Virginia’s inconsistent mandatory outpatient treatment system and how to fix it, according to experts


Nicole Pasia


Behavioral health continues to be one of Virginia’s top health priorities, both in the Legislature and for advocates across the Commonwealth. Solutions to workforce shortages at inpatient behavioral health facilities continue to proceed through the legislature. On the other side, advocates say more work can be done to improve mandatory outpatient treatment (MOT) programs throughout the state.


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MOT may be required by a court order for a person that a civil court determines can continue living within the community, but many need additional assistance from behavioral health services, according to Lisa Daily, executive director of the Treatment Advocacy Center. MOT can include medication prescriptions, periodic drug testing, psychotherapy, and peer support, depending on the person’s individualized needs. 

MOT also differs for an individual in the criminal justice system. Behavioral health dockets within general district courts connect individuals with criminal charges with the appropriate MOT, recognizing that behavioral health issues may have contributed to their charges. However, Daily says more work should be done to connect people with MOT before being charged.

“It’s necessary for there to be a mental health court docket to ensure that if all other opportunities to help somebody failed, you at least have the opportunity to acknowledge that mental health was a factor in what happened. But, in my view, anytime a person ends up in mental health court, it represents a failure of the system because you should have been able to intervene and get help for that person on the civil side.”

One way to improve MOT in the civil court system, according to Edmund Creekmore Jr., PhD, LCP, Independent Examiner for the Virginia Supreme Court, is to implement behavioral health dockets already within the criminal courts. In a public comment at the Subcommittee for Special Populations meeting in June, Creekmore said: 

“If there is already a substantial body of research supporting a finding of decreased recidivism into and diversion from the criminal justice system, why wouldn’t we wish to promote the same advantages in terms of decreasing recidivism into the civil justice system (hospitals, crisis stabilization units, etc.) and divert entirely such cases from the criminal justice system from the outset.  Diversion from the civil court system to nonjudicial delivery of health care services would be the practical and desirable objective of such a system.”

Creekmore and other advocates have expressed the need to restructure Virginia’s current MOT code. Last session, a bill Del. Patrick Hope introduced made significant changes to the code, including the extension of court orders up to six months rather than 90 days.

However, the individualized nature of MOT can be difficult to implement across Virginia’s 40 community service boards, which are responsible for a large part of MOT delivery. This has caused the legislature to revise and clarify language in Hope’s bill ahead of the next session. 

Daily commended the Legislature’s consistent prioritization of behavioral health issues, but said system-wide issues will continue to require attention even after successfully establishing a consistent MOT within CSBs. 

“If you succeed at decriminalizing responses to psychiatric crises, it means that there’s going to be need elsewhere in the system. And that will need to be financed, it will need to be studied, and it will need to be done very carefully.”