The month of June 2016 holds promise for being remembered as the time when “something” was done about mental health reform. The Senate is hard at work on crafting mental health legislation, and the House Energy and Commerce Committee has announced that Tim Murphy’s Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646) will rise again, apparently with a robust managers amendment to address some of the most problematic aspects of the bill.
One of the more ironic aspects of the protracted debate about what defines mental health reform is the discussion of Assisted Outpatient Treatment (AOT). Followers of congressional discussions of mental health reform will remember that since the early crafting of HR 3717, the precursor to the current HR 2646, AOT has been the tip of the spear for Tim Murphy’s campaign to get his bill passed.
Over the past few years, in stump speeches and editorials too numerous to count, the term AOT has become synonymous with mental health reform. Never mind the not insignificant fact that AOT is already on the books in 46 states or, even more telling, that I have yet to hear a politician articulate, with any sense of clarity or understanding, what is involved in the AOT process other than the civil commitment hearing component. Somehow, AOT has become the media darling for the “thing” that is going to prevent mass shootings and make us all safer from seriously mentally ill individuals determined to commit mass murder.
A few months ago I asked our research team to conduct an analysis of the news stories in support of HR 2646 listed on Representative Murphy’s website. Not surprisingly, the articles are filled with provocative and inflammatory language, graphic descriptions of violent incidents, and emotionally charged personal anecdotes. Headlines and articles contain references to "bloodiest rampages," "horror," "heinous crimes," "blood-curdling screams," "murderous assaults" and "apocalyptic assault." Authors have referred to seriously mentally ill individuals as "deranged," "frighteningly unstable," "shooters on the dishonor roll of evil," "a clear and severe risk to the public" and "a threat to society." Some headlines send the message that mental illness causes violence: "Floyd: Dallas police department attack highlights mental health needs," "New Mental Health Bill Could Prevent Mass Shootings," and "Efforts Underway To Prevent All Too Often Tragic Results Of Untreated Severe Mental Illness."
Despite the overwhelming statistics dispelling the idea that mentally ill individuals are inherently violent, the public buys into this notion in part because of the media's depiction of mental illness as a predicting factor of violent incidents such as mass shootings (Hoffner et al. 2015; Swanson et al. 2015).
Sadly, while many of the current 189 cosponsors of HR 2646 will admit that they understand that most seriously mentally ill are not violent, they continue to let the sensationalized misleading headlines in the media pairing violence and mental illness go unchallenged. The tacit approval of the guns, violence mental illness comparison is a disgrace, but then again, this is politics.
The AOT divide - advocate against advocate
It is important to understand that the narrative about AOT that drove much of the discussion in Congress the past two years during hearings on the Helping Families in Mental Health Crisis Act was narrowly defined, focusing primarily on the civil commitment procedure in a courtroom. Justifying the need for AOT, architects of the various versions of the Murphy bill undertook a systematic campaign to eviscerate the peer support recovery movement and SAMHSA. Nowhere was this campaign more evident than in some of the hearings held by the House Committee on Energy and Commerce, Subcommittee on Health. Advocates supportive of the most intensive treatment end of the AOT spectrum railed against advocates supportive of the peer-to-peer support community seeking alternatives to AOT. Another sad tragedy caused by misguided politicians trying to move forward with an ill-defined bill at all costs.
Time for advocates on both sides of the AOT debate to band together
For several years, the Children’s Mental Health Network has called for advocates on both sides of the AOT debate to come together to find ways to meet the needs of individuals with serious mental illness. With the recent announcement by SAMHSA of the Assisted Outpatient Treatment (AOT) Grant Program, advocates on both sides of the AOT debate have an important opportunity to work together to design an AOT process that incorporates the full breadth of community involvement.
The AOT 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 (Commonly known as the “Doc Fix” Bill). Rep. Tim Murphy (R-Pennsylvania) and Senator Debbie Stabenow (D-Michigan) are credited for getting the pilot program into the Doc Fix bill during the height of controversy around AOT being considered as part of HR 3717.
The description of the grant announcement includes language that states that:
...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.
Mental health advocates need to seize on the language in the grant announcement that provides an opportunity for states and communities to put together applications that reflect the full breadth of what is required to make the AOT process work. I know this may seem difficult for anti-AOT advocates, but now is the time to get involved in the design and delivery of these pilot projects. Leaving it up to politicians to define what AOT is will result in more of what we are currently seeing – a gross lack of understanding of the importance of the recovery community in treating and supporting individuals with serious mental illness.
I encourage you to read our review of a community implementing AOT so that you can have a better understanding of what is required to make the process work. Also, take a look at Dr. Dennis Embry’s article on the science behind the AOT process. The recovery community must work in close collaboration with the treatment community if the precious federal dollars devoted to this effort are to have any chance of success. A winning proposal will honor both the need for high-intensity services along with the need for peer-to-peer supports that are designed for and by individuals with a history of mental illness.