Part 3 of our Title 25 series. Read Part 4 here.
Jodi Glover is exhausted. She usually is by the end of the day. Glover works two full time jobs: one as a doctor’s assistant in Cody, the other as the caregiver to her twenty year old son, who was recently diagnosed with schizophrenia.
“Literally he’ll stop eating for three or four days,” Glover said, describing one of her son’s psychotic episodes. “He is totally vacant, irrational, and also has refused to take medication. So as his caregiver, I’ve had to go to some extreme measures.”
Last year Glover initiated the Title 25 process on her son for the first time. That involved calling the police, who took him away from their Cody home in handcuffs to the local hospital. Glover described the experience as deeply painful.
“I had no choice. It was either that or let him die”
Her son Aaron was court ordered to treatment at the Wyoming Behavioral Institute in Casper. His condition improved there, But after a few weeks a judge found him fit to be released. Glover says she found out that her son had left the hospital when she got a call from an attendant there, asking if she could pick him up that afternoon. Glover works in Cody, a four and a half hour drive from Casper, so she said she couldn't be there anytime soon.
“Next thing I know I was getting a call from my son’s cell phone, saying they dropped him off at a mission.” Glover said, trying to control her frustration. “They gave him a bus token and dropped him off at a mission--a homeless shelter.”
For Glover, who was already overwhelmed with worry about her son’s fragile mental state, this was not a welcome call.
“Oh, I was hysterical.”
The Wyoming Behavioral Institute’s disregard for its patients' safety post discharge in this instance is not indicative of most psychiatric health care providers in the state (WBI did not respond to multiple requests for comment). But it does speak to a system wide problem in Wyoming: there is no comprehensive plan for Title 25 patients after they leave the hospital. Voluntary outpatient care, which would include steps as simple as making sure Jodi Glover’s son Aaron had a therapist appointment set up at home in Cody before he was discharged, is inconsistent at best. Moreover, Wyoming makes almost no use of court ordered outpatient treatment.
The result is a Title 25 system that spends thousands of dollars on on the same few patients returning to psychiatric hospitals over and over again. At the Wyoming State Hospital in Evanston about one in four Title 25 patients are readmitted more than once a year. Right now Jodi Glover’s son Aaron is on this path--four months after he got out of the Wyoming Behavioral Institute he began to refuse his medication, and Glover had to initiate the Title 25 process on him again.
Peggy Trent is trying to break this cycle. Trent is the newly elected Attorney for Albany County. Her basement office is littered with legal books, and she had a book of Wyoming’s collected statutes open when we met. Trent first became interested in Title 25 while consulting with Ivinson Memorial Hospital in Laramie on the subject a few years ago. She said that there she saw the same patients return over and over. Each time they returned to the hospital they were in a new crisis, “but they would come back through with the same underlying mental illnesses and underlying substance abuse problems.”
Now Trent is working on a pilot case manager project for Title 25 patients in Albany County. It would be a voluntary program, but Trent said it could do a lot to reduce the time Title 25 patients spend in the hospital. “The case manager would go to the patient, meet with them regularly [after they are discharged]” Trent said. “They would ask, “is [the patient] taking their medicine? How frequently? Are they following through? Families ask those questions, but its more powerful coming from a third party.”
Still, Trent said to really address the problem of recidivism for people like Aaron, who continually refuse treatment, state law would need to change to give courts the ability to order someone to see a therapist or take their medicine. “Court ordered outpatient care” is a controversial idea, both in Wyoming and across the country. Although 45 states--including Wyoming--have statutory language that would allow for this kind of treatment in theory, less than half have well defined eligibility criteria, according to the Treatment Advocacy Center, a national group that advocates for court ordered outpatient treatment.
But in the last few years court ordered outpatient care has started to gain more widespread acceptance. In fact, the poster child for the successful use of this treatment is a place in many ways similar to Wyoming: Nevada County, California.
“Nevada County’s a rural county of about one hundred thousand people,” said Michael Heggarty, Interim Director of Nevada County’s Department of Health. “And it's a pretty conservative county.”
Fifteen years ago Nevada County’s system for involuntary treatment for mental health issues was akin to Wyoming’s system now. Law enforcement and mental health professionals could detain and hospitalize someone during a mental health crisis, but they could not order outpatient care, or intervene before someone was in imminent danger. “There was nothing we could do if someone was not presenting as an immediate danger to themselves or others,” Heggarty said. “That was very frustrating to family members, to community, to law enforcement.”
That changed in 2001.
On the morning of January 10, 2001 a man named Scott Thorpe stormed into Nevada County’s main mental health clinic with a firearm. he killed two people. One of them was a bright young woman named Laura Wilcox.
“That’s how we ended up naming this Laura’s Law.”
Laura’s Law allows for court ordered outpatient treatment--in the weeks before the shooting Thorpe’s family had pleaded with local mental health workers to intervene, but there had been nothing they could do. The law was passed by the California legislature in 2003, but was initially only adopted in Nevada County. The requirements needed to initiate Laura’s Law are strict: the patient has to have consistently rejected voluntary treatment, and either have a history of violence like Scott Thorpe, or be at a high risk of returning to inpatient treatment, like Jodi Glover’s son Aaron.
Laura’s Law was not fully implemented in Nevada County until 2008, when a statewide levy on the wealthy provided the county with the funds needed to get the program off the ground. Heggarty says since then Laura’s Law has made a dramatic difference in the lives of those most at risk for involuntary hospitalization in the area.
“We have been able to reduce the amount of time spent in hospitals by 43 percent,” he said. “Jail days have been reduced by 52 percent, and homelessness has been reduced by 54 percent.”
That data was compiled by looking at the history of those ordered into outpatient care in Nevada County twelve months prior to treatment, and for twelve months after that treatment was over. The sample size for those statistics is only nineteen people: the county updates its data quarterly based on the current number of people undergoing involuntary treatment. But Heggarty said that, since 2008, these statistics have remained fairly consistent.
The Wyoming legislature discussed revisions to Title 25 last year that would have opened the door to court ordered outpatient care, but they did not pass. However there may be some change on the horizon: Wyoming’s Department of Health is currently working to develop a pilot court ordered outpatient program, initially in at least one county. And over the next few months a joint legislative-executive committee will consider a host of changes to Title 25, which may include court ordered outpatient care.
Right now none of this is much comfort to Jodi Glover. Her son Aaron was discharged from the Wyoming Behavioral Institute for the second time just a few weeks ago.
“I’m feeling very hopeless, I’m very scared,” she said, holding back tears. “I don’t know what the future holds. For him or I. It is day to day. Just day to day.”