centers for Disease Control and Prevention. Fatal Injury Data, 2009. Web-based Injury Statistics Query and Reporting System. Available at http://www.cdc.gov/injury/wisqars/fatal.html. Accessed January 12,
  • Substance Abuse and Mental Health Services Administration. Utilization of mental health services by adults with suicidal thoughts and behavior. (National Survey on Drug Use and The NSDUH Report.) Rockville, MD: Author; 2011.
  • Centers for Disease Control and Youth risk behavior surveillance—United States, 2011. MMWR. 2012;61(4) 1-162

 

 

Assisted Outpatient Treatment = Involuntary Commitment

AOT photo insert photo credit phoenix austin knight (c) 2016

Assisted Outpatient Treatment

Reschackling Road Tripping Back to the Asylum:

Restraints On Us All

Jennifer Maria Padron[1] and Amanda Barnabe[2]

Judi Chamberlin, Confessions of a Non-Compliant Patient

“I tried hard to be a good patient. I saw what happened to bad patients: they were the ones in the seclusion rooms, the ones who got sent to the worst wards, the ones who had been in the hospital for years, or who had come back again and again. I was determined not to be like them. So I gritted my teeth and told the staff what they wanted to hear. I told them I appreciated their help. I told them I was glad to be in the safe environment of the hospital. I said that I knew I was sick, and that I wanted to get better. In short, I lied. I didn’t cry and scream and tell them that I hated them and their hospital and their drugs and their diagnoses, even though that was what I was really feeling. I’d learned where that kind of thing got me – that’s how I ended up in the state hospital in the first place. I’d been a bad patient, and this was where it had gotten me. My diagnosis was chronic schizophrenia, my prognosis was that I’d spend my life going in and out of hospitals.

I’d been so outraged during my first few hospitalizations, in the psychiatric ward of a large general hospital, and in a couple of supposedly prestigious private psychiatric hospitals. I hated the regimentation, the requirement that I take drugs that slowed my body and my mind, the lack of fresh air and exercise, the way we were followed everywhere. So I complained, I protested, I even tried running away. And where had it gotten me? Behind the thick walls and barred windows and locked doors of a “hospital” that was far more of a prison that the ones I’d been trying to escape from. The implicit message was clear: this was what happened to bad patients.

I learned to hide my feelings, especially negative ones. The very first day in the state hospital, I received a valuable piece of advice. Feeling frightened, abandoned, and alone, I started to cry in the day room. Another patient came and sat beside me, leaned over and whispered, “Don’t do that. They’ll think you’re depressed.” So I learned to cry only at night, in my bed, under the covers without making a sound.

My only aim during my two-month stay in the state hospital (probably the longest two months of my life) was to get out. If that meant being a good patient, if that meant playing the game, telling them what they wanted to hear, then so be it. At the same time, I was consumed with the clear conviction that there was something fundamentally wrong here. Who were these people that had taken such total control of our lives? Why were they the experts on what we should do, how we should live? Why was the ugliness, and even the brutality, of what was happening to us overlooked and ignored? Why had the world turned its back on us?

So I became a good patient outwardly, while inside I nurtured a secret rebellion that was no less real for being hidden. I used to imagine a future in which an army of former patients marched on the hospital, emptied it of patients and staff, and then burned all the buildings to the ground. In my fantasy, we joined hands and danced around this bonfire of oppression. You see, in my heart I was already a very, very bad patient![3]

mums768-i003-001 judi chamberlin

You may ask yourself as you read through the available literature, what is so wrong with being integrated into the community as opposed to being in a dedicated facility of some type.  The intentions of the Murphy Bill are vacuous or at the very least, grossly grandiose. It starts in the vein of community integration but implementation will take us back to forced and involuntary shackles and asylums[4].

There are currently, as of this writing, 45 US States which practice Assisted Outpatient Treatment (AOT). The US Supreme Court identifies involuntary civil commitment to a psychiatric facility as a, “… massive curtailment of liberty”[5] meanwhile emphasizing “involuntary commitment to a mental hospital, like involuntary confinement of an individual for any reason is a deprivation of liberty which the State cannot accomplish without due process of law.”[6] The US Supreme Court can not find for, “… constitutional basis for confining such persons involuntarily if they are dangerous to no one and can live safely in freedom.”[7] The Court holds that “the mere presence of mental illness does not disqualify a person from preferring his home to the comforts of an institution.”[8]  Assisted outpatient treatment refers to a program of services where public community based mental health treatment is delivered under a civil court order to an individual who meets criteria established by the state where the order is issued.

Criteria for assisted outpatient treatment differ by state but almost universally is for individuals who have a demonstrated difficulty adhering to prescribed mental illness treatment on a voluntary basis and, as a result, have experienced recurring negative outcomes (e.g., multiple hospitalizations, violent acts, or suicide attempts). Called by a variety of names depending on regional location references [AOT, involuntary outpatient commitment, mandatory outpatient treatment, and others] the process is most often used in conjunction with discharge from involuntary hospitalization but in some jurisdictions may also be ordered pre-emptively, prior to crisis intervention. Individuals ordered to receive AOT are, by definition, already known to public mental health systems. Because of their unique treatment patterns, individuals typically have a history of utilizing high-cost resources, often in multiple systems.

Health Management Associates, One Michigan Avenue, Building 120 N. Washington Square, #705 Lansing, MI 48933 Telephone: (517) 482-9236 www.healthmanagement.com

Mental Health America believes that involuntary treatment should only occur as a “last resort” and ought to be limited to individuals experiencing and stated imminent self or other harm[9] and to “circumstances when no less restrictive alternative will respond adequately to the risk.”[10] MHA opposes Assistive Outpatient Treatment (read Involuntary Commitment) intrinsically[11].

The Bazelon Center opposes involuntary inpatient civil commitment except for in response to an emergency, where it must be based on the usual standard for crisis presenting imminent danger to self or others, and when “… there is no less restrictive alternative.”[12]

A MASSIVE CURTAILMENT OF LIBERTY in the land of the free

The National Association of Rights Protection and Advocacy espouse that inpatient and outpatient civil commitment is a grievous injustice[13] to the American people carried out by biased and broken legal systems in less informed regions where the mental health stigma and fear of “the other” prevails and an aggressive, progressive change in policy is desperately needed to meet the means of a misunderstood and misrepresented population of disabled citizens.  When the justice system intervenes and a person’s civil liberties, such as whether or not to be medicated with psychoactive pharmaceuticals, citizens are subjected to the limitations of the confining, often irrelevant, subject matter in past court cases.  Mental health reform will be forced to slow to the pace of the ever changing shape of the law, not patient care and medical needs.

Dr. Lauren Tenney in her foundational article on racialized aspects of the Asylum and Psychiatric Systems, dating back to the 19th century, in Psychiatric Slave No More:
Parallels to a Black Liberation Psychology (2008) broadly but precisely reported Elizabeth Parsons Ware Packard of the 19thcentury draws distinctions between Slave owner and the Asylum system:

“The insane are permitted to be treated and regarded as having no rights that any one is bound to respect  —  not even so much as the slaves are, for they have the rights of their master’s selfish interests to shield their own rights. But the rights of the insane are not even shielded by the principle of selfishness. What does the keeper of this class care for the rights of the menials beneath him? Nothing. His salary is secured by law whether there be few or many under the roof which shelters him. Unlike the slaveholder, he can torment and abuse unto death, and his interests are not impaired by this wreck of human faculties.” (p. 62) In fact, in Women of the Asylum (Geller Harris, 1994) several authors note comparisons to slavery. Davis (1855) writes, “Such patients were used as servants in the bad halls . . . the patients do all that part of labor which the attendants feel above doing” (p. 54). Elizabeth Stone writes, the asylum is “a system of slavery, and any crime can be done there and covered up under the garb of derangement and no one interferes” (p. 39).

Not withstanding, the Substance Abuse and Mental Health Administration (SAMHSA) is fast-tracking AOT to evidence based status. On April 18, 2016 SAMHSA issued a call for the RFA intended to solicit applicants who will develop and implement AOT programs[14].

This 4-year pilot program is intended to implement and evaluate new AOT programs and identify evidence-based practices in order to reduce the incidence and duration of psychiatric hospitalization, homelessness, incarcerations, and interactions with the criminal justice system while improving the health and social outcomes of individuals with a serious mental illness (SMI). This program is designed to work with families and courts, to allow these individuals to obtain treatment while continuing to live in the community and their homes.

Award Information

Funding Mechanism: Grant

Anticipated Total Available Funding: $13,250,000

Anticipated Number of Awards: Up to 15 awards

Anticipated Award Amount: Up to $1 million per year

Length of Project: Up to four years

This pilot program was established by the Protecting Access to Medicare Act of 2014 (PAMA), Section 224, that was enacted into law on April 1, 2014. Within the Act, AOT is defined as “medically prescribed mental health treatment that a patient receives while living in a community under the terms of a law authorizing a state or local court to order such treatment.”

The Assisted Outpatient Treatment (AOT) initiative – otherwise known as Involuntary Outpatient Commitment – is a program carried out by OMH to meet the requirements of Kendra’s Law which requires people to comply with pharmacological management while in the community at the threat of institutionalization for non-compliance (Tenney 2008). In a 2005 report from The New York Lawyers for the Public Interest. entitled, “Implementation of ‘Kendra’s Law’ is Severely Biased” racial discrimination in the psychiatric system is addressed, noting that Blacks made up 16% of the general population, but 24% of those with a label of “Serious and Persistently Mentally Ill” (Tenney 2008).

Grants will only be awarded to applicants that have not previously implemented an AOT program. “Not previously implemented” means that even though the state may have an AOT law, the eligible applicant has not fully implemented AOT approaches through the courts within the jurisdiction that they are operating in.

In addition, grants will only be awarded to applicants operating in jurisdictions that have in place an existing, sufficient array of services for individuals with SMI such as Assertive Community Treatment (ACT), mobile crisis teams, supportive housing, supported employment, peer supports, case management, outpatient psychotherapy services, medication management, and trauma informed care. A portion of the grant funding may be used to enhance the array of services.

AOT (also known as involuntary outpatient commitment, conditional release, and other terms) involves petitioning local courts to order individuals to enter and remain in treatment within the community for a specified period of time. AOT is intended to facilitate the delivery of community-based outpatient mental health treatment services to individuals with SMI that are under court order as authorized by state mental health statute.

The AOT grant program aligns with SAMHSA’s Strategic Initiatives on Trauma and Justice and Recovery Support. For more information on SAMHSA’s six strategic initiatives, you can visit http://www.samhsa.gov/about-us/strategic-initiatives.

The AOT grant program is one of SAMHSA’s services grant programs. SAMHSA intends that its services grants result in the delivery of services as soon as possible after award. Service delivery should begin by the 4th month of the project at the latest.

AOT grants are authorized under Section 224 of PAMA. SAMHSA has consulted with the National Institute of Mental Health, the Department of Justice, the HHS Assistant Secretary of Planning and Evaluation and the Administration for Community Living on the FOA. This announcement addresses Healthy People 2020 Mental Health and Mental Disorders Topic Area HP 2020-MHMD and Substance Abuse Topic Area HP 2020-SA.

The National Alliance on Mental Illness (NAMI), a public national supporter of the Murphy Bill, endorses a weaker standard of care to AOT (read involuntary commitment)[15]. Excerpts from the Public Policy Platformn of The National Alliance on Mental Illness can be found via the NAMI Public Policy Committee of the Board of Directors and the NAMI Dept. of Public Policy and Research, found on the web at http://nami.org.

Analysis of 10 independent studies of AOT[16]

Study | Analysis  
May 2011 Arrest Outcomes Associated With Outpatient Commitment in New York State Bruce G. Link, et al. Ph.D. Psychiatric Services For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment.”
October 2010: Assessing Outcomes for Consumers in New York’s Assisted Outpatient Treatment Program Marvin S. Swartz, M.D., Psychiatric Services Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.
February 2010 Columbia University. Phelan, Sinkewicz, Castille and Link. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Psychiatric Services, Vol 61. No 2 Kendra’s Law has lowered risk of violent behaviors, reduced thoughts about suicide and enhanced capacity to function despite problems with mental illness. Patients given mandatory outpatient treatment – who were more violent to begin with – were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.
March 2005 N.Y. State Office of Mental Danger and Violence Reduced
Health “Kendraʼs Law: Final Report on •    55% fewer recipients engaged in suicide attempts or physical harm to self
the Status of Assisted Outpatient •    47% fewer physically harmed others
Treatment. “ •    46% fewer damaged or destroyed property
•    43% fewer threatened physical harm to others.
•    Overall, the average decrease in harmful behaviors was 44%.
Consumer Outcomes Improved
•    74% fewer participants experienced homelessness
•    77% fewer experienced psychiatric hospitalization
•    56% reduction in length of hospitalization.
•    83% fewer experienced arrest
•    87% fewer experienced incarceration.
•    49% fewer abused alcohol
•    48% fewer abused drugs
Consumer participation and medication compliance improved
•    Number of individuals exhibiting good adherence to meds increased 51%.
•    The number of individuals exhibiting good service engagement increased 103%.
Consumer Perceptions Were Positive
•    75% reported that AOT helped them gain control over their lives
•    81% said AOT helped them get and stay well
•    90% said AOT made them more likely to keep appointments and take meds.
•    87% of participants said they were confident in their case manager’s ability.
•    88% said they and case manager agreed on what is important to work on.
Effect on mental illness system
·             Improved Access to Services. AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.

·             Improved Treatment Plan Development, Discharge Planning, and Coordination of Service Planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.

·             Improved Collaboration between Mental Health and Court Systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.

o There is now an organized process to prioritize and monitor individuals with the greatest need;

 

o    AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve;

o   Increased collaboration between inpatient and community-based providers.

February 2010 Columbia University. Phelan, Sinkewicz, Castille and Link. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Psychiatric Services, Vol 61. No 2 •    Kendra’s Law has lowered risk of violent behaviors, reduced thoughts about suicide and enhanced capacity to function despite problems with mental illness.

•    Patients given mandatory outpatient treatment – who were more violent to begin with – were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment.

•    Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.

October 2010: Changes in Guideline- Recommended Medication Possession After Implementing Kendra’s Law in New York, Alisa B. Busch, M.D Psychiatric Services In all three regions, for all three groups, the predicted probability of an M(edication) P(ossesion) R(atio) ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and “neither treatment,” improving 8–19 points). Some regional differences in MPR trajectories were observed.
October 2010 Robbing Peter to Pay Paul: Did New York State’s Outpatient Commitment Program Crowd Out Voluntary Service Recipients? Jeffrey Swanson, et al. Psychiatric Services In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.
June 2009 D Swartz, MS, Swanson, JW, Steadman, HJ, Robbins, PC and Monahan J. New York State Assisted Outpatient Treatment Program Evaluation. Duke University School of Medicine, Durham, NC, June, 2009 We find that New York Stateʼs AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients.

•    Racial neutrality: We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.Court orders add value: The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.

•    Improves likelihood that providers will serve seriously mentally ill: It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.

•    Improves service engagement: After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.

•    Consumers Approve: Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.

1999 NYC Dept. of Mental Health, Mental Retardation and Alcoholism Services. H. Telson, R. Glickstein, M. Trujillo, Report of the Bellevue Hospital Center Outpatient Commitment Pilot •    Outpatient commitment orders often assist patients in complying with outpatient treatment.

•    Outpatient commitment orders are clinically helpful in addressing a number of manifestations of serious and persistent mental illness.

•    Approximately 20% of patients do, upon initial screening, express hesitation and opposition regarding the prospect of a court order. After discharge with a court order, the majority of patients express no reservations or complaints about orders.

•    Providers of both transitional and permanent housing generally report that outpatient commitment help clients abide by the rules of the residence. More importantly, they often indicate that the court order helps clients to take medication and accept psychiatric services.

•    Housing providers state that they value the leverage provided by the order and the access to the hospital it offers.

1998 Policy Research Associates, Study of the NYC involuntary outpatient commitment pilot program. •    Individuals who received court ordered treatment in addition to enhanced community services spent 57 percent less time in psychiatric hospitals.

Citations

[1] Jennifer M. Padron, M.Ed, CPS, PhDc, Baltimore, Maryland.

[2] Amanda Barnabe, Baltimore, Maryland.

[3] Chamberlin (2016), Confessions of a non-compliant patient, Retrieved May 1, 2016 NARPA, http://www.narpa.org/Judi/confessions.htm.

[4] The New York Times Editorial on Reinstitutionalization and Return to the Asylum, Retrieved May 1, 2016 from http://www.nytimes.com/2015/02/18/opinion/the-modern-asylum.html.

[5] Humphrey v. Cady, 405 U.S. 504, 509 (1972).

[6] Specht v. Patterson, 386 U.S. 605, 608 (1967).

[7] O’Connor v. Donaldson, 422 U.S. 563, 574 (1975).

[8] Id.

[9] Position Statement 22: Involuntary Mental Health Treatment, Retrieved May 1, 2016 from http://www.mentalhealthamerica.net/positions/involuntary-treatment.

[10] This is the same standard accepted by the Bazelon Center: “The Bazelon Center opposes involuntary inpatient civil commitment except in response to an emergency, and then only when based on a stanrdard of imminent danger of significant physical harm to self or others and when there is no less restrictive alternative.” http://bazelon.org.

[11] Position Statement 22: Involuntary Mental Health Treatment, Retrieved May 1, 2016 from http://www.mentalhealthamerica.net/positions/involuntary-treatment.

[12] Bazelon Center Position Statement on AOT, Retrieved May 1, 2016.

[13] National Association of Rights Protection and Advocacy (2016). Retrieved May 1, 2016, from http://www.narpa.org/ioc.in.nys.htm.

[14] SAMHSA AOT GRANT REQUEST FOR APPLICATION CALL, April 18, 2016.

[15] NAMI 9.2.7, 9.2.7.1, 9.2.7.2, 9.2.7.3, 9.2.8, 9.2.9, Retrieved May 1, 2016 from http://nami.org.

[16] http://mentalillnesspolicy.org/national-studies/aotworks.pdf