In Part 1(a) of this post, I discussed the existing, but rarely utilized, statutory framework in Georgia for mandated or involuntary outpatient treatment. In Part 1(b), we'll take a look at what Georgia new Mental Health Parity Bill does to exploit and supercharge this existing framework.
Part 3 of the Bill addresses involuntary commitment in general and begins by expanding uses for involuntary outpatient treatment. O.C.G.A. §37-1-120 defines "assisted outpatient treatment" as involuntary outpatient care, but does so by laying out a new framework of "formalized, systemic effort[s] led by a community service board or private provider in collaboration with other community partners...". Paraphrasing the new statute, the legislature laid out a plan for this ambitious endeavor, to include:
(1) identifying potential candidates for involuntary outpatient treatment;
This is a change of pace from the start. I can't think of a time I've ever known a provider to petition for involuntary outpatient care. If a patient is nearing crisis, the 1013 is the natural tool to which they turn, and thus involuntary inpatient care. And, of course, by that point inpatient care is probably necessary, but it comes at the great cost of loss of rapport and a sense of betrayal, something from which a patient is not likely to recover to the extent that the patient-provider relationship can be preserved. But the Bill's effort to highlight this option help providers who may see a crisis on the horizon based on a patient's history or behavior and provides them with a tool to help avoid hospitalization while still preserving some rapport with their patient. Moreover, it allows for what might be an established patient-provider relationship to be maintained, but in an environment of accountability.
(2) encouraging providers to petition their respective probate courts to hold hearings with respect to those identified individuals;
Again, this tool already exists but is re-highlighted by the new legislation. This is a tricky area as noted above; rapport with a patient can be fragile under these circumstances, but giving providers an option that avoids the trauma of hospitalization and allows for meaningful outpatient care to be maintained may just preserve the relationship enough once stability is attained. Even an individual who's symptoms have been controlled would have a hard time returning to a provider who they feel betrayed him by sending him to an inpatient facility against his will. All that said, it would be important that the Probate Court involved approached these petitions delicately, making clear the aims of involuntary outpatient care and the benefits of accountability on an outpatient basis as opposed to a lockdown facility.
(3) provide evidence-based treatment and individual plans aimed at keeping the individual stable and safe in the community;
Hallelujah! I really credit the legislature for making this a priority. We're dealing with peoples' minds here, and it is critical that the response is not generic, or simply aimed at medication monitoring. If the Courts and providers are going to utilize mandated outpatient care, it must be with the aim of bringing the individual to a place where he or she WANTS to engage with treatment, not with the myopic aim of simply protecting the community. By focusing the care on the individual and taking into account his or her wishes, you give them some sense of control, and in my experience, that is the only way you can expect to find growth in insight and willingness to engage with doctors and therapists. Throwing money at the problem helps, but without consideration of the nuance of psychiatric treatment and the minds involved, there will be little, if any, progress on a large scale.
(4) make sure the rights of these individuals are protected at all stages;
Important to both make this a reality and convey it to those mandated individuals. We can't short circuit due process concerns, and the reasons for a Court's decision in response to a petition, or during the process of mandated outpatient care, be clearly and compassionately communicated to the individual at a hearing. One of my greatest criticisms of the existing involuntary inpatient process is the utter lack of accountability; the mechanisms of due process are in place but are NEVER utilized except for extended hospitalization, and in my experience the statutes aimed at protecting those who are involuntarily hospitalized aren't taught to the staff of hospital providers, leaving these patients without any real rights at all for the period of a week- or so that they are hospitalized. Tell me how that induces a person to remain engaged with treatment when they are discharged.
(5) open lines of communication between providers and the Courts who would be overseeing their care, including details of the individuals' care that will empower the Court to use its authority to keep them engaged;
(6) adjust the individualized plans as needed and monitor them continuously;
(7) establish protocols in the event of non-compliance;
These subsections specifically aim at keeping the Court involved and engaged, something that to this point is nonexistent when it comes to outpatient care. Even in counties where the Courts show some interest in monitoring mandated outpatient cases, that job is mostly left to community-based resources and ACT teams for treatment, and they in turn rely on the 1013 process when things get out of hand. What these subsections seem to lay an obvious path for is accountability court-type scenarios. Accountability courts have already existed in the criminal sphere since the late 1990s and early 2000s, and involve Courts who are specifically created to engage with criminal defendants wrestling with mental health challenges, offer them alternatives to traditional criminal punishment and conviction, and encourage them to develop their treatment structure, all while accomplishing larger life goals. To have such a court structure in the Probate system, before an individual is ever arrested, seems like a perfect opportunity for meaningful change both for these individuals, their families, and the communities in which they live. I am very interested to see similar programs developed in the Probate Courts in light of this new legislation, and look forward to assisting Counties in their inception.
(8) use this framework to help law enforcement find alternatives to incarceration;
In the past, I have spoken at various law enforcement training events about the laws in Georgia regarding mental health both in the civil and criminal systems. I will never forget a young officer asking me once what options were available for law enforcement in cases where they interact with someone who is acutely symptomatic and who has had negative interactions with law enforcement on a repeated basis. She was clearly frustrated: she didn't want to arrest and take these individuals to jail, but there seemed to her that there were no solutions for her in these situations other than incarceration and involvement of the criminal justice system. If this new legislation can foster the growth of meaningful, mandated outpatient accountability frameworks, then police have the alternative to jail they've been looking for; something aimed at keeping these individuals stable, but also helping them grow so that that they can become contributors to their communities. It might help end the revolving jail door for many men and women struggling to find insight and treatment.
(9) have "exit evaluations" prior to an individual's release from mandated treatment to ensure extension of the period isn't necessary;
(10) dovetail services if transition to voluntary care is warranted.
There is no finish line in the process of treatment of mental health challenges, just continual growth and understanding. If this new framework is to be implemented, it is vital that the individuals don't see the end of Court monitoring as the end of their treatment. Part of that goes to the aims of the implemented programs in helping an individual gain insight, growth and engagement with her providers. But keeping a forward-looking plan upon completion of Court involvement is critical to seeing the process repeat itself, and it was good of the legislature to point this out in the Bill.
Beyond defining the framework for mandated outpatient care, the Bill goes further, by establishing a process for the awarding of grants to implement programs in line with the Bill's aims. In other words, they're putting their money where their mouth is, rather than simply revising old, under-utilized statutes as lip service to those who have bemoaned Georgia's mental healthcare system for decades.
By boldly establishing a vision for mandated outpatient treatment, the Georgia legislature is taking a giant step to improving the legal system for mental healthcare on the civil side of the law. It's about time.