The picture emerging of Aaron Rey Ybarra is crushingly familiar.
A young man with documented mental health problems (he was twice evaluated for involuntary psychiatric hospitalization) who’d said he “wanted to hurt himself and others“; who hadn’t seen a mental health provider for months and appeared to be taking his medications sporadically; yet was striving for stability, with a new job and sessions at Alcoholics Anonymous.
The picture still needs to be filled out, and the policies to spin out of this tragedy should include a review of state gun laws. But I read Ybarra’s story as a call for an important mental health reform, largely neglected here in Washington.
Ybarra may have been a good candidate for what’s known as Assisted Outpatient Treatment. It involves court-ordered outpatient therapy, with intensive supervision of a treatment plan that can include housing and other help. Patients have to have a serious illness, including hospitalizations, and often have a history of noncompliance with treatment.
New York has a program, known as “Kendra’s Law,” with about 2,500 people, at a cost of $32 million, according to a New York Times story, but it is estimated by Duke University researchers to save about 50 percent per-patient off state Medicaid costs because patients didn’t go to expensive hospitals nearly as often.
From the Duke study, which included New York and surrounding counties:
In the New York City sample, average costs declined 50%, from about $105,000 to about $53,000 per person, and in the five-county sample, average costs declined 62%, from about $104,000 to about $39,000 per person.
D.J. Jaffe, who writes about Assisted Outpatient Therapy at mentalillnesspolicy.org, has a clear summary in the Times story:
“…It doesn’t just commit the patient to accept treatment; it involuntarily commits the mental health system to provide it. The court order applies to both.”
In short: An evidence-based, cost-saving mental health reform with strong potential to improve patients’ lives while improving public safety. Yet Washington State doesn’t have much of it.
The Treatment Advocacy Center, which issued a report on Assisted Outpatient Therapy, says Washington does have it, in the form of what’s called “less restrictive alternatives.”
King County uses it more broadly than others, but across the state, that law is more often used to let someone out of a hospital, not preventing them from going in. The Washington chapter of the National Alliance on Mental Illness has lobbied the state Legislature for the past few sessions for a broader Assisted Outpatient Treatment law, without success.
“This latest incident shows, it’s needed right now,” said Sandi Ando, the Washington NAMI policy chair. “The important thing is to get people help before they tumble off the edge. Tragically, some act in ways that hurt someone else. More commonly, the tragedies are people hurting themselves.”
Assisted Outpatient Treatment is not widely adopted because of its cost (although cost-benefit analyses never include the cost of not acting). It also rubs up against the question of a patient’s civil liberties, which in Washington tend to trump. I understand the controversy — Assisted Outpatient Treatment takes away some of a patients’ rights to make medical decisions.
But it also mandates earlier treatment, before a person’s mental health dissolves into them needing emergency hospitalization, which is both dehumanizing and expensive. Assisted Outpatient Treatment should be on the Washington Legislature’s agenda next year. When candidates come asking for your vote this fall, ask them where they stand on Assisted Outpatient Treatment, and why.