SAMHSA Once Frowned on Assisted Outpatient Treatment: Now It’s Pushing It

(5-20-19) A new publication by the Substance and Mental Health Services Administration (SAMHSA) about involuntary commitment reveals how dramatically Dr. Elinore McCance-Katz is changing the federal government’s view of Assisted Outpatient Treatment.

Prior to Dr. McCance-Katz’s 2017 appointment to the newly created position of undersecretary for mental health and substance abuse, AOT was not a federal priority. AOT proponents, such as Dr. E. Fuller Torrey and D.J. Jaffe, accused SAMHSA of funding anti-AOT organizations.

Now SAMSHA is promoting AOT in a report released last month entitled Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice .

AOT requires someone, who meets criteria, to undergo court-supervised, mandatory treatment in a community setting. Its opponents frequently call it “forced medication” although AOT can require other treatment services besides or in addition to medication. Its supporters argue it is necessary to rescue individuals with serious mental illnesses who “lack insight” and do not understand they are ill.

Mental Health Weekly, a subscription service that reports about litigation, legislation and corporate policy affecting mental health, interviewed Dr. McCance-Katz about the new report. It quotes her stating that the purpose of the new SAMHSA report “is to start to talk about the needs of the population with serious mental illness [SMI] and how we can best meet those needs.”

“What we’re trying to do is discuss circumstances and conditions under which individuals might need commitment and how that process might be undertaken.”

The SAMHSA report looks back more than 40 years to the closure of state hospitals and the failure of states and the federal government to fully support community based care. It reports there are insufficient hospital beds for Americans with mental illnesses. It suggests AOT laws can be a successful alternative to a lack of beds and postulates that AOT laws can force states to better fund better community services. The rational: if someone is ordered by a judge to undergo treatment, then community treatment must be provided.

From the article:

“A large number of people in this country have serious mental illnesses, Dr. McCance-Katz said. “On the streets they are victimized.” A rational person wouldn’t choose to be homeless, she noted. “People with serious mental illness are unable to undertake what is needed to provide for themselves,” she said.

An apparent shortage of psychiatric beds in many areas has created a situation in which involuntary commitment may be seen as a virtual entitlement — a way to prioritize intensive mental health services for individuals who would have difficulty accessing these services otherwise, according to the document.

MHW Reporter Valerie A. Canady continued:

According to the guide, most states’ inpatient commitment laws were written at a time when commitment entailed lengthy stays in substandard facilities, with little meaningful care. Balancing the risks and other burdens patients faced in those days, the laws established strict standards and procedures for commitment. Today, in virtually every state, lengths of stay for committed patients are (usually) brief, typically a week to 10 days, and the facilities that are used are, by and large, clean, safe and therapeutic. Inpatient commitment standards have softened in recent years, but all still require a showing of substantial disability — serious mental illness resulting in a significant risk of harm (whether or not couched in terms of “imminent dangerousness”).

The guide notes that New York’s AOT statute is “exemplary” in its requirement for a written treatment plan that “shall include case management services or assertive community treatment team services to provide care coordination…” and “any other services … to treat the person’s mental illness and to assist the person in living and functioning in the community, or to attempt to prevent a relapse or deterioration that may reasonably be predicted to result in suicide or the need for hospitalization.”

Short History Of AOT Legislation

Dr. Torrey and a fledgling Washington-based center that he founded first began lobbying nationally for AOT laws in 1997, but the Treatment Advocacy Center didn’t have much success until two incidents in 1999 in the New York City Subway system.

Andrew Goldstein, then 29 and diagnosed with schizophrenia but off medication, pushed Kendra Webdale into the path of an oncoming N train at the 23rd Street station. Subsequently, in a similar incident, Julio Perez, age 43, pushed Edgar Rivera in front of an uptown 6 train at 51st Street Rivera lost his legs.

TAC’s then Director, Mary Zdanowicz, contacted Webdale’s family and they agreed to join TAC in promoting passage of an AOT law named after their daughter – Kendra’s Law. That success established a formula that TAC later used in California – showing the need for AOT legislation by publicizing a tragic death.  In California, the legislature passed Laura’s law, which is named after Laura Wilcox, a young woman who was murdered by a man with mental illness.

Eventually, TAC’s persistence resulted in 46 states adopting AOT laws.

Beyond AOT laws: Changing SAMHSA

TAC, its supporters, and Dr. Torrey played a key role in advising former Rep. Tim Murphy (R-Pa.) in his drafting of the Helping Families In Mental Health Crisis Act, and pushing for its passage. It eventually was blended into the 21st Century Cures Act which passed during the final days of the Obama administration. That law created Dr. McCance-Katz’s assistant secretary position.

Dr. Torrey quietly supported Dr. McCance-Katz nomination by the Trump Administration overriding Rep. Murphy’s choice in a heated behind the scenes battle.

Since taking office, Dr. McCance-Katz has steered SAMHSA toward an agenda that, while clearly her own, mirrors most of what TAC and Dr. Torrey have been pushing for years. Dr. Torrey constantly criticized SAMHSA before Dr. McCance-Katz took control. Before her nomination, Dr. McCance-Katz also blasted SAMHSA. In an article published by Psychiatric Times, she accused the the agency of being openly hostile toward the use of psychiatric medicine, ignoring the seriously mentally ill, and wrote that some of its leadership questioned whether bipolar disorder and schizophrenia were even real, arguing that psychosis is just a “different way of thinking for someone experiencing stress.”

SAMHSA’s newest report on civil commitment is proof of how Dr. McCance-Katz has been steering SAMHSA in a completely different direction from its previous leadership. The release of a report about civil commitment also shows how politically influential TAC and its patriarch have become in a city where they were once outsiders.

Not everyone agrees with SAMHSA’s new direction or supports Dr. McCance-Katz’s leadership, but it would appear there will be little her critics can do until the 2020 presidential election. Even then, trying to rewind the clock after SAMHSA has spent funds pushing AOT could be difficult.










About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.