[Newsletter readers: my full interview with Brian Stettin is continued below.]
We won’t be able to solve homelessness in our community until we — and specifically, our County and State governments — adopt stronger policies providing and, when necessary, requiring supportive services for mental illness and addiction. That isn’t to say that everyone living on our streets suffers from mental illness or addiction, or that everyone suffering from mental illness and addiction is homeless, but we know that the overlap is significant.
That’s why it was such a big deal when, after years of debate and delay, the County adopted Laura’s Law on May 25th. Laura’s Law, also known as assisted outpatient treatment (AOT), is court-ordered mental health care for severely mentally ill people, many of whom are unhoused and can’t fully perceive their own illness. It represents a small, but important step toward getting our most vulnerable community members the care that they need to have a shot at a better life.
In the lead up to that vote, our office organized a community working group made up of diverse stakeholders, submitted a co-signed letter, spoke at the County’s Health and Hospital Committee meeting, organized a petition with over 400 signatories, hosted a press conference, published an op-ed in the Mercury News, and organized over 50 speakers to share their voice at the May 25th meeting.
But it isn’t enough that the County adopted this new program on paper. As with all policies, the difference between success and failure lies in the implementation. That’s why we’ve stayed engaged on the topic and are in frequent communication with the County, expert practitioners, family members, and advocates. With their help, we’ve made progress toward securing an independent, citizen-led Laura’s Law oversight committee, though that work is far from done.
One of the key stakeholders we have worked with is Brian Stettin of the Treatment Advocacy Center, who has been instrumental in advising our advocacy, especially on implementation. He is very familiar with how to do assisted outpatient treatment well, and how not to do it well. Below is a brief interview I recently conducted with Brian on this topic, which I hope you’ll find interesting:
Matt: First, can you remind us of what AOT is, who it serves, and why you believe it’s a critical tool for local governments?
Brian: Sure. AOT stands for “assisted outpatient treatment.” It is an intervention strategy designed for individuals with severe mental illness who are caught in the “revolving doors” of the mental health and criminal justice systems, due to their difficulty — by no fault of their own — in understanding their need to stay engaged in treatment. AOT is civil commitment to outpatient care. It relies in part on the legal mechanism of a court order, which directs the individual to follow their treatment plan while also giving the court oversight over both the individual’s progress and the quality of care they receive. It is a critical tool for local governments because the research establishes that when implemented properly, AOT dramatically reduces hospitalization and criminal justice involvement for its target population. No other approach has a comparable track record of helping this group achieve recovery from their very cruel illnesses. And of course that has many positive ripple effects for the entire community.
Matt: You’ve been critical of SF’s implementation of AOT. Why?
Brian: I really don’t mean to single out San Francisco. Truthfully, their approach to implementing “Laura’s Law” (the California law authorizing counties to establish AOT programs) is typical of many counties across the state. And the problem lies not so much in what they do as in the missed opportunity of what they leave out. SF has reported positive outcomes with AOT and I applaud them for any success they’ve had. But if you compare their results and participation levels to AOT programs in other communities nationally, it is clear that SF and other California counties are only scratching the surface of the potential impact, and not making much of a dent in their overwhelming crisis of untreated severe mental illness. There are two main issues here. First, they are not practicing “step down” AOT, which means placing people in the program upon their discharge from a hospital stay. A routine “step down” practice for those who meet the legal criteria makes it much easier to find all the people in a community who need this program, and allows you to start them off while they are stable, enhancing their prospects for success. Second, they are using court orders only as a last resort, due to an unfortunate interpretation of Laura’s Law. Most of the people they count as being under AOT really aren’t, because they have signed “voluntary agreements” with no court involvement. Only the most intractable go to court. This denies the majority the significant benefits of the court order itself.
Matt: Who is doing this well and what does Santa Clara County need to do differently to ensure the success of the program?
Brian: There are many AOT programs across the country I would point to as models, such as San Antonio, Akron and Reno. But there is a perception that certain challenges with practicing AOT in California are rooted in the language of Laura’s Law, which programs in other states are not constrained by. That’s why I have encouraged Santa Clara County officials to take a field trip to Nevada County, up in the Sierra Nevada, which in 2008 became the first county in California to implement Laura’s Law. They will find a wonderful AOT program operating in perfect harmony with the law, while avoiding the limitations that other counties in the state have imposed on themselves. They won an award from the National Association of Counties for having saved their tiny county half a million dollars through avoided hospitalization and incarceration. Obviously, not everything they have done will be transferable to a county like yours, which has twenty times the population. But I would certainly follow Nevada County’s lead in figuring out how to maximize the program’s reach and leverage the power of the court order for each participant.
Matt: Why is it important to have independent, citizen oversight over AOT implementation?
Brian: At the Treatment Advocacy Center, we have found that the most passionate advocates for AOT are the families struggling to secure treatment for their loved ones who cannot recognize their own need for care. Santa Clara County is one of many examples where AOT is being implemented mainly because ordinary citizens cried out for change. But the need for families to be heard does not end when the program begins. After AOT launches next year, these same families will be best situated to assess whether it is living up to its promise. They will bear witness to how much or how little difference the program is making in the lives of the people they love. So if I were launching an AOT program, I would certainly want to create a feedback loop with these families. I would establish some sort of a forum to share information with them about the policies and mental health services to be included, as well as to receive information from them about how things were working. In short, I would treat the families of program participants as fellow stakeholders. I am hopeful that the Santa Clara Behavioral Health Services will see it the same way. Our conversations have been encouraging.
Matt: Some people argue that mental health care can’t be forced on unwilling patients, but you and I have both advocated for involuntary programs like Laura’s Law. How do you respond to that critique?
Brian: For starters, I ask people to consider the reality of AOT as it is practiced successfully across the country, rather than assume the worst. There is a lot less “force” in the AOT model than some might imagine. If an AOT participant violates the court order, they will not be held in contempt of court, or forcibly medicated, or automatically committed to a hospital. The only legal effect of a court order violation is to make it modestly easier to detain the person for a short term hold to assess their current condition and needs. Which is why AOT programs in real life do not attempt to motivate through fear of consequences. Instead, AOT courts and treatment teams seek to forge bonds of trust with participants and motivate through positive reinforcement. All that said, is there still an element of involuntariness in AOT? Of course. But anyone who dismisses the practice on that basis would have to ignore a pile of studies that show it improves outcomes markedly. In my work on this issue across the country, I have met countless amazing individuals with mental illness who have taken back control of their lives and credit AOT for making it possible. I believe them, and I’m looking forward to meeting more in Santa Clara in the near future!
Matt: Thanks Brian. We’re thankful that you are lending your time to help our community get this right!
As I hope is clear from Brian’s comments, how we implement AOT will directly determine its value. Our office will do everything we can to advocate for successful implementation so that the most vulnerable members of our community get the care they need. As always, we welcome you to get involved by joining our community working group on the issue. Just reach out to firstname.lastname@example.org with the subject line “Laura’s Law working group” to get involved.
[Matt Mahan is the Councilmember representing San Jose’s District 10, which includes Almaden Valley, Blossom Valley, and Vista Park. He and his wife Silvia are raising their children, Nina and Luke, in the West Santa Teresa Foothills neighborhood. Matt was previously co-founder and CEO of Brigade, the world’s first non-partisan voter network for civic engagement, which was acquired by Pinterest and Countable in 2019.]