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ASSISTED OUTPATIENT TREATMENT

‘Black robe effect’ drives success of state’s first court-ordered treatment program in Doña Ana County

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It took the death of a homeless man with a long history of mental health issues in Albuquerque to galvanize New Mexico legislators to finally pass the state’s first assisted outpatient treatment (AOT) law in 2015. A group of local officials – with guidance from a long-time national advocate – created the state’s first AOT program in Doña Ana County in 2016.

AOT “is the practice of providing outpatient treatment under civil court order to individuals with severe mental illness who have demonstrated difficulty engaging with treatment on a voluntary basis,” according to the national Treatment Advocacy Center (TAC). TAC Policy Director Brian Stettin was instrumental in drafting New Mexico’s AOT law and in writing the federal grant that funds the local program.

The shooting death of James Boyd in the Sandia Mountains in March 2014 “was the last straw,” Stettin said. AOT advocates finally had the full attention of the legislature. State Senate President Pro-Tem Mary Kay Papen of Las Cruces “was the hero on that front,” Stettin said, as she led passage of the new law.

“We’ve all held hands and marched forward together to get this done,” said Papen, a long-time mental health advocate. She described AOT as “a very kind way to deal with people with mental illness, to get them to do what they need to do to fly straight and level.”

Studies show that AOT’s “key ingredient is the black robe effect,” said county Health and Human Services Department Director Jamie Michael. “I have seen it in a courtroom,” Michael said. “The individual looks up at the judge and says, ‘You care about me?’ The more engaged the judge is, the better the outcomes,” she said. “Someone in that position to say, ‘I care about you, and I want to help you is very powerful.’”

Third Judicial District Judge Lisa Schultz – the person wearing the black robe – has “dedicated time to the program and been willing to learn about the best way to interact and communicate with someone who has a serious mental illness,” Michael said.

“I have to say that Judge Schultz has been amazing,” Papen said. She’s sort of been like a mother to this program. The job that she is doing, the amount of money it is saving us, emotionally and financially, what she is doing for people in our community is amazing,” Papen said.

Stettin, who has helped get AOT laws passed in multiple states in the past two decades, agreed that the program is most successful when the individual under care perceives the judge as an ally.

The system has expectations of the individual under AOT, Stettin said, and that person has “a right to expect great services.

“A great judge like Schultz” tells every participant, “‘I’m going to fight for you,’  asking again and again, ‘How is the quality of the treatment you’re receiving?’” said Stettin, who is based in Arlington, Virginia. Schultz, he said, is “holding both sides accountable. I can’t say enough about how important she has been.”

Stettin said he has “seen the total range of judges” presiding over AOT cases. “Some do more harm than good. They don’t have that sensitivity understanding people with severe mental illness.” he said. Schultz “is focused on what the person’s life goals are. That is what the whole program is about” – helping people “recognize that their lives are a whole lot better when they’re in treatment than when they’re not,” Stettin said.

“The people we serve are those who suffer from severe mental illness,” Schultz said. “This is a group of people historically who have not been provided with a voice. By creating this kind of wraparound, we actually bring the person to a place of being consciously and intentionally participatory in their own life in a positive way. This team that I am so deeply honored to be a part of provides people with those opportunities to become grounded, become more whole and become, in appropriate circumstances, productive members of our community. While the black robe effect … is important … there is no member of our team who is not equally important,” Schultz said.

Most people come before a judge because of a crime or a civil dispute, she said. The judge has a variety of tools to enforce compliance with the law, including jail in a criminal case.

“Here, a judge cannot and should not utilize any such sanctions, which means it is incumbent upon us to engage in the kind of dialogue that motivates an individual to become a better person,” Schultz said. “I don’t know what higher calling there could be for a judge.”

Schultz encourages participants to adhere to their treatment plan and oversees providers, Michael said. “She asks questions, she gets reports. Nobody wants to walk in the courtroom and disappoint Judge Shultz.”

“I have been exposed to numerous AOT programs across the country, so I can state with some degree of authority that ours is the among most respectful and patient-centered programs available,” said Micah Pearson of Las Cruces, who is president of the National Alliance on Mental Health (NAMI) of Southern New Mexico and a national NAMI board member. Pearson describes himself as, “a person in recovery who has seen first-hand how poorly the standard justice system is designed for persons like myself.”  

Every facet of the local AOT program has shown “tireless commitment and dedication to respecting the dignity and worth of the clients,” Pearson said. “What has impressed me most, however, has been the commitment from the court to learn about mental health and substance use, and all of the things that contribute to situations of crisis. Our program is now a core component of the developing crisis continuum of care in our community.”
AOT has been “really impactful” in Doña Ana County, Michael said. “It has a profound impact on a few people. It’s really meant to serve a very unique individual and one who has had repeated interaction with law enforcement, repeated hospitalization, someone who has found it difficult to adhere to a treatment plan.”

The county is working with New Mexico State University Crimson Research to evaluate AOT’s impact, including interviewing AOT participants, Michael said. Preliminary findings show that in its first three years, district court and local service providers served 113 participants under an AOT order, and more have been added since then, Michael said.

“Assuming a daily cost of $2,000 for in-patient hospitalization and 30 active clients, AOT saves $11,180 per client per month, $134,160 per client annually and $4,024,800 annually across 30 clients,” the study showed.

“There is also good reason to expect the use of AOT will yield savings for the criminal justice and correctional systems through reduced emergency calls, arrests, prosecutions and incarcerations,” the study said.

Stettin said a five-court study in New York State (which enacted AOT in 1999) showed costs declined 62 percent in the first year and an additional 27 percent in the second year after AOT began, hospitalizations were down significantly and medical and outpatient mental health treatment increased.

The local AOT program has been funded by a four-year grant from the U.S. Substance Abuse and Mental Health Services Administration. When that grant ends Nov. 30, Michael said the county will continue to fund the program in partnership with the district court, the district attorney’s office, respondents’ attorneys, Memorial Medical Center, La Clinica de Familia, Mesilla Valley Community of Hope, NAMI of Southern New Mexico and others.