Fixing Mental Health Services without Coercion

Harvey Rosenthal
Executive DirectorNew York Association of Psychiatric Rehabilitation Services (NYAPRS)

In our final post on AOT Harvey Rosenthal explores the role of evidenced-based wraparound services in providing better mental health care outcomes.

Outpatient commitment typically involves mandating individuals to accept the same treatment approaches that have already failed or deterred them in the past. We know a lot more about how to help people in severe distress, but these methods are typically not offered or are not sufficiently available. These include a number of evidence based approaches like

  • Transitional Supports: using critical opportunities to engage people when leaving inpatient and detox facilities and prisons and jails
  • Individualized Care Management: organizing care across multiple behavioral and physical health and social systems that operates from shared information and offers real time response
  • Housing First and other harm- and homelessness-reduction models: offering individuals what they most need to be safe even if they’re not currently willing to take medications or stop using alcohol and drugs
  • Person-centered Planning Tools: utilizing Wellness Recovery Action Plans and Advance Directives
  • Criminal Justice Diversion and Re-entry Services: using court-based mental health workers, Crisis Intervention Teams, and better prison discharge plans and support services
  • Peer and Family Supports: incorporating peer crisis warm lines, respite houses, outreach, bridger and wellness coaching as well as family-to-family support
  • Employment and Education
  • Evidence-based Medicine: relying upon the latest research, providing more individualized care, and utilizing less drugs over a shorter period of time

Reimbursement and Outcomes System Changes are Critical
We now know how to offer vastly improved outreach, engagement, and follow-up services, but most of these supports are either under-resourced or not available at all in local communities. Implementing these approaches may require additional federal, state, and local funding, but they may also be funded by redirecting funds from the avoidable use of costly emergency room and hospital stays.

Further, systems and providers typically offer the services that offer the outcomes for which they’re paid. Reimbursement models must move from paying for participation in the same old programs to tying payment to individualized and innovative approaches that demonstrate success. Affordable Care Act-related reforms that make greater use of managed care’s flexibility and focus on outcomes are already demonstrating greatly improved results for the individual, as well as realizing cost savings for the community. Reforms that restructure care through integrated health home provider networks are also recognizing similar benefits.

Investment in relationship building is crucial, however if these programs are going to be successful. We must be willing to pay up front for an engagement process that can take as long as 3 to 6 months.

Someday we’ll look back on service systems that were so unable to engage some individuals in distress that we turned to the criminal justice system to force that engagement, and hold ourselves accountable.  We will wonder how it was that we let ourselves off the hook with views like “this is the best they can do” and therefore “this is the best we can do.” Now is the time to rewrite that history.

This is a time for collaboration, not contentiousness. Murphy and Barber should forge an alliance that advances proposals that they already share. Both sides agree that we need to enhance services for families, veterans, children, students, people who are at risk for suicide, and criminal justice-involved individuals, and create programs that improve the responsiveness of our workforce. Let’s hope they can roll up their sleeves and get the work done.

Your Turn

  • Which parts of Harvey Rosenthal’s arguments for broad services and meaningful engagement resonate for you?
  • Which examples of engagement and community-based services have you experienced, and how did they help (or not help)?
  • How can we motivate our legislators to adopt policies that recognize the benefits of a more relationship-based, broader services model of client engagement?

[poll id=”22″]

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The parts of broad services and meaningful engagement mentioned by Rosenthal that most resonate with me include transitional supports, case management and real response time.

As a provider, I have seen countless times we lose opportunities to engage people as they are leaving inpatient and detox facilities, as well as prisons and jails. Also, we certainly are in need of more individualized care management services, yet in my experience, many times mental health organizations lack the resources needed to provide good training opportunities for staff, as well as the technology needed to appropriately manage care across multiple behavioral and physical health and social systems.

In terms of real response time, I agree that it is vital. In my state, we face many issues regarding real response time. For one, we struggle with a shortage of psychiatric care, so we face serious access issues. Also, people in rural areas andpeople with chronic issues are often required to drive many miles often to attain quality and affordable care. We also do not always have the people we need to travel to talk to consumers about things like peer programs. Still, people need education about their symptoms, conditions and treatments and they need help to navigate the system. Certainly we also need to respectfully help people understand how to finance their healthcare needs. One solution I see is teleheatlh and telemedicine, as I agree that real time response is extremely important. I think tele health solutions can both augment and enhance care coordination and help to stabilize the consumer’s condition. In addition, it can be used in the development of a WRAP plan and a Crisis Plan. Though I know this is a newer notion compared to location-based delivery, I think it will be part of the modern mental health and addiction system, as well as part of resilience and recovery support.


Mr. Rosenthal is a highly credible individual, recognizing treatment methods and the responsible approaches. In addition, he is in touch with realistic challenges, such as time duration for effectiveness and cost possibilities. What resonates most with me is his awareness that we will regret more and more our reliance on the criminal justice system. Training as an advocate since January, my cognition has become alerted to news reports of horrifying and pitiful overcrowding in prisons. Persons with mental illness issues factor into that sad situation. These persons could improve via access to one or a combination of the treatment methods Rosenthal enumerates. The example of engagement and community-based services that I have experienced to great benefit is peer-to-peer and family-involvement support. Specifically, for the past 10 years I have been associated with a DBSA support group. From this connection have grown other relationships--including correspondence with _BP_ and _Esperanza_ magazines, experiencing the vicissitudes of the DBSA website, and learning about this advocacy training opportunity in  January. One good step leads to another. To motivate our legislators to adopt policies that recognize the benefits of a more relationship-based, broader services model of client engagement, we need to strike a balance between sharing a bit of our personal information and asserting knowledge of statistics. We need to be even tempered, confident, and persistent.