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

The Justice and Mental Health Collaboration Program: Improving Outcomes for Justice-Impacted Individuals with Mental Health and Substance Use Disorders The Bureau of Justice Assistance's (BJA's) Justice and Mental Health Collaboration Program (JMHCP) helps state prosecutors, defense attorneys, community supervision, courts, and corrections agencies transform the way they work with people who have mental health and substance use disorders. To learn more about the program or to apply for grant funding, visit the JMHCP webpage.

Assisted Outpatient Treatment Program for Individuals with Serious Mental Illness The purpose of this SAMHSA grant opportunity is to implement Assisted Outpatient Treatment (AOT) programs in communities to support adults with serious mental illness (SMI) who meet state-specific criteria for AOT. Recipients are expected to implement a multidisciplinary AOT program working with courts, community partners, and other entities to support community-based treatment for adults with SMI who meet criteria for AOT. Eligible entities are counties, cities, mental health systems (including mental health authorities), mental health courts, or any other entities with authority under the law of the State in which the applicant is located to implement, monitor, and oversee assisted outpatient programs. Proposed budgets cannot exceed $500,000 to $750,000 per year.

Waitlists in the Competence to Stand Trial System There has been recent focus on waitlists for competence to stand trial and competence restoration. Importantly, there is not just one waitlist resulting in backlogs and people waiting in jails. These multiple waitlists have far-reaching consequences, including a shortage of beds in state hospitals and the ethical dilemma of detaining pretrial individuals for potentially lengthy periods of time. It’s crucial to ask who these individuals are, where they are located, why are they there, what services they await, and whether their presence in jail is justified.

Highlights from the Improving Behavioral Health Follow-Up Care Affinity Group Almost 40 percent of adult Medicaid and CHIP beneficiaries under age 65 experienced mental illness and/or substance use disorders, collectively referred to as behavioral health conditions, in 2020. Medicaid, as the single largest payer for mental health services in the United States, and the Children’s Health Insurance Program (CHIP) play a key role in promoting behavioral health follow-up care. Follow-up should occur within 30 days of the ED visit or discharge, ideally within seven days. To promote timely follow-up behavioral healthcare in Medicaid and CHIP, the Centers for Medicare & Medicaid Services (CMS) convened the Improving Behavioral Health Follow-Up Care affinity group.

CCBHC State Technical Assistance Center SAMHSA’s Certified Community Behavioral Health Clinic (CCBHC) State Technical Assistance Center (CCBHC S-TAC) is a national technical assistance (TA) center dedicated to supporting states as they implement and advance the CCBHC model. Operated by the National Council for Mental Wellbeing, our team of CCBHC experts are ready to partner with you and your state to provide customized TA to support your state’s uptake of integrated care through the CCBHC model.

Winning By Forfeit?: A Discussion of North Carolina's Forfeiture of the Right to Counsel Sanction and Mentally Ill Defendants While the doctrine of waiver of the right to counsel has long been recognized by the United States Supreme Court, the doctrine of forfeiture of the right to counsel has not yet been decided, nor has it ever reached the Supreme Court. Before a defendant’s waiver of the right to counsel is valid in North Carolina, a colloquy must occur between the trial judge and the defendant to ascertain whether the defendant is capable of proceeding pro se by conducting a thorough inquiry. While the colloquy addresses aspects of the defendant’s competency and mental health in a waiver situation, there is no such colloquy or test regarding a defendant’s mental health in a forfeiture situation. This is significant because forfeiture is usually applied in instances where a defendant engages in disruptive behavior during court proceedings. Thus, North Carolina should employ a test for forfeiture that encapsulates a mentally ill defendant’s mental health to vindicate his rights before he loses his right to counsel involuntarily.

Juvenile Competency Complications: Protocol, Unmet Needs, Developmental Immaturity, FASD, and Comorbidity This article focuses on unifying the protocol for state competency evaluations, but with special concerns about undiagnosed FASD and developmental immaturity in adolescents. States do not mandate any process whereby psychometric tests are first performed prior to psychiatric mental status evaluations, often causing disparities in evaluations which might easily be avoided in court proceedings. Adding to the complications in current competency evaluations are recent studies from Canada and Australia identifying exceptionally high rates of FASD in incarcerated adolescents following multidisciplinary teams' studies directed at identifying FASD. If these studies' rates of FASD turn out to be similar for children in the U.S. juvenile justice system, then systemic reform is called for as we are failing to identify this congenital condition when adolescents enter the system and then continue on into the adult criminal system without recognition of their prenatal exposure to alcohol.

Mental Health In Prison: The Unintended but Catastrophic Effects Mental Health in Prison: The Unintended but Catastrophic Effects of Deinstitutionalization Prisons and jails are not adequately equipped to manage the ever-growing population of mentally ill inmates. Despite deinstitutionalization efforts, prisons have steadily become the new psychiatric hospitals and unfortunately, because of the lack of treatment and the ability to properly supervise this population of inmates, these individuals are dying by their own hands at an alarming rate. This Note argues that the lack of proper care for mentally ill inmates is a violation of their constitutional right, despite their incarcerated status.

The Need to Rethink Psychiatric Judicial Advocacy Whether through surveillance or support requests, national organizations’ judicial action committees must triage the level of advocacy required for each case based on their current resources and the advocacy’s organizational alignment. Some cases consider established policy positions, making the decision to support an amicus brief an easy one. However, more challenging decisions arise in cases without thoroughly established policy positions, such as those regarding involuntary commitment. It is the role of individual psychiatrists to help address which cases should be given support via amicus briefs. Psychiatrists can fulfill this role by engaging with the advocacy arms of their psychiatric organizations and sharing stories of how current policies or court decisions impact patients and practice.

CSG Justice Center Releases State Snapshots of Criminal Justice Challenges Criminal justice trends vary by state, now more than ever. Decisionmakers need up-to-date, state-specific data to navigate today’s challenges. These data snapshots pull together the most recent data for each state on crime, arrests, behavioral health, workforce, recidivism, and more in one place.

Welcome to the New Era of the JPLI Newsletter! With a fresh design and a renewed focus, the Judges and Psychiatrists Leadership Initiative (JPLI) newsletter is evolving to foster a deeper connection with its dedicated readers and the wider community. The transition to a bimonthly schedule allows them to deliver more targeted content, engage in meaningful dialogue, and provide a platform for professional development. In this issue, nominations are open for the 2024 Judge Stephen S. Goss Memorial Awards, upcoming JPLI trainings, and more.

NRI Newsletter The NRI Newsletter is a bimonthly publication offers news and events relevant to the public behavioral health system.

CSG Justice Briefing Reentry 2030 launches in Nebraska; Insights from first national housing symposium; Denver’s Joint Effort in a Police-Mental Health Collaboration; and more.

Study Identifies Key Indicators of Stigma Toward Individuals Who Use Methamphetamines Six variables were significantly associated with higher stigma: older age, higher household income, married status, Republican party affiliation, no history of methamphetamine use, and a higher racism score. The study also showed higher levels of internalized stigma among Black respondents who have a history of methamphetamine use.

Implementing Complex Care Models to Reduce Frequent Service Utilization Among Individuals Experiencing Mental and Substance Use Disorders This SAMHSA webinar will present an overview of complex care models that can help improve services to individuals frequently utilizing services, with a deep dive into two specific models — the Ecosystems of Care model and the Recovery-Oriented Systems of Care model.

In the News

Justice Department Files Statement of Interest in Lawsuit Concerning Unnecessary Law Enforcement Responses to Mental Health Emergencies The Justice Department today filed a statement of interest in Bread for the City v. District of Columbia, a lawsuit in the U.S. District Court for the District of Columbia alleging that the District’s reliance on police officers as the default responders to mental health emergencies violates the Americans with Disabilities Act (ADA). The statement explains that the ADA requires public entities to afford people with mental health disabilities an equal opportunity to benefit from emergency response systems. This may require dispatching a different type of response to mental health emergencies when appropriate, such as mobile crisis teams staffed with behavioral health professionals, to avoid discrimination on the basis of disability.

For WA Patients with Serious Mental Illness, This Little-Known Right May Get Stronger The concept of advanced planning for psychiatric illness emerged in the 1990s; more than half of U.S. states now have a psychiatric directive statute on the books. Research suggests such directives can help lessen the odds of involuntary treatment and other potentially traumatic experiences, like being cuffed and taken to a hospital by a police officer. But mental health advance directives never gained steam in patient or health care circles. And like Washington, many states have struggled to implement their psychiatric advance directive laws. According to Swanson, such directives are most effective for people who have periods of stability and are able to write down reasonable, evidence-based care requests. They serve as a kind of “psychiatric resume” — a guide to what works well, and what doesn’t, for individual patients.

The Supreme Court Confronts a Public Health Challenge: Homeless Encampments Homelessness is a soaring public health crisis, with a record 653,000 unhoused people in the United States, according to federal estimates. In April, the U.S. Supreme Court will delve into an issue central to the plight of those living in homeless encampments: whether they can be fined or slapped with criminal charges for living or sleeping outdoors when there’s no shelter or housing available. City of Grants Pass v. Johnson centers on whether it’s cruel and unusual punishment to impose fines and criminal citations for camping or sleeping outside, which is against the law in many cities.

Supreme Court Rejects UnitedHealth Appeal, Boosting Behavioral Health Providers’ Standing with Insurers The U.S. Supreme Court rejected a request by United Behavioral Health to hear a behavioral health claim denial case. This decision creates binding precedent in the U.S. Court of Appeals for the Tenth Circuit. It reinforces existing law and case law that require health plans to take the input of patient’s clinicians seriously. It also puts a finer point on the importance of health plans meaningfully engaging with clinicians and members when assessing claims.

New Mexico Faces Critical Public Safety Gap: Competency and Behavioral Health Treatment “Right now, we just keep doing the same thing, and we’re just having people go through the system with no real help for them, and it’s not good for the community,” Bernalillo County District Attorney Sam Bregman said. It’s an issue that New Mexico’s top public defender agrees needs to be fixed. “It’s important that people know that treatment, instead of incarceration, isn’t just to be nice to the person facing the charge,” Chief Public Defender Bennett Bauer said. “It’s really what builds community safety.” Both Bregman and Bauer suggest that court-mandated treatment could help.

Michigan Senate Passes Bills Expanding Judicial Programs for Mental Health and Addiction The Michigan Senate passed bipartisan legislation Thursday to give more people access to mental health and drug treatment courts. Current law excludes those who have committed violent crimes from taking part in the treatment court programs. The package would provide for some exceptions to that. It would give judges and prosecutors the leeway to give violent offenders access to treatment court, with consultation of the victim.

Jail Diversion Corrects the System If insanity is doing the same thing over again and expecting a different result, then many of the systems designed to rehabilitate aren’t mentally sound. Locking up nonviolent offenders with mental and substance use disorders neither uses resources wisely nor is it moral. That’s why it’s imperative that the responders who deal with life’s hard cases have options — and the wherewithal and support to use them. Jail diversion, which formally started in the last few years, is built on a startlingly simple foundation — use what we know about human behavior to prevent or limit incarceration.

Gov. Mike DeWine Wants Twin Fix: More Psych Beds, Better Mental Health Care in Jails Nine out of 10 beds in state psychiatric hospitals are occupied by people sent there by the courts, leaving no space for others in mental health crisis. DeWine said he wants to fix that as well as help county jails provide mental health services to incarcerated people. The governor said he'll soon appoint a group of experts — judges, sheriffs, mental health professionals — to make specific recommendations.

Instead of 22,000 Inmates, We Could Have 12,000, Saving $200M a Year Oklahoma Gov. Kevin Stitt's Modern Justice Taskforce has told us what we already know — that our jails are filled with people suffering from addiction, mental illness, or both. More than half have not been convicted of a crime. They are waiting for their day in court, and they are too poor to pay, or otherwise incapable of posting bond. The average jail stay is three weeks in Oklahoma, compared to a national average of 12 days. The jails are neither designed, nor staffed, to treat the conditions of those who are confined there.

Texas Supreme Court Upholds Rights of Individuals Facing Involuntary Commitment The Texas Supreme Court affirms the rights of individuals facing involuntary commitment, recognizing psychiatry residents as qualified professionals. This decision addresses critical mental health care access issues and underscores the court's commitment to protecting individuals' legal rights during commitment proceedings.


Disarming Myths About Stress Over 90,000 books on Amazon deal with stress, including how to manage it, master it, control it, get rid of it, and recover from it. Some proven methods that mitigate stress include meditation, breath work, exercise, visualization, green space or virtual green space, counselling, complementary therapy, changing your mindset, and culling toxic friends, family and colleagues. Mindfulness, in particular, is an effective way to reduce stress symptoms. Some tools work for some but not for others. The sheer volume published on this topic and suggested tools dispute the myth that everyone is affected by or deals with stress the same way.

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