An Assisted Outpatient Treatment Program Would Aid Hawaii’s Homeless - Honolulu Civil Beat

About the Author

Michael Wilson

Michael Wilson is a licensed social worker in Hawaii who received his master of social work from the Silberman School of Social Work at Hunter College in New York City. He has spent the last 10 years working with individuals diagnosed with a serious mental illness ranging in age from 5 years old to the elderly.

My passion is providing humanistic mental health services that treat individuals fairly, ethically and as a whole human being. Prior to moving to Hawaii in April, I spent the last three years working in an interdisciplinary psychiatric team providing intensive wrap-around services for individuals with a long history of psychiatric hospitalizations and diagnosed with a serious mental illness.

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To say there is a mental health and homelessness crisis on Oahu is an understatement. All one has to do is take a walk down almost any main road in Honolulu to see the tents that people call home, or to hear the screams coming from someone in distress.

One attempt to help manage this crisis is with the enactment of ACT, assisted community treatment, which is also known outside of Hawaii as AOT, assisted outpatient treatment.

The ACT program of Hawaii mandates treatment to individuals with a serious mental illness. These folks usually have a long history of hospitalizations and/or incarcerations due to medication or treatment noncompliance, and the purpose of this program is to prevent further institutionalization.

We definitely could debate the legitimacy and ethics of mandated services. However, what I would like to address is the idea of what is considered “treatment.”

Case Management ‘Ineffective’

In Hawaii, mandated treatment for an individual consists of assigning a psychiatrist to prescribe medication and case management services. If an individual refuses medication, they can be taken to the hospital by the police and compelled to take it.

A case manager is there to help enforce treatment and connect them with services such as outpatient therapy and assistance with benefit applications, as well as connecting them with housing providers. For an individual experiencing homelessness with a serious mental illness such as schizophrenia, putting someone on medication may quiet the voices, but it doesn’t do anything about homelessness or address the complex and challenging clinical needs of a serious mental illness.

HPD rolls into Moiliili Neighborhood Park handing out citations to homeless and folks living in tents along Isenberg Street. March 23, 2021
Clinical care should be part of outreach programs to help Hawaii’s homeless population. Cory Lum/Civil Beat/2021

Providing case management services has also been shown to be largely ineffective in helping address these issues. Sure, you can try to get a homeless individual diagnosed with a psychotic disorder who has been residing in the same park for the last five years to travel and attend an outpatient clinic, but the likelihood of this happening is extremely rare.

Now, if the clinicians traveled to this very park and provided not just medication and case management services but also intensive clinical care, this would be much more effective and one way to help manage this crisis.

If we want to see how this could be done, all we have to look at is the gold standard of mandated treatment programs — the AOT program in New York City.

It not only mandates over 800 individuals with serious mental illnesses to take medication and submit to case management, but in almost all cases involves a full clinical treatment team consisting of a psychiatrist, registered nurse, substance-use specialist, social workers and peer advocates.

This team provides medication, health services, individual and group therapy, substance-use treatment, advocacy and case management. It has a low worker-to-client ratio and lets team members meet their clients six times a month to provide comprehensive clinical treatment wherever the client lives including the street, homeless shelter or apartment.

New York City’s program is comprehensive, evidenced-based and works with individuals until they are ready to transition off mandated services and into a lower level of care such as outpatient services and case management.

Furthermore, the folks in these programs are more likely to receive appropriate mental-health housing or placement within homeless shelters whether they can afford it or not.

For whatever reason, Hawaii does not have a program such as the one described above, even though this is a program that has been utilized worldwide and is extremely effective in reducing hospitalizations and improving life outcomes.

It is a shame that individuals with a serious mental illness in these islands are not being served properly with empirically based interventions and are currently being served by programs that research shows are neither adequate nor effective for this population.

This leads to important questions: What will Hawaii’s mandated program actually achieve? Is it destined to fail and be used as another example as to why the state shouldn’t invest in mental health services for the sick and disenfranchised?

It is a shame that individuals with a serious mental illness in these islands are not being served properly.

If Hawaii truly wants to do something about the amount of sick individuals who are currently living on the street, we need real change. We need programs that are evidence- and research-based; that are humane, smart and effective.

We need to treat these people as humans, as people with real wants, needs and desires, something that those in politics and nonprofits seem to have forgotten. We can’t keep thinking that the solution for this population is criminalizing and punishing homelessness, then moving these folks from Waikiki, to Chinatown or to the next neighborhood that won’t kick up a fuss, until the problem magically disappears.

We also shouldn’t be enacting programs destined to fail that don’t provide the proper level of treatment as it’s a disservice and a waste of time. Hawaii needs wrap-around services that have been researched, evidence-based and have been shown to be successful.

Once that has been done, then a proper conversation about mandating treatment can be had, one that would be less about forcing individuals to take medication against their will and rather one about providing proper, adequate care.

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About the Author

Michael Wilson

Michael Wilson is a licensed social worker in Hawaii who received his master of social work from the Silberman School of Social Work at Hunter College in New York City. He has spent the last 10 years working with individuals diagnosed with a serious mental illness ranging in age from 5 years old to the elderly.

Latest Comments (0)

I read this to be educated about the idea. It is an appealing approach just as HousingFirst was. I have read all the comments before me. It could perhaps take off as a pilot and innovation, which means prioritizing some from the target population. How would you recommend going about prioritizing?

Ca · 5 months ago

I'm glad you wrote this, your job must be difficult.  Since you are new to Hawaii you will answer your why questions over time, trials, success and lack thereof.  Societal resistance in Hawaii stems from being on an island.  That means the pie of survival is limited and can't be expanded.  There is a lot of money being thrown around to solve the problems, so in order to change the current system, you can't remove anyone that is making money.  You will need to keep them on the payroll, showing them a different way to get the cash.  Example, Police make a ton of money.  Prison guards and intake clerks make money.  The judiciary, court appointed lawyers, clerks, etc. make a lot of money.  Drug dealers and makers make money. Watch the online houseless forum from September, you will hear the houseless folks asking for assistance to be less transactional.  They want community.  They need community.  It's such a bummer that few in society need so much assistance.  Think of schools, how teachers are typically overworked not by creating lesson plans, but rather by trying to help those struggling because society says that at a certain age, everyone needs to be at a prescriptive level.  

time4truth · 5 months ago

Since the personality and needs of homeless people vary considerably, we need to think about several solutions, not just one.  This one sounds like an excellent one to use, but by itself, it will not solve the problem. Housing First, not requiring freedom from drugs or agreement to take medication, paired with the kinds of interventions in this article, also seems to be effective for some people (by housing, I don't mean shelters). For whatever reasons, others would find that uncomfortable.  Only one thing is clear, pushing people from place to place and sweeping up their belongings is neither "compassionate" nor effective, but is costing us money that could be used to help people.

JusticePlease · 6 months ago

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