Assisted Outpatient Treatment (AOT) Community-Based Civil Commitment

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.

Assisted Outpatient Treatment (AOT) Community-Based Civil Commitment Assisted outpatient treatment (commonly abbreviated “AOT”) is a form of civil commitment that authorizes the judicial system to commit eligible individuals with severe psychiatric disorders to mental health intervention in the community. Also known as “mandatory outpatient treatment/MOT,” “outpatient civil commitment,” and by other names, the purpose of court-ordered community treatment is to improve the health, safety and welfare of both the individuals under AOT and the public. AOT in some form is authorized by statute in 47 states and the District of Columbia but is unevenly practiced and not available everywhere it is allowed.

Task Force Recommendations Implementation - Resources and News

Will better mental health care help stop crime in Vermont? The three branches of government gathered in Montpelier on Thursday for the first-ever judiciary-led mental health summit. The goal-- to better address issues of mental health of so many going through the court system and hopefully prevent others from going through the system in the first place. Addressing repeat offenders and those who constantly cycle through the system thanks in part to mental health issues was a top priority of the summit. “What we’re really talking about are low-level misdemeanor crimes, and particularly people who recidivate, who commit the same crime over and over again, need treatment and they’re not getting it,” Vermont Supreme Court Chief Justice Paul Reiber said. A possible alternative approach could be found in Florida. A judge for Miami-Dade County explained how they have dramatically cut down on repeat offenders through pre- and post-arrest diversion systems that keep offenders with mental illness out of courts and jails.

Behavioral Health Project Consultant The Vermont State Court System is currently seeking a Behavioral Health Project Consultant for a three-year, part-time contract beginning Fall 2023. In recognition of the impact that individuals with mental health issues have on Vermont’s courts and to respond to their needs, the Vermont Supreme Court has established the Vermont Judiciary Commission on Mental Health and the Courts. The Commission would like to retain a consultant to work with the Commission and its justice partners and stakeholders to assist with expanding and improving the judicial response to mental and behavioral health issues, to assist with the development and implementation of training curriculum and materials, and to facilitate and support justice partners and stakeholders in the Commission’s work.

Research and Resources

The Structural Harms of Providing Mental Health Services Through the Bipartisan Safer Communities Act Many have proclaimed that the Bipartisan Safer Communities Act is the most sweeping gun control legislation to be passed in decades. However, the bill is not primarily a gun control bill—instead, much of the Act seeks to improve mental health services in hopes of preventing gun violence. Such a move is not rooted in established evidence, which finds little predictive value in knowing an individual’s mental health history. In fact, people with mental health disabilities are more likely to be victims of violent crimes than perpetrators. The Act therefore shifts the debate about gun reform from one about easy access to guns, to one about improving mental health services. This is not without consequence. Investments in community-based services are sorely needed, but tying these reforms to gun violence prevention will increase stigma.

Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10,460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33–38) from 12 different countries. Interpretation: Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support.

Early Lessons from CalAIM Initiatives to Address Behavioral Health Needs California, like many states, has historically provided services to people with behavioral health conditions through several different and often uncoordinated systems, making whole-person care delivery challenging. Through CalAIM, California’s Medicaid transformation initiative, the state seeks to offer more person-centered care, including for people with behavioral health needs. Enhanced Care Management (ECM) and Community Supports, launched as part of CalAIM, offer opportunities to better support people with complex physical, behavioral health, and social needs. This brief outlines considerations to improve processes related to: (1) developing contracts between managed care plans, county behavioral health agencies, and ECM providers; (2) identifying eligible members for ECM; (3) addressing duplication across care management programs; (4) delivering ECM to eligible members; and (5) contracting and delivering Community Supports.

Veteran Intercepts in the Criminal Justice System The original intent of the Sequential Intercept Model was to “envision a series of ‘points of interception’ or opportunities for an intervention to prevent individuals with mental illness from entering or penetrating deeper into the criminal justice system.” The current project builds on prior efforts to adapt (as V-SIM) the original SIM to the justice-involved veterans population challenged by various forms and degrees of mental illness, as well as by substance abuse, and by the trauma from physical injuries (with psychological trauma-overlapping Traumatic Brain Injury of particular note). Each decision point in the criminal justice system represents an opportunity to intercede at the lowest level possible and to minimize the collateral consequences of a veteran get- ting more deeply involved in the justice system.

Policy Research Holds First Spanish-Language Sequential Intercept Model Mapping On June 15 and 16, 2023, the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) GAINS Center, operated by Policy Research, hosted a Sequential Intercept Model (SIM) Mapping Workshop in San Juan, Puerto Rico. The workshop was conducted in Spanish. This was the first SIM Mapping Workshop Policy Research conducted in a U.S. territory or in a language other than English. The SIM informs communities by mapping resources, opportunities, and service gaps at key intercept points that people with mental and substance use disorders experience in the criminal legal system.

Recovery from Substance Use and Mental Health Problems Among Adults in the United States This SAMHSA brief report presents self-reports of recovery among adults aged 18 and older in the United States who thought they ever had a problem with their use of drugs or alcohol and/or mental health. These findings provide a clearer characterization of the factors associated with recovery among adults and how future efforts can foster a whole-health approach to sustain recovery from mental health and substance use conditions.

Racial disparities in diversion: A research roundup Research shows diversion “works,” reducing harmful outcomes and increasing access to social services. However, studies also suggest diversion is routinely denied to people of color, sending them deeper into the criminal legal system. We review the research and remind practitioners that most diversion programs aren’t designed around racial equity — but should be.

Peer-Focused Organizational Support for Empowering Crisis and Suicide Prevention Teams Support for the Behavioral Health Workforce demonstrates a fundamental commitment by leadership to create a nurturing and empowering environment where teams can thrive both personally and professionally. When employees feel supported and valued, they become more engaged and motivated, leading to increased productivity, higher job satisfaction, and ultimately, the achievement of organizational goals. In this context, organizational support isn't just a nice-to-have; it's a key factor in building resilient, adaptable, and innovative peer teams. This edition of the 5 Things Digest webinar offers a few resources to support organizations to provide vital support to their teams.

Dr. Kenneth Thompson on How Peer Support Is the Foundation of Recovery The National Guidelines for Behavioral Health Crisis Care call “significant use of peers” an essential quality that must be “baked into” comprehensive crisis systems. Research has shown peer support programs provide layered benefits. Those who engage in them experience improved quality of life and social functioning. They experience fewer crisis events and hospitalizations; the same is true for peers. According to a study published in APA PsycNet, certified peer specialists in Pennsylvania overwhelmingly reported in a statewide survey they’d experienced personal, recovery-oriented benefits working as a peer support specialist.

From Fentanyl Test Strips to Mass Spectrometry: A Case Study in Civilian Drug Checking The second webinar of our "Understanding the Changing Illicit Drug Landscape" series will highlight innovative drug-checking technologies that are used in response to the highly variable drug market.

Biden-Harris Administration Awards Nearly $130 Million to Expand Certified Community Behavioral Health Clinics Across US The U.S. Department of Health and Human Services (HHS), through the Substance Abuse and Mental Health Services Administration (SAMHSA), announced that it has awarded $127.7 million to expand Certified Community Behavioral Health Clinics (CCBHCs) across the country. “CCBHCs serve anyone who asks for help for mental health or substance use, regardless of their ability to pay, and in turn, people being served by CCBHCs experience less homelessness, less illegal substance use, and reduced use of jails, prisons, emergency rooms and hospitals for behavioral health issues,” said Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA. “This is a model of care that truly works to serve the whole community.”

CSG Justice Briefing Center for Policing Equity learning communities deadline extended; Recovery Month resource; mobile crisis teams; and more.

CSG Justice Briefing Suicide Prevention Week; Community Responder Learning Communities; Gender-Responsive Approaches; and more.

In the News

California's controversial CARE Court brings mental health care into the courtroom On any given night, more than 170,000 people are living on California's streets or in its shelters. It is the largest homeless population in the country -- fueled by a lack of affordable housing and the state's failure to provide adequate mental health care. One-in-four has a serious mental illness. That's the landscape Gov. Gavin Newsom says he's trying to change, starting this week, with a controversial, new plan on track to cost billions. It's called CARE court because it brings mental health care into the courtroom. Now judges will order people to get help and counties to provide it under a new law that emphasizes accountability and consequences.

Opinion: This coercive law doesn’t just take away individual rights. It lacks adequate resources. The new law provides courts with the power to force treatment plans for up to two years and, theoretically, provide access to medication, housing and therapy. However, it does not actually mandate counties to provide behavioral health treatment or housing at all. Instead, all CARE court-ordered services are “subject to available funding,” according to the fine print of state law. In other words, services will only be provided if they are available. The grim reality is there are currently not enough mental health providers or affordable housing units to meet the state’s needs and this new law does not dedicate funding to meet this need.

Missouri will add mental health workers in jails. It should add hospital beds too. Brendan Roediger has clients across Missouri with two distinctions suggesting the last place they should be is a jail cell. “They are innocent and incompetent,” Roediger says. “In theory, we don’t have a system that puts innocent and incompetent people in jail.” In Missouri, Roediger says, judges, lawyers, sheriffs, police chiefs, jail directors and mental health officials are all raising alarm bells about the problem. Jeanette Simmons, deputy director for behavioral health at the state Department of Mental Health, says there are 252 people [in jail] who fit Roediger’s dual categories of “innocent and incompetent.”

‘Mississippi chose to fight’: Court overturns Justice Department efforts to overhaul state’s mental health system The Department of Justice sued the state in 2016, arguing the failure to provide mental health services that people could access in their communities resulted in them being involuntarily committed to state hospitals for treatment over and over again. U.S. District Judge Carlton Reeves sided with the DOJ in 2019, and in 2021 approved the remedial order and appointed a monitor to evaluate the state’s compliance. The conservative three-judge panel at the United States 5th Circuit Court of Appeals overturned all of that. The panel found that the DOJ’s claim that adults with serious mental illness in Mississippi were “at risk” of institutionalization was not sufficient to prove discrimination under the Americans with Disabilities Act.

Deadly Consequences: Police response to mental health calls prove fatal More than 60% of people shot and killed by New Hampshire police over the last decade had a mental illness, according to a Concord Monitor analysis called “Shots Fired,” which was published in 2021. Two years later, despite increases in training and awareness, those statistics remain unchanged. In the eight times police have shot and killed someone in New Hampshire since the analysis was published, five of those individuals had a history of mental illness, a rate of 62.5%.

Montana inmates with mental illnesses languish in jail awaiting treatment before trial Some inmates awaiting trial in Montana remain in jail for months because of severe mental illness. They can't go to trial until they can get mental health treatment. As Montana Public Radio's Aaron Bolton reports, there's only one hospital in the state where they can go, and it's completely overwhelmed. The waitlist for the state hospital has nearly doubled over the past year, often hovering around 70 people. Wait times can vary from a month to over a year, and women tend to wait longer because only six beds are reserved for them out of 54 total.


New Jersey rolls back mental health disclosure for new lawyers, following national trend The Supreme Court of New Jersey on Thursday said it will revise a question on the state’s mandatory "character and fitness" questionnaire that asks candidates to disclose conditions affecting their ability to practice including substance abuse or a “mental, emotional or nervous disorder or condition," and whether they are seeking treatment. “These revisions to the character and fitness questionnaire encourage bar candidates to take positive steps to treat their mental health and addiction issues,” said New Jersey Chief Justice Stuart Rabner in a prepared statement. “That approach will enable them to become better lawyers and serve the public well.”

Task force recommends steps to improve lawyer well-being The Task Force on Well-Being in the Law released a comprehensive report with 21 detailed recommendations to address the high rates of depression, anxiety, and substance use in the legal profession. A collaboration between the Michigan Supreme Court and State Bar of Michigan, the task force emphasizes in the report that improving well-being is critical to professional performance, client service, and the public’s trust in the legal system itself. “Our profession must take concrete, substantial steps to address lawyer well-being because well-being is an essential component of competence,” said Michigan Supreme Court Justice Megan K. Cavanagh, co-chair of the task force.


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