Issue Position: Mental Health Services

Issue Position

On March 6, 2015 the Management Council designated Title 25 funding and entry issues as an interim topic for an appointed joint legislative subcommittee.

The subcommittee framed the Title 25 issues as follows:

Rising Costs

Increased Demand

Disjointed Title 25 process

Connection with the state funded mental health and substance abuse system of care.

Wyoming currently has no uniform reporting system for Title 25 data. Reliable data is imperative in both oversight and monitoring any ongoing process. Efficiency cannot be either measured or improved without adequate data. This, apparently, needs to be done with statutory authority to insure that all participants in the system comply and uniformity of data is insured.

If the legislature did nothing else to lower costs and deal with entry issues it should be to establish an independent examiner, especially in the counties of Natrona and Laramie. Neither hospitals that profit from hospitalizations nor mental health providers who treat patients should be considered as examiners. Neither is independent or objective. . Hospital examiners are pressured to hold people by their peers, the treating psychiatrist and the hospital administration. Mental health providers resent the legal process and many of them believe the decisions should be based not on legal criteria but on therapeutic judgment. Many individuals are held that do not meet legal criteria because they need therapeutic assistance.

An update to the Title 25 procedures manual is important as it has not been revised in over 25 years and most practitioners don't know one exists. The manual should include best practices and standards, a standardized assessment tool and relevant case law. This would assist in providing a uniform process throughout the state.

The 2016 legislature passed an amended outpatient commitment procedure measure, a bill that does little actual reform of the statute and will do nothing to reduce health care costs or support the mentally ill in our communities.

The states that have developed effective outpatient commitment laws have strict legal criteria for commitment. (Patients must have a history of serious violent acts or threats and be unable to survive safely in the community without supervision. Treatment plans are put together by a physician, the consumer, a patient advocate, and treatment providers. Consumers have access to attorneys trained to provide mental health legal services. Every court order is overseen by both the court [at 6 months intervals] and state departments of mental health. Orders are effective for 1 year only. The legal standard for commitment is clear and convincing evidence.)

The criteria in the new law is vague and entirely too broad. It criminalizes mental health with treatment planning that mimics probation or parole conditions; the oversight is inadequate and the legal standard is set to low for protection of a liberty interest. This, of course, raises serious legal questions.

Kendra's Law and other successful state laws require significant oversight and monitoring by state mental health officials along with regular court review. In addition, treatment plans must be written and specific in the services and medications to be provided and all providers must strictly follow court orders.

Successful outpatient commitment programs are thought by many mental health professions to be effective not because of their coercive nature but in spite of it.

The National Coalition for Mental Health Recovery writes : " However, repeated studies have shown that no evidence that mandating outpatient treatment through a court is effective; to the limited extent that court ordered outpatient treatment has shown improved outcomes, the outcomes appear to result from the intensive services that have been made available to participants in those clinics rather than from the existence of a court order mandating treatment. In addition, studies have shown that force and coercion drive people away from treatment."

Best practices community support prior to and post hospitalizations should be considered in place of coercive and intrusive legal methods.

Best practice for mental health services would include:

Maximize the use of community based services as an alternative to institutionalization, maximize consumer involvement in all aspects of planning and administration, research and provision
Wrap-around -- health care, including mental health care, pharmacology, therapy, case management, peer involvement, evidence based practice
rehabilitation counseling
skill training
independent living
occupational skills
wellness management
family education and therapy
individual psychotherapy
crisis intervention
substance abuse treatment
residential programs
housing assistance
medication
All of these elements should be available prior to hospitalization and post hospitalization with a narrowly tailored outpatient commitment process. Without the intense support services outpatient commitment is nothing more than dumping mentally ill patients on the street.
Initial steps to improve the Title 25 process:
Reliable single source data collection.
Independent examiner.
Practice manual

Source