Thank you and I’m really going to miss you, Carrie Fisher

This is my homage to the great outspoken, graceful, articulate, powerful and so exciting Carrie Fisher, who I heard had died today from complications post massive cardiac arrest 2 days ago. God bless you, Carrie Fisher. I have to tell you this:

princess-leia

I have always respected you. I have to admit I half way fell in 16 year old girl love for you when I saw you in STAR WARS playing the indomitable brilliant and pain in the ass to the boys, Princess Leia. I loved you in it an couldn’t quite make up my mind the temporal beauty of your looks. Classic and well, pained. Why is that? And that quick wit and smile had me in the palms of your hands… yes. A brilliant woman only. Only. Solamente Uno. One. You had it and thank God it was you.

carrie-fisher-2

Your work on behalf of Mental Health and Wellness is quite brave also, if I tell you that myself, darling. Bravo.

Here is today’s hot off the press releases that I will endorse for you to enjoy as much as I do: Carrie Fisher.

 

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Innovations in Peer Supports

I first met Larry Fricks, Founder, Appalachia Consulting Group, the first day that I showed up for the DBSA Texas Certified Peer Specialist training in 2007 in Austin, Texas. My father paid for that certification training because I couldn’t afford the $900/training that year. I was promised a job and I needed a job. I ultimately wasn’t hired in MH in Texas anywhere but my higher purpose was in giving back and it led me to where I am today.

The backstory to my procuring and earning my Texas CPS is a basic one. Texas at th time (2007) did not have CPS certification training or program but there were quite a few stunning people who had befriended me and I them. The list is long.

Being resourceful came easy. I had somehow gotten Fricks’ mobile number and telephoned him when I was at Dallas HIV/AIDS training while working with AIDS Services of Austin after 2007. I must have sounded desperate. I asked him how Texas could “get” a CPS training. My reasoning was honest. I wanted to see it in place and my CPS ’07 training had changed my life. He explained how CMS and a Texas Medicaid Director with supports from the MH Recovery Community could strategize and leverage a State of Texas CPS.

In ’08 NAMI Texas and Mental Health America Texas, along with DBSA Texas and the Texas Consumer group collaborated to apply for a SAMHSA Transformation grant. I, of course, excitedly, helped. Texas was awarded a grant in ’09 and the rest is well, history. I was thrilled. I saw the rise of many of my Texan Peers and formation and branding, brilliantly, of via HOPE Texas Mental Health Resource directed by Dennis Bach.

I saw Larry again when via HOPE brought him to Texas to dialogue on Peer supports and CPS Core Competencies with colleagues and co-horts in Central Texas. Appalachia Consulting eventually won the RFA to spearhead the initial CPS certification training.

I liked Larry all at once and respected the work that he and others at the Georgia Mental Health Consumer Network along with the State of Georgia DBHDD Medicaid language guru had developed and changed for those like myself. Larry coined the CPS Medicaid language perhaps near 23-24 years ago now.

Today the CPS exists in nearly 44 states in the United States and luckily in all states where I have worked as a person with shared life experience. What continues to stand in our development is clinical direction resistance to offering Medicaid waivers that could financially sustain a CPS in most states.

In Maryland where I currently reside and work, Adult CMS with support via Medicaid waiver(s) is resisted and I simply wonder at this. Brandee Izquierdo, Director of the State of Maryland Office of Consumer Affairs shines and advocates for thousands in the state. Linda Oney, Director of Training at the University of Maryland, supports and provides oversight for the Maryland Certified Peer Recovery Specialist (CPRS) certification. There are others who work selflessly like On Our Own of Maryland with shining stars Denise Camp, Daphne Klein and for instance, multiple On Our Of Maryland sites (Prince Georges, Montgomery County, Frederick) who subsist in keeping doors open for others like Jen Padron when I was first starting out.

Years later, I eventually made my way from Texas to North Carolina, Georgia, Maryland and Washington, DC to offer my work in MH/SUD as an advocate, activist, program designer and project manager. It’s been quite a ride but I won’t lie and say it isn’t difficult. It is.

Working as a CPS is financially unsustainable for the individual working as a CPS. The pay is miserably low. Unless a person has a sugar daddy or a sugar mama, is married within a 2 income household combined with personal wealth on top of perhaps receiving SSDI means that not many more can afford to do this good work. It worries me. I see poverty. I see hunger not only of the body but for Spirit and of Community.

When a Peer’s  walk and journey finds the CPS it is a marker. It’s a benchmark. It is Spirit led.

Many advanced trainings like WRAP (Copeland 2016), or WHAM (Appalachia Consulting Group and National Council 2016), or Emotional CPR (Fisher 2016) or Intentional Peer Support (Hansen & Mead 2016), and now Mental Health First Aid (National Council 2016) is hungrily devoured by the base CPS community nationally and globally (iNAOPS 2016).

I see the Recovery Coach and Intentional Forensic Peer Support CPS endorsments and certifications seeding and growing nationally. It’s exciting stuff and stuff of legend in my constituency that I walk and work with.

I’m told to be patient. I’m encouraged to be supportive of the growth and in sum, while I am, I urge faster growth. The CPS is brilliantly a tool of Recovery and it is the Peer who literally controls it. The threat of co-optation may undermine mutuality with clinical control over the CPS embedding into Integration. Several years ago, Padron & Associates worked with Cenpatico to develop a peer workforce demonstration pilot project which ultimately was blocked by clinical oppression. It was a stunning end to arduous labor on my part and attempts to see innovation come to fruition. Today, Klein, Padron & Associates continues the struggle.

I see this time and time again in my work. Without full clinical supports, executive and individual US State Director leadership for the CPS to receive CMS Medicaid waiver(s) the CPS is dead in the water, basically. I see it now in Maryland. There must be positive partnership and collaboration. Peers can talk and yell and scream until we’re blue in the face to procure “approval” for state CMS Medicaid waivers and without it, the CPS is not sustainable.

I kindly urge Maryland leadership but not only Maryland’s Director to support an Adult CMS Medicaid waiver for the CPRS because quite simply, it’s the right thing to do. It does not open Pandora’s Box. It supports. It sustains. It offers substantial financial sustainability to an idea that works. I volunteer to show you how.

It remains that people like myself are still dying on average <25 years earlier than those individuals who are not receiving US Public Community Mental Health services and supports (NASHMPD 2006, SAMHSA/CMHS 2016).  Still, the average age of morbidity and mortality rests uncomfortably at 52 years of age.  The work of many others nationally on psychiatric torture, survivorship to trauma induced by psychiatry (e.g., Stop Shock), Recovery as touchy feely as it is, is respected by me and I stand in support as I’ve walked it and continue to.

This Friday, June 24, 2016 the National Council for Behavioral Health and SAMHSA/HRSA led by Larry Fricks is hosting a national webinar at 1-2 PM EST. I have invited colleagues Brandee Izquierdo and Dr. Jessica Wolf to co-present on Peer/CPS disruptive innovations and emergent initiatives regionally, nationally.

I hope you will register for it and sit with us to dialogue. Wolf’s work recently surveying the United States along with others will present on CPS educational attainment strategy and professional growth. Her Toolkit 1.0 encapsulates how the Certified Peer Specialist certification supports such personal occupational growth, establishing strategies instilling not just Hope but basic common sense knowledge. Izquierdo’s recent work developing the State of Maryland CPRS iFPRS (Intentional Forensic Peer Recovery Support) presents on ideas, philosophy and basic tenets to Peer to Peer (CPS) supports and services.

My presentation is meant to show benefits and a roadmap on the how’s, why’s and where the CPS benefits millions of Peers. I came from this. I am a part of it. This is my family and this is my tribe.

Larry Fricks’ work with SAMHSA/HRSA and NatCon presents Innovation Community is designed to engage organizations in acquiring knowledge and skills and applying their learning to implement measureable improvements in a high priority area related to healthcare integration. Lessons learned over the course of the innovation community are compiled and shared with the health care field so other organizations can benefit.

The innovation community is designed to address three key components associated with innovation implementation, including:

Topic-specific foundational information, knowledge, and best practices

Innovation implementation planning

Adoption and sustainability of the innovation

Check out registration information and I hope to dialogue with you this Friday.

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

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