Results Group Wrong About Laura's Law in Stanislaus : Mental Illness Policy Org

Results Group Wrong About Laura’s Law in Stanislaus

In August 2017, The Results Group prepared a biased and inaccurate report on Laura’s Law for the Stanislaus Supervisors. Following is an analysis of that report by Mental Illness Policy Org. (PDF version of this analysis here)

On behalf of our members in Stanislaus County we urge the Board of Supervisors to reject the unprofessional, ill-informed, inaccurate and biased report prepared by The Results Group and immediately and robustly implement AB-1421 in Stanislaus County.

Overall, The Results Group demonstrated their lack of understanding of AB-1421 and their bias against it by positioning ACT, ICM and FSPs as alternatives to AOT, rather than as integral components of AOT. As the Legislative Digest notes, “The [AOT] program would involve the delivery of community-based care by multidisciplinary teams of highly trained mental health professionals with staff-to-client ratios of not more than 1 to 10”. AOT is not an alternative to case management services it is a mechanism to ensure treatment-refusers accept those case management services.

The Results Group proposes offering treatment refusers ACT, ICM or FSP without the court order. They fail to understand that AOT is only for those who refused that offer in the past and are likely to do so in the future. AB-1421 is quite specific, “The consumer must have been offered opportunities to participate in another high intensity treatment, …but continue(s) to refuse to engage in services.”[1]

The Results Groups thesis that the problem can be solved by offering treatment-refusers services they refuse stretches credulity. Up to 50% of those with schizophrenia or bipolar have anosognosia, a condition that makes them unaware they are ill.[2] When you are unaware you are ill, for example, “know” for a fact that you are the Messiah, you are not going to accept treatment for an illness, since you don’t believe you have one. The Results Group is either oblivious to the research on anosognosia or intentionally kept it out of its report.

The Results Group sows misinformation when it suggests large incremental funding is needed to implement AOT. The 21 to 36 individuals The Results Group identified as being eligible for AOT are already eligible, by virtue of being SMI, for ACT, ICM, or FSP services.

The only incremental cost of Laura’s Law, are the court costs, as all other costs are for services the individuals are already entitled to. The court and administration costs associated with Laura’s Law (i.e. components not currently funded) are at most $5,000 per person in the first year and go down after that.[3] Total incremental costs (i.e., court costs) for 21 to 36 individuals would only be $105,000 to $180,000 and they would not come from the mental health budget. Again: individuals eligible for Laura’s Law are the exact individuals BHRS should be prioritizing for services, rather than shunting them off to jails, prisons, shelters and morgues because they want to prioritize all other individuals instead.

The Results Group claims on page 5 to have “scanned the relevant peer-reviewed research literature to determine the evidence base for AOT,” but in the footnote admit, “It was beyond the scope of work for this project to do a comprehensive, independent literature review, but we examined meta-analyses and reviewed secondary sources that summarize the state of the literature.” The use of secondary rather than primary sources and the reliance on meta-analysis which glob together disparate studies that fail to address the issue at hand is at best lazy and certainly unprofessional. We have attached the literature review that The Results Group failed to provide in their report.[4] The literature review shows AOT is effective, cuts homelessness, arrest, violence and incarceration while saving money.

The Results Group quotes only two meta-studies.[5] 44% of the 749 patients in one study The Results Group relied on (Kisely) were not even in America or in AOT. They were patients from England who received “community treatment orders (CTO)” in that country. There is little similarity between CTOs in England and Laura’s Law in California and the whole treatment system in England is radically different than in the California. English CTOs are used to release people from hospitals and don’t involve a judge, court, or any legal procedure.[6] The Results Group should have (and may have) known this but failed to disclose it. The authors should have known and disclosed, that the Kisely meta-analysis excluded all studies in the U.S. that were done in the last 15 years! Even if one accepts that Kisely is a relevant study, The Results Group left out an important finding of that study, “People receiving [court ordered community treatment] were, however, less likely to be victims of violent or nonviolent crime. Only bias against AOT can explain why that finding was not reported by The Results Group.

The Results Group did report that the Meddrun meta-analysis found “participants of AOT have lower odds of arrest, reductions in hospitalizations and Emergency Department use, and improved engagement of services.” But The Results Group report left out the findings that showed participants in AOT also had reduced risk of victimization; lower risk of harm to self or others; reductions in hospital recidivism, reduction in length of hospitalization, improved engagement in services and higher quality of life. Why did they leave those out?

A core argument put forth by The Results Group, is that because all the studies in California of AOT that show positive benefits and show it saves money were of small populations, they could not be relied on. But AOT is only intended to help a small group. While willing to accept as part of their narrative studies in foreign lands, like CTOs in England, The Results Group failed to include any results from throughout the United States where much larger populations were studied and would provide guidance. We attached those studies as they were reported in appendix D of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill (Prometheus Books, 2017) by DJ Jaffe, Executive Director of Mental Illness Policy Org..

The authors did mention that the Substance Abuse and Mental Health Services Administration

(SAMHSA) studied AOT and found it to be “an evidence based practice, but they left out this important critical SAMHSA finding: “Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized.”[7] They faulted the SAMSHA report because it “does not conclusively suggest that AOT is more effective than ACT or ICM.” True. But that’s because the SAMHSA report was on AOT, not on ACT and not on ICM. And it found AOT works. Further, as previously stated, ACT, ICM and FSPs are a key component of AOT. AOT extends the number who accept them by court-ordering patients to accept them. They are not alternatives.

The authors failed to include in their report, findings from the in-depth study by the Agency for Healthcare Research and Quality (AHRQ) which found AOT “programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior.”[8]

The authors failed to include the results of a study by the Department of Justice that found “Assisted Outpatient Treatment is an effective crime prevention program.”[9]

The authors failed to include the findings of the American Psychiatric Association Council on Psychiatry and the Law that AOT is warranted for “patients who need treatment in order to prevent relapse or deterioration that would predictably lead to their meeting the inpatient commitment criteria in the foreseeable future.”[10]

See attached list of studies that The Results Group failed to inform the supervisors about.

The “Results” Group argues on page 7 that the Black Robe Effect “is not supported in the research literature.” They must not have read the literature. A study of this exact issue found “The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.”[11]

To further minimize the important of the Black Robe effect the Results Group pretends that “data from probation department of Stanislaus County [that] indicates that 60% of individuals who go through mental health court drop out, reinforc[es] the limitations of the black robe effect for compliance.” It does no such thing. Those in mental health court committed a crime. Those in Laura’s Law did not. To compare the rates of non-compliance of those who are facing criminal sanctions with those in Laura’s Law is intentionally misleading.

The Results Group solicited input from 200 individuals but specifically admits that information from informed individuals who are part of advocacy organizations was excluded.[12] Of those The Results Group did consult in one-on-one interviews, over half were from BHRS, the funders of the report. This is likely what led to the bias in their report. They interviewed BHRS, found they didn’t like AOT and then reported negatively on AOT. There is no evidence that The Results Group reached out to police, sheriffs, judges or others who have to deal with the consequences of BHRS’s refusal to serve those who need involuntary services and are huge supporters of Laura’s Law.[13] While they held community forums for ‘broad audiences’ and one specifically for high-functioning consumers well enough to attend a meeting, they did not hold one specifically for family members, the real experts on serious mental illness. Nor were any held in psychiatric hospitals or jails where the seriously mentally ill live.

Even with the bias, 67% of those who attended the input sessions said they favored you, the Board of Supervisors implementing AOT. Even 53% of consumers said they favored it. When this survey was extended to an online audience (page 10), “87% of respondents believe that Stanislaus County [Supervisors] should implement Laura’s Law.” It is important to note that the percentage who favored Laura’s Law grew as they learned more about it, showing that the small resistance to Laura’s Law is only due to misinformation.

When discussing Marin County, which did adopt Laura’s Law, the Results Groups goes to great lengths to list concerns of those who opposed adoption, but none of the arguments in favor of it which carried the day and caused the Marin County supervisors to adopt the law. It is hard to attribute this to anything other than bias in The Results Group.

When discussing the results in San Francisco, the Results Groups failed to quote the following information which comes directly from San Francisco:

Individuals in contact with AOT during the evaluation period showed overall reductions in PES contacts, psychiatric hospitalization, and incarceration. During the evaluation period:

87% of AOT participants were successful in reducing or avoiding PES contact.
65% were successful in reducing or avoiding time spent in inpatient psychiatric hospitalization.
74% were successful in reducing or avoiding time spent incarcerated.

Well-Being, Social Functioning, and Independent Living Skills AOT Participants were surveyed, and respondents overwhelmingly reported a positive outlook on their future.

89% of respondents feel confident that they can reach their treatment goals.
90% of respondents feel hopeful about their future.

Benefits of AOT engagement and case management were also reflected in the survey responses of program participants.

63% of respondents believed that regularly meeting with a case manager will help them to find or maintain stable housing.
67% of respondents believed that regularly meeting with a case manager will help them to maintain good physical health.
63% of respondents believed that regularly meeting with a case manager will help them live the kind of life they want.

We are unable to come up with any reason why the Results Group would leave these findings out, and only report on their own interpretation of other data in the report.

The significant finding from Kern County, as it is from many counties, is that the mere existence of an AOT law helps coerce patients into accepting voluntary services without going through a court process. The Results Group fails to inform the supervisors that this option will not be available unless Stanislaus supervisors adopt AOT.

The Results Group claims to not understand the difference between court ordered medication and forced medication. Like the Results Groups failure to understand that ACT/FSP/ICM are all part of AOT, and not an alternative to it, this indicates how superficial their understanding is.[14]

We do thank The Results Group for noting that ”Nevada County AOT participants saw a reduction of hospital days by 68%, incarceration days by 100% and homeless days by 100%.” However, The Results Group pooh-poohs those results because they do not represent large numbers of people. They fail to understand that AOT is not for large numbers of people. It is to help a small group that needs a court order (or threat of one) in order to enable them to access FSP/ICM/ACT.

The Results Group noted that “Counties with strong engagement with their law enforcement partners noted that referrals from these partners were more likely to be eligible [for AOT]. Yet Results Group did not do any outreach to law enforcement in their own report, other than probation.

The Results Group report is terribly misleading on costs. The Results Group reports that AOT increases and decreases costs, but fails to report on the fact that there is a large net decrease. Los Angeles County reported savings of 40%.[15] Nevada County reported that savings from reduced hospitalization: was $213,300 and savings from reduced Incarceration was $75,600.[16]

Every study on AOT costs has reported net savings. Florida reported average savings in hospital costs alone of $14,463 per consumer.[17] The total savings in hospital costs for just 21 consumers was $303,728. Savings in incarceration was $14,455. In New York urban areas the net savings for year one was 50% with an additional 13% in subsequent years.[18] Rural and suburban areas did even better with net savings of 62% in year one and an additional 27% in subsequent years.

Savings pre-and post AOT in non-NYC counties of NYS

Increased outpatient costs were more than offset by decreased hospitalization and incarceration resulting in savings of 50%

On page 21, The Results Group purports to compare the eligibility criteria of AOT to FSPs. As previously stated, AOT is not an alternative to FSPs. AOT is a way to see that those who won’t volunteer for FSP, get those case management services. The chart erroneously says AOT is not available to those who require medication management, have difficulty maintaining a residence, difficulty engaging in productive activities, has multiple needs, is at risk of being conserved, etc. Those are the exact groups AOT is for.

The Results Group also compares AOT to conservatorships but those who get conserved are generally locked up at great cost to taxpayers and loss of all rights. AOT prevents the costs and the lock up.

The Results Group positions the fact that AOT may only help a few in the reasons not to implement Laura’s Law. Clearly that is a reason Stanislaus County should implement Laura’s Law.[19] It also fails to note that it reduces incarceration itself (not just the cost of it). The report again ignores the evidence AOT works (attached), and continually hammers at the fact that it cannot be the Black Robe effect. Surely the fact the law works should take precedence over we don’t know why it works.

The Results Group, absent any literature, absent a shred of evidence, suddenly, on page 27, out of left field, promotes Individual Placement and Support (IPS) – a program promoted by the county behavioral health director, as an alternative to AOT. They simply ignore the fact that to be in AOT recipients, by definition, “must have been offered opportunities to participate in another high intensity treatment, …but continue to refuse to engage in services.” The Results Group fails to understand that offering more services, like IPS, to a consumer who refuses to engage in services will not result in the consumer engaging.

In spite of the fact that all implementations of AOT, in California and across the country, have had positive and cost-saving results, The Results Group claims, ‘the evidence is not robust.’ In spite of extensive evidence that by definition those eligible for AOT won’t access ACT voluntarily, they propose ACT as an alternative.

The Results Group failed to report on studies of AOT (attached), presumably because they make it clear AOT works.

* * *

Whereas,

Extensive evidence from California and other jurisdictions shows AOT reduces homelessness, arrest, incarceration and hospitalization;

Extensive evidence shows AOT reduces costs;

AOT has support of law enforcement, consumers, and families,

87% of Stanislaus respondents believe that Stanislaus County [Supervisors] should implement Laura’s Law’

Resolved,

The members of Mental Illness Policy Org. in Stanislaus Country urge the Board of Supervisors to fully implement Laura’s Law.

Thank you.

DJ Jaffe

Executive Director, Mental Illness Policy Org.

Author, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill

PDF Version

FOOTNOTES

[1] 5346.

[2] Torrey, E.F., Impaired Awareness of Illness https://mentalillnesspolicy.org/medical/anosognosia-studies.html

[3] The best detailed published cost data was “The Cost of Assisted Outpatient Treatment: Can It Save States Money?” published in the American Journal of Psychiatry. Program administration and legal costs were $4,971 in urban areas and $5,106 in rural.

[5] Kisely SR, Campbell LA, O’Reilly R. (2017). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews, Issue 3. Meldrum, ML, Kelly, EL, Calderon, R, Brekke, JS, and Braslow, JT (2016) Implementation Status of Assisted Outpatient Treatment Programs: A National Survey. Psychiatric Services 67:6, 630-635.

[6] Treatment Advocacy Center, “No Relevance to Assisted Outpatient Treatment (AOT) in the OCTET Study of English Compulsory Treatment,” TAC, May 2013, http://www.treatmentadvocacycenter.org/storage/documents/Research/may2013-octet-study.pdf (accessed July 14, 2016).

[7] Substance Abuse and Mental Health Services Administration, “Assisted Outpatient Treatment,” National Registry of Evidence-Based Programs and Practices (SAMHSA-NREPP), 2015, http://legacy.nreppadmin.net/ViewIntervention.aspx?id=401 (accessed July 12, 2016)

[8] Agency for Healthcare Research and Quality (AHRQ), Management Strategies to Reduce Psychiatric Readmissions (May 2015). Summary at http://mentalillnesspolicy.org/national-studies/ahrq_endorses_aot.pdf (accessed July 12, 2016).

[9] Department of Justice, “Program Profile: Assisted Outpatient Treatment (AOT),” 2012, www.crimesolutions.gov/ProgramDetails.aspx?ID=228 (accessed July 12, 2016).

[10] American Psychiatric Association Council on Psychiatry and Law. “Mandatory Outpatient Treatment Resource Document, APA Document 199907 (Arlington, VA) 1999.

[11] Marvin Swartz, Christine Wilder, Jeffrey Swanson, et al., “Assessing Outcomes for Consumers in New York’s Assisted Outpatient Treatment Program,” Psychiatric Services 61, no. 10 (2010): 976–81, http://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2010.61.10.976 (February 8, 2015); Marvin Swartz, Jeffrey Swanson, Henry Steadman, et al., “New York State Assisted Outpatient Treatment Program Evaluation,” Office of Mental Health, June 30, 2009, https://www.omh.ny.gov/omhweb/resources/publications/aot_program_evaluation/ (accessed July 25, 2016).

[12] “Information about counties filtered through advocacy organizations was not included.”

[13] AOT is supported by both the International Assoc. of Chiefs of Police (IACP) and National Sheriffs’ Association. In California it is supported by Santa Barbara County Sheriff’s Dept., Lompoc Police Dept., California Peace Officers’ Association, California State Sheriffs’ Association, County of Ventura District Attorney, Irvine Police Association, LA County Police Chief’s Association, Marin County Sheriff’s Office, Sacramento County Sheriff’s Department, San Bernardino County Sheriff’s Department, Ventura County Sheriff’s Department, Yolo County Sheriff’s Department, Oxnard Peace Officers’ Association, Oxnard Police Department Community Police Advisory Board, Baldwin Park Police Department, El Monte Police Department, Fontana Police Department, Fresno Police Department, La Habra Police Department, Long Beach Police Department, Monrovia Police Department, Napa Police Department, Pasadena Police Department, Pleasanton Police Department, Ridgecrest Police Department, Selma Police Department, and Suisun City Police Department. List of additional supporters in California at https://mentalillnesspolicy.org/states/california/lauraslawsupporters.html The Results Group did interview probation officials.

[14] The court can order someone to comply, but cannot get police to enforce the order. The result is that compliance is due to the individual wanting to comply with the judge’s order, versus any fear of consequences (Black Robe Effect).

[15] Marvin Southard. “Assisted Outpatient Treatment Program Outcomes Report.” Department of Mental Health, Los Angeles County, Los Angeles, CA, February 24, 2011.

[16] Marvin Southard. “Assisted Outpatient Treatment Program Outcomes Report.” Department of Mental Health, Los Angeles County, Los Angeles, CA, February 24, 2011.

[17] Available at http://mentalillnesspolicy.org/States/florida/florida-aot-results.html

[18] Independent researchers calculated costs and savings separately for urban NYC and more rural and suburban counties. Savings are net after accounting for increased Medicare/Medicaid reimbursed psychotropic drug cost and community treatment costs. They are primarily due to reduced incarceration and hospitalization. Jeffrey Swanson, Richard Van Dorn, Marvin Swartz, Pamela Clark Robbins, Henry Steadman, Thomas McGuire, John Monahan. “The cost of assisted outpatient treatment: can it save states money?” American Journal of Psychiatry 170 (2013): 1423–1432.

[19] We do agree with The Results Group finding (page 18) that only 21 to 36 individuals would be eligible for the program.