Friday, August 22, 2014

About Assisted Outpatient Treatment (AOT)

Assisted Outpatient Treatment (AOT) is for a very small group of the most seriously mentally ill who already accumulated multiple incidents of hospitalization arrest or incarceration associated with their failing to stay in voluntary treatment. AOT allows judges, after full due process to require certain mentally ill to accept six months of mandated and monitored treatment as a condition for living in the community. It provides an off ramp before incarceration. As Linda Dunn said, Assisted Outpatient Treatment is like putting a fence by the edge of the cliff rather than an ambulance at the bottom. (Barnidge 2014)

The research on AOT is extensive and positive. (Mental Illness Policy Org 2013). Six months of mandated and monitored treatment has been shown to reduce homelessness 74%; hospitalization 77%; arrest 83%; incarceration 87%, physical harm to others 47%; property destruction 46%; suicide attempts 55%; and substance abuse (48%). By replacing expensive incarceration and hospitalization with less expensive community care Assisted Outpatient Treatment cuts costs to taxpayers in half. (Swanson, et al. 2013). AOT also reduces victimization. (V.A. Hiday 2002). These results are particularly outstanding because AOT is limited to the most seriously ill, often a very hard to treat population.

The mental health industry stands in the way of implementation. They claim AOT increases institutionalization when it decreases it, increases the use of ‘force’ when it prohibits it, drives people from care when those in it support it, increases stigma when it reduces it, is expensive when it saves money, and affects many when it affects few. (Jaffe 2010) They claim voluntary programs work better, but AOT is only used after voluntary programs fail.

In addition to allowing judges to order individuals into treatment, it also allows judges to order the mental health system to provide it. This likely accounts for the industry objections. It limits their ability to cherry pick the highest functioning for admission. AOT is broadly supported by the public, police, families of the seriously ill and those who experienced it. In New York it is called Kendra's Law. In California, it is called Laura's Law.
* * *
The Helping Families in Mental Health Crisis Act (HR 3717) proposed by Rep. Tim Murphy and 95 cosponsors in both parties would provide states funds for pilot AOT programs. Ask your Representative to co-sponsor HR 3717.

Thursday, August 14, 2014

New Report: California Mental Health Services Act Fails Seriously Mentally Ill

California Mental Health Services Act Oversight Commissioners (MHSOAC) just issued a press release saying Prevention and Early Intervention (PEI) programs (20% of total MHSA Funds) are working.

However, they didn't even study adults with serious mental illness. They only studied "youth, young adults and the elderly " In fact, the youth being studied were not those with mental illness, but those "Displaying Emotional Disturbance as a Result of Trauma". The elderly population studied had 'depression'. Depression is not a serious mental illness, Severe Major Depression is, although it is clear that depression can become severe major and using MHSA funds to prevent that would be allowable. I am unable to analyze the data to see if thats what they did. Here are links to the 3 studies

More bothersome to me is that in May MHSOAC  got the results of a study of Community Support Services (CSS) Programs (Roughly 80% of MHSA funds). That study shows the CSS program is NOT working. MHSA did not put out a press release on that. I just discovered the report. The report measured School Attendance, Employment, Homelessness/Housing, and Arrests. It found:

Attendance (only measured for youth)
 "Results indicate that among child FSP consumers, in each FY a majority did not report changes in attendance ratings from intake (PAF) to most recent valid quarterly assessment (3M)..... Among TAY FSP consumers, the largest proportion of participants reported no change in attendance ratings from intake (PAF) to most recent assessment (3M) in each FY. "

"Across age groups and years, a majority of FSP consumers did not change employment status. "

"Across age groups, most FSP consumers did not report changes in housing status. "

Across the three most recent years, there appears to have been a general downward trend in the percentage of arrests in every age category. ....(H)owever, it is not clear if this trend is attributable to the effect of services provided or is instead a consequence of proportionally more consumers added in these later years not having prior arrests, making them less likely to be arrested.  
(i.e, they are taking less symptomatic people who are less likely likely to have an arrest record. -dj)

Wednesday, August 13, 2014

NAMI/National less than honest with members

Call 202 224 3121 or go here and urge your U.S. Representative to co-sponsor HR 3717, the Helping Families in Mental Health Crisis Act.

NAMI State and local chapters do brilliant work trying to improve care for people with the most serious mental illnesses and provide comfort to them and their families. NAMI/National is ignoring the most seriously ill in order to be politically correct.
Representative Tim Murphy (R. PA) has proposed HR3717 the “Helping Families in Mental Health Crisis” that does much of what NAMI local and state members have been begging for.
  •  It slightly frees families from HIPAA Handcuffs so they can get certain medical info about mentally ill loved ones
  • Forces SAMHSA and other agencies to use their funds to treat people with serious mental illness as opposed to improving the mental health of all others.
  • Increases NIMH funding.Requires government to invest in evidence-based programs rather than just politically correct ones.
  • Takes steps to see that some hospital beds are preserved for those who need them.
  • Stops federally funded lawyers from working to close hospitals and free people with serious mental illness from treatment (Something that led to the death of Joe Bruce’s wife at the hands of his son, Willie).
  • Provides funding for Assisted Outpatient Treatment. AOT (Kendra’s Law in NY, Laura’s Law in CA) is only for a small subset of the most seriously ill that has already accumulated multiple hospitalizations, arrests, incarcerations, and episodes of homelessness caused by going off treatment that was available to them. AOT allows courts to provide those individuals a case management team and require them to stay in six months of monitored treatment in the community (with all sorts of due process protections). It also allows courts to order mental health programs to admit the most seriously ill, rather than cherry pick the easiest to treat. This combination has been proven to reduce incarceration, hospitalization, arrest, homelessness, and other negative outcomes of untreated serious mental illness by about 70% each wherever it has been used.  By reducing the use of expensive and inhumane hospitals, jails and prisons, it cuts the cost of care in half, which can be reinvested to help even more people.
  • Gives states an incentive to implement “need for treatment” civil commitment standards. Current law in many states prevents treatment of someone who is psychotic, hallucinating, or delusional until after they become danger to self or others. That’s ludicrous. Laws should prevent violence, not require it.

You can see a comparison of HR3717 to another bill here that NAMI has not shared with members.  Because of these provisions, most individual NAMI members, many NAMI local affiliates, and NAMI State Chapters have been vigorous supporters of The Helping Families in Mental Health Crisis Act. But NAMI/National refuses to lead the fight.
In a recent blog, NAMI/National Executive Director Mary Giliberti, formerly of the Bazelon Center explained NAMI’s failure to rally support because the bill is not supported by everyone in the mental health industry and she fears  'the harm caused by infighting." NAM/National should not be ceding control of its policy to those  who might disagree with it. NAMI/National, like state and local chapters, should stand up for those with serious mental illness, not side with the mental health industry. She also refuses to rally support for the bill because it has AOT provisions in it, and allows access to treatment before someone becomes dangerous. But those specific provisions are part of NAMI’s own policy!
History is repeating itself. Circa 1988 some NAMI/National Board members spent seven years trying to get the rest of the NAMI/National board to develop a thoughtful policy on Involuntary and Court Ordered Treatment. NAMI/National refused to adopt a policy or even a process to consider a policy. After seven years, a provision in the NAMI/National bylaws was used to work around the NAMI/National boards refusal to lead. A policy endorsing AOT and other reforms was put to a direct vote of the entire NAMI membership at the annual meeting in 1995. It was  overwhelmingly endorsed by them.  It wasn't even close.  AFTER the NAMI grassroots acted, the NAMI/National board adopted the policy as their own. And then they let it sit, refusing to advocate for it.  
Cut to today. A bill in Congress, The Helping Families in Mental Health Crisis Act (HR3717) would provide federal funding for the AOT pilot programs and civil commitment improvements that NAMI members voted for. The NAMI policy says:
“Involuntary inpatient and outpatient commitment and court-ordered treatment should be used as a last resort and only when it is believed to be in the best interests of the individual in need”
Giliberti defends NAMI’s failure to rally support for the bill by arguing that NAMI does not focus on treatments that are used as a “last resort” for the seriously ill, and only work for “first resort” treatments that help all others. This decision sentences many of the most seriously ill to jails, shelters, prisons and morgues. It is cruel to those who need NAMI’s help the most. Giliberti goes on to describe AOT as ‘controversial’ and a ‘third-rail’. But AOT is widely supported by police, the public, consumers who have been in AOT and most importantly, NAMI’s own members who voted on the issue. It is true that some in the mental health industry oppose it because it somewhat eliminates their ability to cherry pick the easiest to treat for admission to their programs. NAMI/National should be fighting against that, not supporting it.  
For some individuals with very serious mental illness AOT is the last off ramp before incarceration. It is like placing a fence by the edge of the cliff, rather than an ambulance at the bottom.   It's important. Politicians will make their compromises, our job is to tell them what's right.
Please call 202 224 3121 or go to  and urge your Representative to “Cosponsor HR3717, the Helping Families in Mental Health Crisis Act”. Even if NAMI/National won’t stand up for the most seriously ill, local and state members still can. Bless you.
Video of Dr. Murphy discussing schizophrenia and the Helping Families in Mental Health Crisis on floor of House of Representatives several days ago.

Comparison of provisions related to serious mental illness in adults
in the Helping Families in Mental Health Crisis Act (HR 3717) and the
Strengthening Mental Illness in our Communities Act (HR 4574)


Helping Families in Mental Health Crisis Act (HR-3717)
Strengthening Mental Health in Our Communities (HR-4574)


62 Republican
34 Democrat

66 Democrat
0 Republican
Starts to address hospital bed shortage that prevents seriously ill from getting care when needed
Provides funds for Assisted Outpatient Treatment Pilot Programs (last off ramp before jail).
Gives states incentive to implement need for treatment/grave disability standards so mentally ill loved ones can be treated before becoming danger to self or others.
Writes exceptions into HIPAA/FERPA so parents can get information about diagnosis, what prescriptions need filling, and pending appointments of their loved ones to help them
Funds NIMH research into reducing violence by untreated seriously mentally ill
Requires government to prioritize the most seriously ill rather than least ill
Inhibits SAMHSA from giving grants to non-evidenced based programs and funding anti-treatment advocacy (ex. eliminating hospitals, banning ECT, opposing AOT…)
Inhibits PAIMII from overruling parents involved in care of loved ones
Focuses on medical model of treatment
Gives law enforcement and people with a medical background an important role on advisory boards
Cuts funding of programs that are not working
Eliminate the 190 day lifetime limit
On inpatient psychiatric hospital care under Medicare
Reauthorizes Garrett Lee Suicide Programs
Support for Mental Health Courts
Train police to handle mental illness calls better
Protects Classes of medicines
Increases data collected by DOJ on mental illness


Sunday, August 10, 2014


A bill in Congress (HR3717, the Helping Families in Mental Health Crisis Act) would change SAMHSA and some wonder why change is needed. SAMHSA (Substance Abuse and Mental Health Services Administration) was created by Congress to “reduce the impact of…mental illness on America’s communities” and “target … mental health services to the people most in need”. SAMHSA has failed to do either. SAMHSA refuses to require its funds reach the most seriously ill and enacts policies to see they don't.

SAMHSA largely ignores the most significant impacts of mental illness on the communities, specifically violence, incarceration, hospitalization, homlessness and suicide. Instead, SAMHSA focuses on improving metrics like 'feeling of empowerment' 'hopefullness' and other softer outcomes.

SAMHSA also ignores the "people most in need", i.e, the 4-9% NIMH defines as having serious mental illness. Instead, SAMHSA focuses on "improving mental wellness" for all Americans. This leaves the seriously ill underserved.

Some Examples of SAMHSA Mismanagement (See documentation at

  • SAMHSA supports and funds groups that don’t believe mental illness exists.
  • SAMHSA’s Guide to Mental Illness Awareness Week suggests schools invites groups that don't believe mental illness exists, believe mental illness is a 'gift', and that getting the right diagnoses is of limited value.
  • SAMHSA is working to replace the scientifically-validated medical model that helps the most seriously ill with a non-scientific 'recovery model'.
  • SAMHSA certifies programs as being evidence based even when they do not help seriously mentally ill and/or lack evidence.
  • SAMHSA funds groups lobbying to prevent mentally ill from being treated until after they become ‘danger to self or others’ which causes an increase in violence.
  • SAMHSA's 600 person staff does not include a a medical doctor specializing in mental illness and only one on substance abuse making it incapable of directing mental illness policy.
  • SAMHSA encourages states to spend a portion of their $2 billion in block grants on preventing mental illness when we do not know how to prevent mental illness.
  • SAMHSA wastes massive money on make-work projects and useless publications.
  • SAMHSA refuses to adequately monitor the Protection and Advocacy for Individuals with Mental Illness program (PAIMI/P&A) with the result that rather than helping people who need treatment get it, it lobbies to get mentally ill who need hospital care out of hospitals and out of treatment
  • SAMHSA refuses to support evidence based programs that do reduce violence, incarceration, hospitalization and homlessness like Assisted Outpatient Treatment
SAMHSA's Response:

Numerous attempts over multiple years to engage SAMHSA in addressing these issues through the media, letter writing, congressional hearings, and meetings with Administrator Pamela Hyde have failed. At a recent meeting held for that purpose, Administrator Hyde told participants that while she recognizes the reality of violence by people with untreated serious mental illness, addressing violence by people with serious mental illness is stigmatizing to those without mental illness and therefore would not be addressed. She claimed more money was needed from Congress in order for SAMHSA to focus on serious mental illness instead of mental wellness; and generally failed to see any problem with the status quo. Hence we are making our SAMHSA documentation public.

Solutions to problems at SAMHSA:

HR3717 The Helping Families in Mental Health Act sponsored by Rep. Tim Murphy, has numerous provisions to address the problems at SAMHSA. It has 96 cosponsors from both parties, but needs more to pass.  Please go here to call your representative and ask him or her to cosponsor that critical legislation. Other solutions include:

Replace the current administrator, Pamela Hyde with someone who has passion for improving the lives of people with serious mental illness and knows how to do it. Perhaps an M.D. We note that NIMH had similar mission-creep problems prior to the arrival of Dr. Thomas Insel, but he was able to refocus the agency back to serious mental illness.


Hundreds of thousands of Americans with very serious mental illnesses are homeless or incarcerated. SAMHSA remains oblivious. President Obama has called on SAMHSA to lead a national dialogue on reducing violence by persons with mental illness, and they are not up to the task. As a result, there are now three times as many persons with mental illness incarcerated as hospitalized. We must ends SAMHSA's activities that divert resources andmake it more difficult to provide treatment for people with serious mental illness.

Documentation of the claims made above can be found at

Thursday, July 24, 2014

Info on mental illness related violence in PA

Facts about Pennsylvania Mental Health System and Violence

List of Acts of violence by untreated mentally ill in PA
Pennyslvania needs 3800 more psychiatric beds for the most seriously ill assuming they had perfect services
Chart two at

Pennsylvanians are 2X as likely to be incarcerated for mental illness as hospitalized

5000 of the most seriously ill Pennsylvanians should be under Assisted Outpatient Treatment (a court order to stay in community treatment due to the fact they had previous violence, arrest, homelessness or hospitalization associated with going off treatment. Seeing they receive AOT would cut costs to PA taxpayers by $260 million by replacing more expensive jails, prisons and hospitals with less expensive community care.


People with mental illness are not more violent than others, but people with serious mental illnesses (schizophrenia, severe bipolar) who are left without treatment are more violent than others especially if they have a history of violence.

Violence on psychiatric workers

As a result of our failure to provide mandatory and monitored treatment for persons with serious mental illness until after they become danger to self or others, psychiatric workplaces are becoming increasingly dangerous. The New York Times reported that “According to the federal Bureau of Labor Statistics, half of all nonfatal injuries resulting from workplace assaults occur in health care and social service settings. …The most dangerous settings are psychiatric units and nursing homes, where patients are often confused, disoriented or suffering from mental ailments.” (Tuller 2008)

  • •    A study of 348 inpatients in a Virginia state psychiatric hospital found that patients who refused to take medication "were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations."
Kasper JA, Hoge SK, Feucht-Haviar T et. al. Prospective study of patients’ refusal of antipsychotic medication under a physician discretion review procedure. American Journal of Psychiatry 1997;154:483–489.
  • Officials at Napa State Hospital in California logged about 3,000 acts of aggression against patients and staff in 2012. This may not be surprising since 90% of patients admitted to the six state psychiatric hospital in California get there only after being channeled through the criminal justice system. (Romney 2013)
  • Psychiatric nurses are frequent victims of workplace violence, much of which is perpetrated by patients (Marilyn Lewis Lanza 2006)
  • The American Psychiatric Nurses Association Position Paper on Workplace Violence quoted research showing 75% to 100% of nursing staff on acute psychiatric units have been assaulted during their careers; 62% of psychiatric clinical staff and 28% of nonclinical staff reported that patients assaulted them at least once and 28% of clinical staff and 12% of nonclinical staff reported an assault within the last 6 months. It quoted research showing the rate of nonfatal, job-related violent crime among general medical physicians is 16.2 per 1,000 while for psychiatrists and mental health professionals, the rate is 68.2 per 1,000. (American Psychiatric Nurses Association 2008). Even these results may be understated. “Of those physically assaulted on the job, 38% talked with a colleague afterward, but only 19% filed a formal report”. (Jacobson 2007)
To reduce violence in the workplace, the APNA endorses the use of violence prediction metrics based on the fact that those who are violent in the past are most likely to be violent in the future. It is important to note that the non-profit community based mental health industry strongly opposes this approach arguing instead that violence is not associated with mental illness and can not be predicted.  They are wrong

 Info prepared by Mental Illness Policy Org

Tuesday, July 15, 2014

Statement/Facts on Laura's Law vote in Los Angeles, CA

Statement by DJ Jaffe, Exec. Dir. Mental Illness Policy Org. and links to facts about Laura's Law to be used if LA Supervisors enact it today. Feel free to use it before hand as part of our encouraging passage.

"We thank the LA Board of Supervisors for passing Laura's Law. For many of the most seriously ill it is the last off ramp before jail. It is like putting a fence by the edge of a cliff, rather than an ambulance at the bottom. In Los Angeles if someone is so sick they don't know they need treatment, they can not get it until after they become danger to self or others. That's ludicrous. Laws should prevent violence, rather than require it. Laura's Law will help LA move from a tragedy before treatment system to a treatment before tragedy system.

The Los Angeles Mental Health Authorities have historically ignored the most seriously ill, in favor of the highest functioning. Laura's Law will mandate the mental health system provides treatment rather than offload the mentally ill to jails, shelters, prisons and morgues. We also encourage local Representatives to support HR-3717, the Helping Families in Mental Health Crisis Act, which could provide LA additional funds to implement the law."


Data that may help you report: 

California Factoids
Laura's Law is not an alternative to community services, it is a way to see those services get utilized by those too ill to do so on their on volition.  

Mental Illness Policy Org is an independent, non-partisan, science-based think-tank on serious mental illness. Let us know if you need other research on serious mental illness. Thanks for reporting on this. Please share with colleagues.

DJ Jaffe
DJ Jaffe
Executive Director
Mental Illness Policy Org.
Follow us on Twitter: @MentalillPolicy