and welcome. I'm Dr. Deborah Pinals, and I serve as a forensic consultant for SMI Advisor. Additionally, I serve as the director of the program in psychiatry, law, and ethics, and as an adjunct clinical professor of psychiatry at the University of Michigan Medical School. I'm also senior medical and forensic advisor for the National Association of State Mental Health Program Directors. I am delighted that you are joining us for today's SMI Advisor webinar, The Utility of Outpatient Civil Commitment. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Continuing education is available, and today's webinar has been designated for one category, category one credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers, and credit for participating in today's webinar will be available until April 1st, 2024. Next slide. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Next slide. Captioning for today's presentation is also available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a slide window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel, marked Q&A. We'll reserve about 10 to 15 minutes at the end of the presentation for this question and answer period. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Steven Siegel. You can go to the next slide. Dr. Siegel has devoted his career to maximizing the opportunities of vulnerable groups. He has accrued 52 years of international perspective on mental health, health, child welfare, and justice system activities in the U.S., Commonwealth countries, the Middle East, and the world. His research has increased understanding and helped better services for people with severe mental illness related to their health care, medication utilization, justice system involvements, housing, homelessness, stigma, legal rights, coercive interventions, and consumer self-help. Dr. Siegel, thank you for leading today's webinar. We'll now turn to the presentation. Hello. I'm glad to be here, and I have no conflicts of interest with respect to this presentation or the subject matter. Today, I hope that at the end of this webinar, you'll be able to describe the purpose of outpatient civil commitment. Based on the data presented, you'll be able to describe the three potential strengths and weaknesses of outpatient civil commitment implementation, and you'll be able to explain the consequences of reducing outpatient civil commitment by use of limiting it to those who lack capacity. Our agenda today will be first to look at outpatient civil commitment law, its provisions and variations, to consider the outcomes under the law, and the characteristics of patients who have been assigned to outpatient commitment worldwide. We'll look at the context in which outpatient civil commitment is implemented as there's considerable variation within different mental health systems. We'll look at the outcomes addressing the protection of health and safety, that is, the limited well-being responsibilities of the law. We'll consider the outcomes addressing the provision of needed treatment and providing a less restrictive alternative to care in hospital. We'll consider the strengths and weaknesses of outpatient civil commitment. We'll look at stakeholder views and concerns, hopefully in the light of the data that we presented, and then we'll come to some conclusions. First, outpatient commitment law worldwide addresses the protection of health and safety of self and others. It is often referred to as compulsory community treatment, assisted outpatient treatment, community treatment orders, and conditional release. It all really derives from the Supreme Court decision in Donaldson versus O'Connor, where the court held that it is not constitutional to confine anybody or subject them to involuntary care if they are not dangerous to themselves and others. So I'm going to speak about outpatient commitment and refer to it as OCC for convenience purposes. OCC is a legal intervention. It's a contract. It's not a treatment. It is initiated to protect against imminent threats to health and safety of self and others due to a mental disorder. Now, it's inclusive of provisions of protecting against grave disablement and potential deterioration. It requires individual participation in needed treatment that the patient is refusing or would be refusing due to their mental illness. Two outpatient commitment laws address the less restrictive alternative provision of the law. First would be the single episode assignment law. Single episode assignment law. Here the episode is defined by the duration of the patient's threat behavior. This is usually the duration of the patient's hospitalization experience. So some patients may come to hospital and be assigned to outpatient commitment immediately, though that's a small number. But most patients spend time in hospital and the duration of their hospital episode is limited because they are released earlier on outpatient commitment with supervision. Thus the less restrictive alternative is the reduction of the number of days during their threat conforming episode. The second approach in some laws is to add a prevent deterioration clause. That now applies to about two-thirds of U.S. jurisdictions. Many of those jurisdictions have a requirement for potential substantial evidence of past deterioration in order to assign somebody to such an outpatient provision. These assignments usually come at release from hospital and the requirement that they have for evidence of past deterioration usually is previous experience of coming to a psychiatric emergency room with eminent threats to health and safety. The episode here would be defined by the duration of the illness. The less restrictive alternative should be defined by the duration of community residence to the next hospitalization. The criteria are the same for OCC for inpatient compulsory admission in a majority of jurisdictions. Consequently, OCC is a less restrictive alternative to hospitalization. When the OCC contract is breached either due to patient lack of participation and or the inadequacy of community services, the patient is required to return to hospital to obtain needed treatment. OCC ends when the patient no longer poses a threat to health and safety or no longer poses a threat of potential deterioration or is timed out according to the law. The purpose of all OCC is to provide needed treatment to get a person through an episode of illness posing an imminent threat to health and safety or to prevent the recurrence of such an episode. It is to avoid life-altering negative experiences going forward and to the extent possible to keep the person in community residence. Statutes do not mention preventing hospitalization. Hospitalization is part of the intervention, the provision of needed treatment. There is another law that has been adopted or ratified in many countries under the United Nations Charter on the Rights of Persons with Disabilities, the CRPD. This is not ratified by the United States. It allows people with capacity to refuse OCC assignment and not all countries that have adopted the CRPD have the capacity to refuse OCC assignment provision. The CRPD recognizes the duty of people with severe mental illness before the law. In other words, it holds the severely mentally ill responsible for their criminal acts and advocates for their transfer to forensic facilities when found guilty of a criminal offense. We'll discuss here now legal outcomes addressing the purpose of OCC, other desirable treatment outcomes, and we'll consider OCC patient characteristics, that is, the population characteristics of those assigned to OCC. Let's first look at the legal outcomes. Let's first look at the legal outcomes. Quality-of-life measures limited to reductions in threat to health and safety of self and others, including criminal offending, victimization by criminal offending, mortality, diagnosis of life-threatening physical illness, are legitimate legal outcomes under OCC assignment. Ensuring participation in needed treatment during OCC is, in fact, a legal outcome. Delivery of care as a less restrictive alternative to hospitalization is a legal outcome. Other reported patient characteristics in several studies include treatment outcomes. Now, these are desirable, but not within the legal scope of OCC, and they include quality of life in general, housing provision, or satisfaction. Hospitalization and rehospitalization are the provision of needed treatment, the OCC intervention. They are a response to predicted deterioration, inadequate community service availability, hospital bed availability, or enforcement of poor patient compliance. Let's look at the characteristics of people worldwide who are assigned to OCC. OCC patients present with imminent threats to health and safety. This is a major requirement. OCC patients are generally more severe, have more severe symptomology than other patients needing inpatient care. This is not a requirement, but it is observed characteristics in studies. They lack insight and are refusing treatment. The refusal of needed treatment is a requirement. Though not an OCC requirement, the majority of OCC-assigned patients are those with diagnoses of schizophrenia and non-effective psychosis, 70% to 85% usually in studies. In studies, these patients have experienced multiple inpatient admissions and extensive outpatient services, though having such experience is not necessarily a requirement for outpatient commitment in many jurisdictions or under the law. They're also characterized by poor premorbid adjustment. The outpatient civil commitment population represent a small proportion of any admissions cohort. On the other hand, their numbers are cumulative because they're generally suffering long-term illness that is episodic, where the episodes are often poorly predicted. Let's look at outcome studies, outcomes of outpatient civil commitment. In multiple international comparisons, OCC patients are at greater risk than hospitalized, non-OCC comparison for negative outcomes. They are not the equivalent of other hospitalized comparison groups. Matching is not possible, nor is randomization from OCC to no OCC. Physicians do not let people out of a hospital that are actually dangerous if they're going to be placed in a non-supervised situation. Comparing the OCC to hospitalized, non-OCC assigned groups, even with statistical adjustments, should always produce more negative findings for the OCC population. Thus, the no-impact expectation is OCC remains worse off than the non-OCC comparison group. Thus, the null hypothesis is inappropriate for OCC comparisons. Bringing the OCC group to the same service use level as a non-OCC group is a positive outcome. Finding no difference in threat levels of dangerous behavior is a positive outcome. No OCC, no randomized controlled trials of OCC exist. The three Cochrane-reviewed studies do not control post-randomization and conflated at their primary outcome, hospitalization, with their intervention, hospitalization. OCC varies by context, especially by the procedures and the characteristics of different mental health systems. So, as such, we're going to look at Victoria, Australia, Victoria's relevance to the United States. Victoria's OCC criterion is the protection of health and safety, as it is in the U.S., and it is the same criterion for OCC assignment. OCC in Victoria and the United States are legal matters, and the consequences of non-adherence to treatment are the same. Hospitalization is meeting the inpatient criterion. Affirming an OCC order differs only by who makes the decision in these two countries. A single hearing officer in the United States and a tribunal consisting of an attorney, a psychiatrist, and a community member in Victoria. Finding against a petitioner for OCC assignment in the U.S. would be done by a judge, and it rarely happens, so we have no formal records of this in the U.S. In Victoria, between 2000 and 2010, 20% of the OCC cases were discharged before their hearings, and only 5% were discharged after their hearing. Victoria is in a unique situation. It has statewide multi-system data. We have records of all mental health, health, police contacts, social services, and tribunal contacts. There are national databases, which relate to mortality and neighborhood social disadvantage. There is a national assessment program of symptomology of patients at admission and release from hospital and at follow-up. All of these data have been integrated for the mental health and social welfare research group at the University of California, Berkeley. No such data for evaluation purposes exists in the United States. Australia also is unique in a sense it has a single-payer health care system. Victoria makes voluntary services available, so arguments that treatment would be obtained on a voluntary basis, if they were available, do not apply in the Victoria system. Assertive community treatment developed in the United States was first replicated internationally in Australia. ACT is the model of community care in Australia and in Victoria. We're going to look at three decades of OCC in Victoria, Australia, as contexts for care. First, we'll look at 1990 to 2000, which I call a period of deinstitutionalization. This was a transition from hospital to community care. Victoria focused on the development of an extensive community care system with a heavy reliance on OCC to facilitate that transition. The jurisdiction still had psychiatric hospital beds for civilly committed patients during this time. The second period we will focus on, 2000 to 2010, I call the victory of community care. By 2000, all psychiatric hospitals in Victoria closed. The state unit supporting this transition was disbanded, which was somewhat unfortunate. This unit had helped build an incredibly competent community care system with significant reliance on the general hospital as backup and outpatient commitment. OCC was more frequently used in Victoria than in other jurisdictions in support of community care. Then we look at 2010 to 2019, and we see a successful effort to defeat, I put that in quotes because it is the statement of civil libertarian clinicians, to defeat OCC utilization with a focus on patient capacity to refuse treatment. The lobby for the defeat of OCC won support and ratification of the CRPD. The capacity criterion was inserted into civil commitment and OCC assignment criteria law in Victoria and actually throughout Australia. The initial OCC assignments in this period dropped by 3%. Overall OCC dropped by 15% during this decade. Other criteria for OCC assignment, however, remain the same. You still had to be refusing treatment. You still had to be posing a threat to health and safety of self and others. Now, let's look at OCC outcomes, empirical outcomes by context. First, we'll look at mortality. OCC versus non-OCC has been associated with all-cause mortality risk in six of nine studies internationally. If we look at the two studies, of two of the studies where it was not so found, we see a potential positive outcome given patient group severity differentials. Pre-CRPD, Alec found in Australia, no difference between groups in a small study, although all suicides and deaths due to unnatural causes were in the comparison sample. Post-CRPD, my group found no difference between the groups. Again, a potentially positive outcome giving the impact of the CRPD on constraining OCC utilization. The third study does not compare OCC versus non-OCC, but it compares deaths during OCC with deaths post-OCC. This took place in New Zealand, and in the Beagle Hall study found higher mortality rate during OCC versus off-OCC. Now, it should be noted that 80 to 81%, I believe, of the deaths in the Beagle Hall study were due to medical causes. And I'm going to come back to this because this is very relevant to the next slide, but it's very important to note that because this is very relevant to the next set of outcomes we are approaching. We're going to look at protecting health and safe health using available care in three studies. First, we're going to consider getting a diagnosis for at least one of five life-threatening illnesses. Pre-CRPD, outside of OCC supervision, the likelihood that an OCC patient received a physical illness diagnosis was 31% less than non-OCC patients and the same as outpatients. This is very unusual because the prevalence and incidence of these conditions is well-established to be much higher among the very severely mentally ill. So under OCC supervision, the likelihood of such a diagnosis was 40% greater than non-OCC patients and five times that of outpatients. Now, if we can relate this... Oh, okay. Each episode of OCC equal to 14% increase in the likelihood of receiving a diagnosis. The second study is post-CRPD. So we're still talking about people who were assigned to OCC in comparison to other hospitalized patients. Outside of OCC supervision, the likelihood that a patient would receive a diagnosis of physical illness of one of those five physical illnesses was 36% less than non-OCC patients and only 1.3 times the general population of outpatients. Under OCC supervision, the likelihood was two times non-OCC patients and 6.6 times that greater than outpatients. Each episode was responsible for a 4.6% increase in the likelihood that an OCC patient would receive a diagnosis. Now, we're going to shift from getting a diagnosis to getting a specialized medical procedure. Remember now, Victoria, Australia, and Australia is a single-payer mental health system. Medical care is available to anybody who gets a diagnosis. So OCC assignment in this particular study showed that OCC patients had equal access to a specialized medical procedure as did non-OCC patients. What that says is once the OCC patients got the diagnosis, they got the procedure. We go back to the Beaglehole study on mortality, and we had more deaths under OCC supervision and less deaths after OCC. That should note that many of those OCC-assigned patients didn't get their diagnosis until they got on to OCC, and that diagnosis was often too late for the specialized medical procedure to address their illness, the life-threatening illness. So you had a dire death rate under OCC during the provision of OCC, and those who actually got the medical procedure probably had a lower death rate following their OCC assignment. Next, we move on to crimes against persons, violence and suicide. In three U.S. studies found reduced arrest risk, less serious violence, perpetration, and suicide risk, and with six months of OCC, people had lower incidence of violent behavior. Going back to Australia, four Australian studies reported 63% reduced violence during OCC versus the comparison group, but higher violence prior and higher violence after OCC. Another study reported shorter duration of disturbed behavior during OCC versus pre- and post-period. In our study, we found the reduced risk of initial and repeat involvement in major crimes against persons, and we are working with the police data in Victoria, which reports every incidence of police contact with a patient, and the result of every incident. Perpetration of crimes against persons post-CRPD with the capacity to refuse treatment and a 15% reduction in OCC use. Patients' major crime incidence increased over the pre-CRPD period. The OCC patients' incidence increased 225%. Their rate in comparison to the state's rates, free versus post, went from 3.67 times the state's to 8.2 times, 8.27 times the state. The non-OCC patients were up 180%, and their rates went from 4.1 to 5.6 times the state rate. The outpatients were up 3,197%, and their rates went from about equivalent of the state's rate to 3.4 times the state. But why would you have an increase among the non-OCC patients? The reason for that is these people had the capacity to refuse treatment. So, a hospitalized patient could refuse OCC assignment. Thus, in the data, they would have joined the non-OCC hospitalized patient comparison group, and their crime statistics would contribute to the rate of increase in the non-OCC group. Similarly, under the capacity to refuse treatment criterion, patients could refuse hospitalization and outpatient care. On the other hand, they would still have been reported and included in the system as having one outpatient contact, and as a result, would have been included among the outpatient group for comparison purposes. And that is why you're seeing these elevated increases. All increases were driven by assaults and abductions in all cohorts, and these are primarily assaults because there are really few abductions. Victimization by major crimes against persons, that's another one. In the U.S., North Carolina group reported less criminal victimization than the control group. Pre-CRPD in Victoria, OCC reduced initial and repeat victimizations by major crimes against persons. Post-CRPD with capacity restrictions in 2010 to 2019, 34% of all patients were victimized by a major crime, upped from 28%. 25% of outpatients had one victimization versus none pre-CRPD. OCC patients were victimized by major crimes, victimization by major crimes increased 278%, non-OCC patients by 467%, outpatients by 1,871%. The numbers here are all driven by assaults, major crime assaults, and abductions. Again, few abductions. Treatment and medication adherence. 10 study meta-analysis in England, Australia, New Zealand, U.S., Canada, and Spain found that greater attention to medication was received during OCC, but did not extend beyond the duration of the OCC order. In the U.S., there has been an association of increased medication possession associated with OCC assignment. OCC duration of six months has been associated with more medication compliance. In Australia, pre-CRPD, they were significantly able actually to reduce medication dosage during OCC in a small study. And generally, medication changed from poor to good during OCC, but declined post-OCC. There were no difference in medication compliance between OCC and the non-OCC group over this period of study by Bauer, and so that might be taken as a positive. Post-CRPD, you had increased dispensing of psychiatric medication in New Zealand. The provision of needed outpatient treatment. OCC in five countries was associated with a moderate effect of increased community service use. In a more recent study, not included in this meta-analysis, in New Zealand, patient experienced increased psychiatric community context. OCC in Western Australia, community contacts were greater for OCC patients than controls. Less drinkers. What does variance in OCC hospitalization indicate? Hospitalization occurs when a person fails to cooperate with treatment, receives inadequate treatment in the community, and deteriorates. Hospitalization does not occur when a person ends up in jail or in prison. The rehospitalization provision in OCC is not enforced, as it wasn't in the New York study, and there are no beds available in the hospital. Looking at the less restrictive alternative outcomes, again, there are two conditions. One is exit early from the hospital, and the other one is increasing one's time in community residence prior to the next hospitalization for these long-term patients who have repeated episodes. We're looking at the duration of episodes in three years of care. In deinstitutionalization, all hospital episode durations were reduced in these three studies. And under the community care situation, again, hospital episodes were reduced in duration. In the CRPD, initial OCC use decreased by 3.5%. Interestingly, initial hospitalizations increased by 5.9% during this decade, and OCC was associated with reduced hospital episode durations. It might be, ironically, that in trying to achieve a similar libertarian objective, they've abandoned OCC, increased hospitalizations, and may be somewhat responsible for what everybody talks about as wishing to avoid. That is the revolving door. As opposed to, we're talking now about, you know, about increased community residence prior to the next admission. This is the attempt to prevent deterioration, to expand time in the community for people who have multiple episodes. We found no difference between the control and the OCC in the New York study, and that's because rehospitalization wasn't enforced. And in the North Carolina study, this was not covered. It was released to prevent deterioration until expected another episode. In the CRPD jurisdiction between 2013 and 2017, the OCC group had a shorter time to readmission than the control group. I wonder because they're more serious and you don't use OCC that often that you were actually promoting a more revolving-door experience for this OCC population. That's a hypothesis, not a proven fact. The CRPD in Victoria, patients on OCC spent 112.68 more days in the community than re-hospitalized non-OCC patients. So, three randomized trials with hospitalization designated as an outcome focused on preventing deterioration and failed to find between group differences. These studies get a lot of attention. However, significant numbers of patients in the trials were not qualified for OCC. In North Carolina's study, only 35% of their study population had non-effective psychosis diagnosis versus about 70 to 85 percent in most studies. In the New York study, as well as in the North Carolina study, violent history was excluded. Re-hospitalization in New York was not enforced. In the UK study, which compared two versions of short versus an extended version of OCC, the patients actually released had better symptomology scores on the BPRS and the GAF scores than normative for OCC patients, and they had almost perfect insight into their illness. I mean, these patients were unlikely to refuse treatment. The three randomized trials referred to repeatedly in the literature as randomized control trials did not exercise post-randomization control. The New York study didn't enforce re-hospitalization. In North Carolina's study, treatment was locally varied. Patients not qualified for OCC were released by an independent court 90 days into the trial. In the UK study, treatment was local, and 72-hour returns to hospital, it's my understanding of their report, were not counted as hospitalizations and not reported. So, let's get the stakeholder views. Given what we've just learned to this point in time, we're going to look at OCC assignments. Assignees, 581 people. The themes of their reports are from seven jurisdictions. As with respect to interactions with providers, they're feeling coerced and controlled. Feelings of a lack of respect and dignity. We certainly need to improve our interactions with these people. They found that positive relationships with clinicians helped. Difficult relationships with clinicians don't help. As far as treatment goes, they believe that medication adherence was seen as the main reason for OCC, as opposed to getting them through a threat episode and getting other types of services to them. They did see OCC as providing a safety net for them, and they valued it because of the services provided. OCC, they viewed OCC as preferable to being in the hospital. And there was ambivalence regarding balancing acceptance of enforced treatment with feelings of increased wellness. As to the law, they had concerns that clinicians lacked knowledge about the OCC's community treatment orders, OCC legislation, and process. And this is sort of my experience in some reviews that I've had where reviewers seemed to indicate that they had not read the law by their statements. Clinicians, their views, and we're talking about 700 clinicians in six jurisdictions, they also emphasized medication compliance as the main reason for OCC. There is still room for improvement, they report, and there are benefits for individuals on OCC despite the tensions that exist within and between clinicians on this thing. The family, OCC enables families to influence clinical care, that's their beliefs. They're dissatisfied with some aspects of OCC, as I think everybody has to be somehow dissatisfied with some aspects. And they see the benefits of OCC outweigh the disadvantages. So, I come to some conclusions. OCC is effective when it's fully implemented. OCC is less affected when it's not fully supported by the mental health system in which it is implemented. And the CRPD additions related to civil commitment, emphasizing capacity to refuse treatment, have increased health and safety threats and seem to have criminalized many severely mentally ill previously subject to OCC. Stakeholder views need to be addressed as a means of improving OCC utilization. I think as a means also of improving treatment and treatment approaches, and as a means of improving OCC outcomes. I thank you very much for listening to me for all this time. The right of the psychiatric patient to be free is a precious and important one. Yet even that right must be reasonably weighed against the right of the patient and those around him to be protected from tragic and serious untoward effects of the patient's illness. Thank you. Here's your bibliography, folks. Thank you, Dr. Siegel, for that fantastic presentation. I really appreciated your thoughtful analysis. Before we shift into the Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app, and you can go to the next slide, yep, to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app exclamation mark. All right, or slash app. I think the exclamation mark is a part of that. All right, so now let's moderate. I'm going to moderate the Q&A. I see we have several questions for you, which is wonderful. So the first question is that for an LCR, who are the community members involved when determining services required due to the deterioration? For a, who are the community members involved in determining services required? I think that's an important issue to consider. I think that we have in many jurisdictions consumer advocates, consumer self-help programs. At one point, I directed a center on self-help research, and at that point, we had consumer groups in some of the jurisdictions that we studied involved in helping provide services. We did studies of 10 combined efforts of consumer-led self-help organizations in combination with community mental health organizations, and when those consumer-led organizations were empowering organizations, in combination with community mental health organizations, they actually helped very much improve the outcomes of such patients. Okay, great. Thank you for that answer. Our next question is, can you explain what you mean by more severe symptoms than other patients needing inpatient care? That seems a little bit counterintuitive, and I'm confused by the, the person says I'm confused by the comparison groups, and thanks you for the helpful presentation. So, can you clarify that distinction between severity of symptoms? Right, we use the Health of the Nation's scale, rating scale, to look at 12 symptoms at admission to hospital and release from hospital. In Australia, they had an independent group of clinicians independently assess the, the symptomology, that is, violence, hallucinations, delusions. The 12 symptoms in the Health of the Nation's scale were assessed by these independent, at admission and release, by an independent evaluator, who did not make the decision, by the way, as to whether they were going to be assigned to OCC or not OCC, or admitted to the hospital, or not admitted to the hospital. Now, what we have done is we looked at their profiles, or the severity of their ratings on each of these 12 symptoms, and the pattern of severity, the OCC patients consistently had a higher severity ratings on these 12 symptoms than any of the other groups. So, these people are, people are being selected to OCC because they pose a threat, an imminent threat to health and safety, and the symptom ratings tend to show that. The rating scales were initially developed in Europe by John Wings Group, and I think that they really tell us that we are looking at a group with long-term illness. I must say that I worked with Ernest Broomberg at the Psychiatric Epidemiology Research Group in Dutchess County early in my career, and we worked with social breakdown syndrome cases, which is somewhat the equivalent of the assessments that we got in the HANOS, and similarly, I conducted, we had conducted studies in California's psychiatric emergency room assessments, where we developed the three ratings of involuntary admissibility scale, and we looked at 710 evaluations across 10 rooms, and the people who are likely to be assigned to these orders present more severely than those who are hospitalized, who are not assigned to the orders, and I think I would love to see more validation of this, but we've, this validation came across two decades, and we're talking about 80,000 people. Wow, yeah, interesting. So another question we got is that after the client completes the court guidelines of OCC, what does patient follow-up look like, or does this vary from state to state? It varies from state to state. It varies from jurisdiction to jurisdiction. This is the major challenge to care for the people with severe mental illness and long-term mental illness. We need to focus more on the provision of user-friendly services post-OCC. If you get a service, if you assign yourself to a, or buy into a service, so to speak, and you commit for a certain period of time, and during the service it doesn't, it's difficult, or you have major side effects, and when you get out of that service and you no longer have to comply with it, then you may not, you may drop it. We don't have enough research on long-term monitoring of psychoactive medications and of treatment provision. We need to work on that. It's not, we tend to attribute failures to the OCC law, but we need to work on improving the treatment that the people get within OCC and definitely following OCC, and, you know, holding jurisdictions responsible for providing good care post-OCC. Well, wouldn't the same thing hold true pre-OCC as well, that if you could maximize engagement, you could prevent any OCC, because it almost implies that OCC is necessary, and then the treatment should be better. Well, look, I've seen multiple episodes of care, and I don't think we have very good predictors of that, and a lot of the patients, you have to understand that patients are refusing treatment. These patients are refusing treatment. They're refusing treatment even in a system where the treatment is voluntarily available. They're refusing treatment even when they are potentially facing life-threatening physical illnesses. So, the idea that we should, and I have no problem with improving the treatment before and after, but I do not think that this is going to be engaging of a lot of these individuals. A lot of these individuals need a situation where, under OCC, they have a demonstration that they can receive a treatment that they can live with going forward. Right. Another question that came from the audience is, do you have any thoughts on the California Care Court legislation? Oh, yes. An easy question. Yes, I mean, I think we need more beds. We have a new bill that is coming up that will enable the construction of beds. I worked at Hudson River State Hospital, and in the Dutchess County unit, which was one of the first community mental health centers, and we managed two-thirds of our patients outside of the hospital. And when patients needed to come back to the hospital, they could come back from the hospital. When families needed respite care, they could come back to the hospital. I must say that we need a protected environment that enables patients to get through episodes that are personal threats to health and safety, and enables them to also stay in the community. That's about it. Yes. Sorry, go ahead and finish, because we're almost out of time. Okay, I said that's an important thing that we need to add to the Care Court. We need more beds. Okay. Yeah, and I would just suggest that that concept of needing more beds has been thoroughly studied through the APA. There's a great resource document that shows that, you know, just more beds, likely not the full answer, since there's an entire continuum of care that depends, that are interdependent. So knowing what's more, what's needed more of, is complicated unless you look at the whole system. So there is an APA resource document on that that people might be interested in. But we can move, where this was fascinating, and we can move to the next slide. Okay. And let people know, if there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, post a question or comment on SMI Advisors Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of the SMI Advisors national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. Next slide. SMI Advisor offers several other evidence-based resources that are related to the topics that we reviewed today on this webinar. I encourage you to visit the AOT Resource Hub. Here you can find a foundational white paper on implementing AOT, which is OCC, access online training modules on establishing and maintaining successful AOT programs, and even more. Access the AOT Resource Hub by clicking on the link in the chat or by downloading the slides. Next slide. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. Next slide. Please join us next week, February 9th, as Dr. Peggy Swarbrick presents Wellness Tools for Personal and Professional Practice. Again, this free webinar will be Friday, February 9th, from 12 to 1 p.m. Eastern Time. Thank you for joining us. Until next time, take care.

webinar

outpatient civil commitment

serious mental illness

OCC

mental disorder

provisions

severe symptomology

stakeholder views

post-OCC treatment

CRPD