Psychiatric Advance Directives

Implementation of the National Judicial Task Force to Examine State Courts' Response to Mental Illness Report and Recommendations

The Task Force made a number of important findings with corresponding recommendations supported by over 100 resources for courts and our partner stakeholders. Each Behavioral Health Alerts revisits an original Task Force resource or a new resource that supports a Task Force recommendation.

Psychiatric Advance Directives An emerging tool for achieving the balance between self- determination and the need for involuntary treatment is the Psychiatric Advance Directive (PAD). The concept is to allow those with recurring episodes of disabling mental illness, while in a stable phase, to explicitly provide anticipatory legal directives for consent to particular treatment or preferences relative to specific treatment components. In some circumstances these PADs also explain past treatment histories, successful and unsuccessful, with particular medications, approaches, and strategies. While the legal force of PADs varies greatly from state to state, the treatment preferences and tips would seem to be helpful regardless of their legal effect.

Research and Resources

Certified Community Behavioral Health Clinics: A Vision for the Future Solving the nation’s ongoing mental health and substance use crises takes innovation. That’s precisely what the CCBHC model allows — the flexibility for participating community-based clinics to expand their services and tailor mental health and substance use care to meet the individual needs of their communities.

Public Psychiatry and the Jail Diversion Production Model Connecting Systems in Miami-Dade County What Simpatico and his colleagues at MTS have developed is the WayFinder Miami model jail diversion production system. The real-time, web-based technology interconnects the court system, CIT-trained officers, Veterans Affairs (roughly 12% of those incarcerated are veterans), and case management. Those in any connected system can search for a person they encounter. If the person is already in WayFinder, staff can quickly find the constellation of systems with which they’ve had contact.

Emerging Adults Online Training Series Virtual Kickoff The series includes modules on the topics of young adult brain development, needs, risks, and protective factors for young adults, the behavioral health needs of young adults, and more! Each bite-sized module will include pre/post-tests for knowledge assessment, intertwined with scenario-based learning activities to enhance real-world application.

Shaping Crisis Response Spotlight Series The National Association of Counties (NACo), in collaboration with The Pew Charitable Trusts and RAND, hosted a series of conversations with county leaders to understand the progress, challenges and lessons learned from 911/988 interoperability across various models, including embedded clinicians, call transfer and co-located response. This series will spotlight the work of five of the innovative counties shaping crisis response systems.

Insanity and Incompetency: Courts, Communities, and the Intersection of Mental Illness and Criminal Justice in the Wake of Kahler and Trueblood The criminal justice system is grappling with matters beyond its expertise and infrastructure. The criminal justice system was designed with many-sometimes conflicting-purposes in mind, such as deterrence, retribution, incapacitation, and rehabilitation. The criminal justice system was never designed to heal trauma, administer treatment, or make people whole. The criminal justice system was built as if incarcerating people with mental illnesses were the exception, but it is the norm. (GGU Law Review, Westlaw link)

Innocent Until Proven Mentally Incompetent The United States Constitution, American jurisprudence, society, and pop-culture recognize a “constitutionally rooted presumption of innocence.” The presumption of innocence is undoubted law that is “ingrained within our history and national psyche,” and preserved by due process afforded to all. Why then are those criminally accused with dementia, a degenerative mental disease, deprived of such a liberty? (St. Mary’s Law Review, Westlaw link)

Stepping Up to Elevate the Voices of Lived Experience The Council of State Governments Justice Center is partnering with C4 Innovations and the Lived Experience Advisory Panel (LEAP) to discuss elevating the voices of people with lived expertise in the behavioral health and criminal justice systems. During this webinar, C4 and the LEAP will provide an overview of the LEAP’s work, from formation to final recommendations. They will offer key takeaways from their focus groups, explore strategies for effectively integrating their lived expertise to drive impactful systems change, and discuss what meaningful engagement entails when collaborating with people who have lived expertise.

A Practical Approach to Inclusivity AOT programs across the country serve racially and culturally diverse participants. Simultaneously, racial disparities in the mental health and court systems impact these programs, as there is often little corresponding racial and cultural diversity amongst AOT team professionals who seek to engage participants in treatment. Join us as Thurmond Gillis, Jr., LAC, NCC, CADC, Program Manager with Care Plus NJ’s first episode psychosis intervention program, teaches us how implicit bias can interfere with efforts to engage individuals who are different from ourselves, and how pillars of cultural humility can be applied to create an inclusive environment for all.

Stigma Education - Substance Use & Opioid Use Disorder In its new video, Stigma, the New England Regional Judicial Opioid Initiative (NE RJOI) tells the story of stigma through the eyes of judges, court personnel, law enforcement, and individuals with lived experiences. Created in partnership with the Opioid Response Network and the American Academy of Addiction and Psychiatry, the video's central message is that substance abuse is a treatable illness, not a moral failing.

TAC Research Weekly: Increasing use of psychiatric advanced directives among people with SMI A psychiatric advanced directive (PAD) is a way for people with severe mental illness to document their preferences for treatment in advance of an acute episode of mania or psychosis when their ability to consent to or make sound treatment decisions may be compromised. A recent article from “Voices of Bioethics” discusses how peer-support specialists can help to increase the utilization of PADs among people with SMI. In addition to promoting the use of peer-support specialists to assist with PADs, the author also recommends creating infrastructure for a nationwide PAD database to ensure that patients’ preferences are respected even if they are receiving treatment out of state or from a new provider.

CSG Justice Center Justice Briefing Survey on impacts of housing instability for criminal justice agencies; new crisis stabilization and community reentry grantees announced; and more.

In the News

State officials tout ‘once in a lifetime’ investment in North Carolina’s mental health services Between federal COVID relief funds and the $1.4 billion sign-on bonus North Carolina received for expanding Medicaid, state lawmakers were able to make significant investments in mental health services in the latest state budget. The result is pages of mental health policy and spending in this year’s budget document, where lawmakers committed to significant rate increases, bonuses and education for a variety of mental health workers. They set into motion big structural changes to the way behavioral health services are delivered to the most vulnerable populations across the state. And they directed hundreds of millions to support children in foster care and expand preventive mental health care and crisis care services.

Court-ordered treatment program for people with serious mental illness shows a reduction in arrests A court-ordered treatment program for people with serious mental illness shows a reduction in arrests, psychiatric hospitalization and homelessness, according to testimony from the Kentucky Cabinet for Health and Family Services. After six months in AOT (assisted outpatient treatment) , the program has shown an 86% reduction in inpatient hospitalization among clients, a 74% reduction in ER visits, a 57% reduction in nights in jail, a 40% reduction in arrests and homelessness and a 14.3% reduction in detoxification requirements. “We also see improved quality of life among participants, with about 79% saying that their overall quality of life was significantly better from baseline to six months,” Clark said.

California aims to expand mental health treatment with new conservatorship definition of 'gravely disabled' California Gov. Gavin Newsom signed a bill Tuesday that is intended to expand the categories of people who can be involuntarily detained for mental health treatment. The law expands the definition of “gravely disabled” in conservatorship law (guardianship in most states), which governs the appointment of conservators who can direct care for a limited time. The previous definition allows appointment of a conservator for people who have a serious mental illness that leaves them unable to secure food, clothing or shelter. The new law expands the definition to allow conservatorships for people who can’t provide for their personal safety or necessary medical care because of either a severe substance use disorder or serious mental illnesses.

Washington counties win initial legal victory over scarce mental health beds In the battle with state officials over who which populations should receive scarce mental health beds, a group of Washington counties say they won an initial legal victory Friday. A majority of Washington counties sued the state’s Department of Social and Health Services in August, over the agency’s abrupt release of patients with mental illnesses. These people had been charged with crimes but deemed incompetent to stand trial. State officials said they needed to make bed space for people who were still awaiting trial. Now Pierce County Superior Court Judge Michael Schwartz has granted a preliminary injunction in favor of the counties, forcing DSHS to adhere to its previous practices.

10th Circuit reminds judges: Be attentive to mentally ill litigants The federal appeals court based in Denver reminded judges last month to be mindful of self-represented litigants who appear to be mentally ill, and to arrange for assistance when required. Although the 10th Circuit panel agreed with the decision to toss the petitioner’s claims, it called attention to the federal rule requiring judges on their own initiative to appoint a legal guardian to protect pro se litigants who lack mental competency. "Though we think Tunson-Harrington hasn’t presented sufficient evidence to trigger a district court’s mandatory (appointment) duty, we remind district courts to be vigilant to mental-health evidence in cases brought by pro se litigants."


Create Healthier and More Engaged Employees with Mental Health First Aid at Work Do your employees know what to do or say if a coworker seems to be struggling with mental health challenges? Consider this: 40% of employees have reported that their jobs have had a negative impact on their mental health, and 75% of employees indicated that stigma was present in their workplaces. With MHFA at Work, businesses can teach employees at every level how to recognize and respond to colleagues who may be experiencing a mental health or substance use challenge in the workplace, build a resilient mindset and implement best practices for self-care.


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