Wider use of assisted outpatient treatment could help individuals with mental illness

In the wake of back-to-back mass shootings in El Paso, Texas, and Dayton, Ohio, President Trump raised the wrath of some mental health advocates when he called for increasing the number of psychiatric hospitals and making greater use of involuntary hospitalization, also known as civil commitment, for individuals with serious mental illness who become dangerous when they go off treatment.

“I think we have to start building institutions again because you know, if you look at the ’60s and the ’70s, so many of these institutions were closed. And the people were just allowed to go onto the streets,” the president told reporters. “And that was a terrible thing for our country.”

In an earlier statement immediately following the two shootings, the president opined that we “must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence and make sure those people not only get treatment but, when necessary, involuntary confinement.”

While some mental health advocates may have been disturbed by the president’s willingness to connect mental illness to violence — after all, it is only the untreated seriously ill who are more prone to violence than the general population — he was right to call for more psychiatric hospital beds and an easier path to civil commitment.

I have been studying mental illness and the mental health industry for more than 30 years. I’ve documented how the decline in the number of psychiatric beds available for people with serious mental illness is putting the police, public, and patients at risk. As the number of psychiatric hospital beds began dramatically decreasing in the 1960s, rates of imprisonment of the mentally ill went up just as dramatically. Today, individuals who lack the hospital care they need are routinely arrested for bizarre (and criminal) behaviors that hospitalization could have prevented; at least six times more mentally ill individuals are now incarcerated than hospitalized.

The most important and compassionate change the Trump administration and the federal government can make is to increase the number of psychiatric beds available to those who need them. This can best be achieved by eliminating Medicaid’s Institutes for Mental Disease (IMD) exclusion, which precludes Medicaid from paying states for treating mentally ill adults while they reside in psychiatric hospitals. By withholding funds from state psychiatric hospitals, the exclusion creates a financial incentive for states to deny hospital admission to people with serious mental illness, discharge them before they are ready, and close psychiatric hospital beds.

The decline in beds is not a relic of the past, but continues today. The IMD exclusion is a cruel form of federally sanctioned discrimination against the mentally ill that moves care to correctional institutions and increases costs to taxpayers.

The president’s other call, to change procedures for civil commitment, requires a multipronged approach because the standards and process are to a certain extent defined by the U.S. Supreme Court and interpreted by the states, not the federal government. As ludicrous as it sounds, many states still rely on laws that require individuals to become dangerous to themselves or others before they can be treated without their consent.

A more reasonable approach is to enact laws that prevent danger, not require it — think seatbelt laws. With prevention in mind, every state should supplement their “danger to self or others” standards with “grave disability” and “need for treatment” standards. Grave disability allows the short-term civil commitment of individuals who, because of mental illness, are substantially unable to provide for their basic needs, including food, clothing, shelter, health, or safety. Need for treatment permits civil commitment if an individual has a mental disability and is in need of treatment to prevent substantial deterioration.

The president and Congress should create financial incentives for states to adopt those standards.

But civil commitment does not always have to mean inpatient care in a hospital — and in many cases it shouldn’t. Forty-seven states have laws allowing for assisted outpatient treatment, but few make use of their laws.

Assisted outpatient treatment (AOT) allows a judge to order certain seriously mentally ill individuals to stay in up to one year of court-supervised treatment while they continue living in the community. It is only for a small subset of individuals with serious mentally illness who have already accumulated multiple episodes of homelessness, arrest, incarceration, or hospitalization due to their failure or inability to comply with treatment while living in the community.

Extensive research shows that assisted outpatient treatment reduces homelessness, arrest, incarceration, and hospitalization by 70% or so and cuts costs to taxpayers by 50%. Because outpatient commitment is less expensive and less restrictive than the alternatives of inpatient commitment or incarceration, it is widely supported by advocates for the seriously mentally ill; has been endorsed by the International Association of Chiefs of Police, the U.S. Department of Justice, the National Alliance on Mental Illness, the United States Conference of Catholic Bishops, and the American Psychiatric Association; and has been declared an evidence-based practice by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Agency for Healthcare Research and Quality.

In addition to directing SAMHSA to release a report on assisted outpatient treatment that it has been inexplicably withholding from the public, there are many other ways the Trump administration could increase the use of assisted outpatient treatment. Here are the three that I believe would have the greatest impact:

First, the administration could robustly fund and make permanent the two small, short-term assisted outpatient treatment pilot programs that are being run by SAMHSA and the U.S. Department of Justice.

Second, states would gladly use assisted outpatient treatment if they had the funds to do so. The Center for Mental Health Services distributes $722 million in mental health block grants to states. The president and Congress should require states to set aside at least 10% of that for assisted outpatient treatment programs. Mental health block grant funds are supposed to be used to help the seriously mentally ill, and setting aside these funds for AOT would ensure they do.

Third, the president should unilaterally direct the Centers for Medicare and Medicaid Services to allow Medicaid to reimburse the physician and court costs that are needed to obtain an assisted outpatient treatment petition. Those small but annoying costs are essentially case management services. Allowing for their reimbursement would remove one impediment to expanding the program.

President Trump was correct to call for more psychiatric hospitals and an easier path to civil commitment — even if some say he expressed it unartfully. Congress should support these efforts to improve care for the seriously mentally ill. It’s the compassionate thing to do.

DJ Jaffe is the executive director of Mental Illness Policy Org., an adjunct fellow at the Manhattan Institute, and the author of “Insane Consequences: How the Mental Health Industry Fails the Mentally Ill” (Prometheus Books, 2017).