Important Considerations for Implementing Assisted Outpatient Treatment: A Collaborative Advocacy Agenda

Mark Ragins, MD
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For my entire career a vicious debate has raged about involuntary outpatient treatment largely pitting parents and clinical professionals on the pro side against consumers and rehabilitation professionals on the con side.  Like it or not, packaged as Assisted Outpatient Treatment (AOT), involuntary outpatient treatment is increasingly coming to a neighborhood near you.  Los Angeles County is nearly ready to begin implementing AOT under Laura’s Law.  The time for contentious advocacy aimed at stopping AOT has ended and the time for collaborative advocacy aimed at implementing AOT as well as possible is upon us.  Whenever a major new initiative like this is launched, even in its pilot stages, there is the likelihood of more unintended consequences than intended consequences.  Here are a series of important considerations for implementing AOT and some concrete recommendations for a collaborative advocacy agenda.

The cornerstone of the con position has always been that even if AOT is done with the best of intentions forcing someone to do something or to change in a way they don’t want to change is inherently an assaultive thing to do.  There is a large risk the coerced person will react resentfully and even aggressively in response.  There is also a large risk that the people exerting power coercively will be corrupted by their power and abuse it. This damaging effect on staff who forcibly treat people is why I personally wouldn’t want to be involved in it.

Robust grievance processes should be included to decrease the powerlessness and helplessness of the people being forced into treatment to hopefully decrease their resentment and aggression.

Checks and balances should be included to limit the power of the people involved (including families, referral sources, legal agents, and treatment staff) including oversight to detect abuse.

The cornerstone of the pro position has always been that there are some people with mental illnesses who will not respond to any intervention besides force to do what’s good for them.  This implies that other means of persuasion besides threats of punishment should be used before resorting to force.  In general we have four levels of persuasion available to us:

  1. Avoiding punishment
  2. Seeking rewards
  3. Internalizing rewards
  4. Pursuing higher values or principles

Avoiding punishment is the lowest of these forms of persuasion.

  • The criteria for implementing and discontinuing AOT should include the person’s motivational level and the need to use the lowest form of persuasion.
  • Outcomes for the legal process should include how often they brokered an agreement using a higher form of persuasion instead of either just granting or denying the petition for AOT.  (Apparently the exemplary program in Nevada County has about 90% brokered agreements for services without granting the AOT petition.)
  • Outcomes for the involuntary treatment process should include how often they achieve a voluntary engagement as a reason to terminate AOT, rather than people no longer meeting medical or legal criteria as a reason to terminate.  (It seems to me that people who are released from involuntary treatment without being persuaded of its value and to continue in it are often harder to engage over the long run than people who were never treated involuntarily at all – an unintended negative consequence.)

A key argument has been effectively made by the proponents of AOT that it actually reduces the amount of coercion these people experience because without AOT they are hospitalized and jailed more frequently.  It’s tempting to include the amount of recent coercion someone has experienced as a criteria for inclusion in AOT to maximize this benefit (either directly or indirectly by limiting who can petition for AOT to coercive agencies like jails, prisons, and hospitals).  Doing this would create another “fail first” system and lose the possibility of proactively diverting people from these traumatic and devastating settings.  However, screening for and predicting future risk of coercion is likely to be an unreliable process, especially if the population being screened broadens.  Diverting people who are certain to be heading to hospitals, jails, or prisons at their point of admission would be a compromise between prevention and “fail first.”  There is still the likelihood of people trying to get someone hospitalized or incarceration who they wouldn’t otherwise because they’re expecting AOT diversion.

  • A rapid response, point of contact, diversion to AOT from hospital, jail, and prison admissions should be included.
  • Referral criteria should overtly include an evaluation of the likelihood of reducing coercion overall by enrollment in AOT.

The effectiveness of AOT appears to rely upon intensive treatment resources (and perhaps housing subsidies) – generally ACT / FSP level, about $15000 per person.  This level of resources is not available for everyone who needs them (except perhaps in New York).  By way of contrast, in California the state parole department runs poorly funded, coercive outpatient services (POC) that appear to be ineffective (though to be honest, I don’t know if their effectiveness has really been studied.)  In any event, AOT advocates have not been advocating for a civil version of POC.  They’ve been advocating for an involuntary version of ACT / FSP.  This lack of resources has been a major obstacle to implementing Laura’s Law in California and it has only been through the diversion of MHSA funds that AOT can even begin in Los Angeles.

  • AOT should authorize and triage to a system of care with different cost levels to help manage the costs of the services they are mandating. Just because someone needs involuntary outpatient treatment doesn’t mean they need highly intense services (especially indefinitely).

The MHSA set aside a substantial portion of the new revenues from taxing millionaires for voluntary Full Service Partnerships (FPSs).  These programs have largely been successful in engaging people in community based services who had been heavily homeless, jailed, hospitalized, and institutionalized and had been unserved or underserved by the existing services.  Statewide they have demonstrated success in reducing homelessness, incarceration, and hospitalizations rivaling any AOT programs.  They also cost a lot of money.  At this point almost all FSP programs in Los Angeles are full almost all of the time and most people who want services are turned away back to the street, jails, and hospitals.  An effort is underway to create flow within these programs, helping people “graduate” to lower levels of care to open up the opportunity for new people in need.  This effort is quite difficult and often resisted by everyone concerned (including families, staff, consumers, and judiciary).

The success of FSP programs has not gone unnoticed.  There are growing, passionate referral sources from chronic homelessness, jail diversion, incompetent to stand trial, hospitals and institutions, aging out of foster care, families, early prison release (AB109 step down), outpatient clinics, and even immigration detention centers.  All are clamoring for access to FSP programs.  Any one of them could likely fill the entire FSP capacity.  Although touching family stories are often relied upon in the promotion stages of obtaining services, as time goes on those with more influence within the system tend to have more access.

The promoters of AOT joined those clamoring for access to FSPs.  They emphasized that even with engagement efforts there are clearly people heavily in need of FSP services who do not agree to them voluntarily and would likely benefit from them involuntarily.  They convinced the California legislature to remove the “voluntary services only” restriction on the usage of MHSA funds to allow access for these involuntary AOT people.   There is a possibility that because of the legal authority attached to AOT people, they will be given higher priorities than these other competing FSP applicants and over time push them out.  We could find ourselves in the situation where people would intentionally not agree to FSP services to be put on AOT to get access to FSP services.  This situation has occurred over time with involuntary hospitalizations pushing out voluntary hospitalizations.

  • An FSP access committee with substantial power should be established to negotiate between these competing applicants for FSP services.  The AOT process would need to be made subservient to this committee, such that the AOT court can’t mandate services beyond their allocation.

One of the key FSP resources that is very popular is housing subsidies.  Social Security doesn’t provide enough income to live in even the worst housing hardly anywhere in Los Angeles (or apparently any major real estate market in the country).  HUD Section 8 subsidies are extremely limited and continually reduced.  Applicants face multiple year waiting lists or closed waiting lists.  Allocations for special mental health programs like Shelter-Plus certificates are rapidly filled too.  One of the reasons it’s sometimes hard to flow people beyond FSP is because they can’t afford housing without it.  The success of AOT people is likely to depend on their access to housing subsidies.  Any existing resources are already oversubscribed.

  • AOT should develop a funding stream for housing subsidies independent of existing mental health funds.  This would likely add about $5000 per year to the cost of each person.
  • AOT should develop funding streams for housing that persist after AOT so people don’t remain on AOT indefinitely just to access housing subsidies.

Gaining access to services and resources is not the only appeal of AOT.  The coercive abilities are in themselves appealing.  It is natural for people who are frustrated to want to “make them do it.”  The level of frustration in our society is enormous.  There are strong desires to make people follow laws, make kids go to school, make people come to this country legally, make them take care of their children,  make them lose weight, stop smoking, and take care of their health, make them stop using drugs, stop being homeless, and, of course, make them take their psychiatric medications.  Many of these important issues have gotten legal coercive powers to help them.  Over the years, forcing people with mental illnesses into treatment has received legal support.  AOT is an expression of that support and an acknowledgment of that frustration.

With regularity, other frustrated people have attempted to use mental health laws to promote their own agendas.  Once legal support is obtained, the legal process has routinely imposed its own standards and prioritized its own frustrations.  (I heard of a mental health court in New Mexico that mandated the local clinic to serve drunk drivers and wife beaters, two populations that frustrated the courts the most but who the clinics had been rationing out to use their limited resources elsewhere.)  Everyone’s assumption is that once AOT is established it will be used to address their particular frustrations, often unaware of how many competing frustrations there are.

The legal system is also notorious for ignoring budgetary realities.  Criminal court judges sentence people to prison without regard to how much prison capacity exists, to how sending more people hopelessly degrades the program, or to how other valuable public services (like education) will need to be cut to pay for their orders.  Special education hearings mandate services far above the ability of the school district to provide them and as a result we now have about 1/3 of our “normal” students’ funds diverted to special education students.  Given the present level of rationing mental health funds, including a financially irresponsible legal partner is highly risky. (For example, it’s estimated that treating in psychiatric hospitals all the people currently in jail found incompetent to stand trial would use about 1/3 of our entire mental health budget.  These people are very frustrating to the legal system and could be mandated AOT services, massively reducing everyone else’s services.)

  • The AOT process should have a transparent budget and be required to make responsible rationing decisions to remain within the budget – including the judges.

Depending on whose frustrations are driving the petition process, the people in AOT may need a diversity of services.  There is a perception that the most important obstacle to mental health and community living is refusal to take needed medications.  This is only true for a subset of frustrating people.  In our FSP program other common obstacles include – ongoing substance abuse, inability to control anger often from childhood trauma, immediate gratification craving and low frustration tolerance, impaired cognitive abilities (developmentally, brain damage, or substance abuse), severe poverty and poor money management skills, physical illnesses (especially chronic pain), learned helplessness and hopelessness, stealing, and an inability to tolerate being around other people.   We need to make highly individualized assessments and recovery plans using a whole team of people with different skills and life experiences to help them engage in our program, overcome these obstacles, and become more self responsible and self reliant.  In contrast most court ordered treatment orders are stereotyped, cookie cutter, and include an almost magical belief in the power and infallibility of psychiatric medications.

  • AOT orders should be carefully developed including people with relationships with the person who know them well and the person themselves (incorporating their perspectives), be highly individualized, regularly reviewed and revised, and go beyond medication compliance.  At a minimum, substance abuse and trauma should be included alongside mental illness concerns.

Our court system is amazingly overburdened.  The criminal justice system has almost entirely replaced a system of hearings and judicial decision with a system of plea bargaining negotiations.  Model mental health courts and drug courts have found a need to diverge substantially from prevailing court procedures to be effective.  Some exemplary court practice include: More time per case is allocated.  Judges become actively involved, interacting directly with the clients and even forming relationships with them and directly negotiating with them instead of lawyers negotiating with each other.  Resource providers are available at the court and their input and agreement is incorporated into the judgments and plans.  There are ongoing frequent judicial progress reviews, not just of ongoing eligibility but of progress and need for plan changes.  It’s been estimated that AOT requires $3000 per year of legal services per person.

  • The court participating in AOT should be well funded and proactively alter its roles and procedures to facilitate AOT in the ways model mental health courts and drug courts have.
  • There should be an ongoing review of and improvement of the legal services involved in the AOT program.

In putting together analysis and recommendations our advocacy goal should not be to make it seem impossible to implement AOT successfully or to over-regulate it or include “poison pills” to sabotage it.  We need to collaborate in an honest attempt to address a variety of serious concerns as we move forwards in implementing AOT.  I hope that the people who have been promoting AOT have already incorporated many of these considerations and ones like them into their plans.

* * * * *

Editorial note: Dr. Ragins sent this in response to an invitation for perspectives on assertive outpatient treatment (AOT) legislation, Such as the Murphy bill.  Dr. Ragins states that this brief, which was originally prepared for a board member of Mental Health America of Los Angeles (MHALA), had the effect of shifting the board member’s perspective such that he proposed that MHALA officially stand against implementation of AOT laws. We expect that there will be a full and thoughtful discussion of this blog, however, due to a family emergency, Dr. Ragins will be unable to participate.

 

44 COMMENTS

  1. I just want to address one point: the forms of persuasion. Personally, I find it hard to believe that the higher forms of persuasion can be effectively used if a person is aware of the power of the people they are negotiating with to use coercion. Even if one tries it “nice” first as it is usually referred by the professional community is likely to be seen as a trick and manipulation tactics (which it essentially is). I’ve seen people in crisis where the first question they ask when met by someone who is supposed to help them is the one about their powers for the use of force and as soon as they realise that is a possibility they essentially stop cooperating, either outwardly or covertly (by lying, denying problems etc.).
    I don’t think that any sensible alternative treatment can be applied in the framework which allows coercion as these forms of treatment require patient’s cooperation. The only one that does not in fact is drugging. So I am afraid if one would compare the drug-based and alternative interventions within the coercive setting the alternative approaches may suffer.

  2. I am sorry to read that Dr. Ragins is having a family emergency. I hope everything is ok. “In contrast most court ordered treatment orders are stereotyped, cookie cutter, and include an almost magical belief in the power and infallibility of psychiatric medications.” I have seen my own state’s fill-in-the-blank court orders for forced outpatient treatment, and they give complete power to the “Treatment Provider.” They also dictate conditions of payment to the Treatment Provider. While this section is also fill-in-the-blank, I think it is safe to assume that this means unless it is absolutely impossible, you will have to pay or go into debt for your own court ordered forced treatment. If this isn’t a situation rife for abuse, I don’t know what is.

  3. I’ve seen the same thing happening with involuntary hospitalisation where I live: theoretically you need two independent doctors to commit someone involuntarily but the practice is that the person who happens to be there decides and the hospital just fixes the documentation later. It always makes me want to laugh and cry at the same time (I know, clear sign of a bipolar disorder ;p) when people start talking about due process and that every case will require TWO PROFESSIONALS to agree. Like it has ever happened that they disagreed and the person has not been not committed due to that…

    • The safeguard of two doctors’ approval would only be meaningful if the 2nd doctor came into the assessment blind, i.e. with no knowledge of the diagnosis/history/commitment status of the individual. The way the process is currently set up, the 2nd doctor’s POV is necessarily tainted by the 1st.

      • “with no knowledge of the diagnosis/history/commitment status ”
        Which in practice cannot happen therefore the safeguard is 100% meaningless. Plus one has to take into account that doctors have all the incentives to commit and a negative one not to do that (potential problems would the person kill themselves or cause trouble). So they lock up everyone at least for a few days just in case. Think for a moment if police could do the same and it was the policemen who judge based on subjective ideas for “dangerousness” rather than criminal acts themselves and the judge would be seen as needing the expertise of the same policemen to decide if the detention be prolonged, potentially indefinitely… This system has abuse of power built into it.

  4. What is the key point, or points, you wished to address in your book?

    DR. GOMORY: The book essentially takes a critical look at the entire field of psychiatry, from its inception as a formal medical specialty assumed to have special competence over madness and argues using the latest rigorous research available that its fundamental character is unscientific and it is a pseudo-medical profession. We found for example that its use of coercion is the only long-term consistent treatment that it has employed, the other “treatments” used dependent on the latest theoretical fashions or fads include confinement in locked facilities, physical restraint, lobotomy, electroshock, stupefying and energizing psychoactive drugs and talking therapy.. Our analysis of the DSM’s diagnostic approach, demonstrates that it uses arbitrary conceptual diagnostic labels that have no reliability and as a result no real world validity, an analysis now recognized by the National Institute of Mental Health on its website along with most scientific experts interested in the topic. And finally, we look at psychotropic medication. These really are a subset of a wide array of psychoactive chemicals that turn out not to target any specific illnesses but are generic and general behavioral change agents that anyone taking them, diagnosed or “normal” (assuming equal dosages) react to identically. Their behavior and mood states will become hyperactive/elevated or suppressed/depressed.
    – See more at: http://csw.fsu.edu/articles/mad-science-psychiatric-coercion-diagnosis-and-drugs-book-launch/#sthash.jWvAAEI7.dpuf

    http://csw.fsu.edu/articles/mad-science-psychiatric-coercion-diagnosis-and-drugs-book-launch/

  5. United States Is Cruel, Inhuman and Degrading to Poor, UN Report Charges

    The UN Human Rights Committee says the U.S. should stop criminalizing homeless people for being homeless.

    http://www.alternet.org/news-amp-politics/un-human-rights-committee-united-states-cruel-inhuman-and-degrading-poor?akid=11662.280646.NtWtpx&rd=1&src=newsletter977049&t=5

    I find it appalling that money is wasted on such literal mental death treatment when Dr. Ragins admits most of the would be victims don’t have enough money for even the worst kind of housing on social security disability or even less income. It is patently absurd to expect homeless and or poverty stricken people treated like garbage by U.S. society to demonstrate perfect emotional and physical health given the callous, greedy, selfish, abusive, narcissistic society in which they live. Pope Francis has been getting much acclaim by exposing such social evils generated by crony capitalism.

    As if it isn’t traumatizing and horrifying enough to cope with being homeless or desperately poor, being terrorized and victimized by forced neuroleptic poisoning to make you a drugged, brain damaged zombie unable to cope in the best of conditions is a veritable death sentence to these homeless people, but all too profitable for their oppressors.

    At first, I was very angry and upset with Dr. Ragin’s article, but though I vehemently disagree with such forced treatment even in the guise of gaining cooperation for fake voluntary treatment, by the end, I saw that he is just “telling it like it is.” And I was glad to see this paper by Dr. Ragin caused the Mental Health America leader to change his position on AOT and forced treatment that I saw in the video of the Tim Murphy AOT hearing. I would guess that the reason is that Dr. Ragin deals with poor people in crisis in his own work and exposes that there are many, many different crises and problems when working with such people and there are no “magic pills” to solve such systemic injustice, poverty, oppression, abuse, trauma, substance abuse and other huge challenges. Dr. Ragin also shows that lack of money is a huge factor in the ability to provide treatment while the prison and legal systems are overwhelmed due to lack of resources as well. He also shows that the expansion of services in one area causes a crisis in other areas as with the insatiable special education budgets whereby schools get incentive money, parents get special services and the victim kids get destroyed with life destroying stigmas and toxic drugs while the regular school budget for normal or gifted children gets decimated. This is why letting the squeakiest wheels or most obnoxious people often funded by special interests like Big Pharma shouldn’t get to dictate policy.

    Thus, Dr. Ragin’s honest report about the reality of AOT and the many huge social challenges it purports to solve makes me feel that those like Tim Murphy and E. Fuller Torrey are simply disingenuously applying mere window dressing and Band-Aid pretend fixes. This is to pretend to solve systemic, massive social problems by blaming the victims, typical of biopsychiatry and why it was created in the first place for social control in the guise of mental health. Moreover, it is a great cover up for the growing huge inequality, poverty, lack of jobs, slave working conditions and low wages that require food stamps and other aid and the increasingly oppressive, fascist conditions imposed on us all by the 1% psychopathic power elite robbing the 99% as they hijack the globe to pursue their insatiable, sadistic need for complete domination and control over the rest of us now that they’ve managed to steal most of the world’s resources and wealth described at web sites like Thrive.

    When one considers the huge amount of money going to the so called mental health system, the legal system, the prison system and all the other horrible, oppressive systems used by the powerful and wealthy to increasingly prey on the suffering of the poor, it is very obvious that such increasingly fascist countries like the U.S. Great Britain and others have totally lost their moral compass at least in our government with their corporate cronies.

  6. I’ve begun to see this in terms of violent warfare, with the vast majority of the violence being unprovoked violence again’st the mentally ill. Since the whole non-violent protesting that people at MFI support has only made matters worse, I honestly think it’s time for someone who gets trapped under those orders and is forcibly injected, to get a gun and come back and shoot the people who did it to them. Maybe if more of the poor and socially ostracized citizens have access to the studies showing these drugs cause irreparable brain damage, it might just come about naturally.

    Medicalizing assault and battery, does not change the fact that it’s assault and battery. People have a right to defend themselves, and to seek justice for what has been done to them. Those rights exist independent of the government and the law.

    • I have a lot of sympathy for what you say, but you are putting yourself in a very vulnerable position when you say these things openly. For one thing, anyone who goes around and shoots people is essentially committing suicide. Another bad effect of such an event is that the public will turn against our cause, as violence scares people.

      I sympathize too with the frustration you feel about the ineffectiveness of nonviolent demonstrations. But we are up against a powerful and vicious enemy who are not going to give up their power because of one demonstration. I think we should keep in mind the civil rights movement of the 1960’s. They made progress after many years when the public saw that their cause was just. If their protests had been violent, the results would have been very different.

      • “Another bad effect of such an event is that the public will turn against our cause, as violence scares people.”

        But think of the irony. At the very least such an occurrence would put a big giant elephant in the room concerning the issue, and that’s that psychiatric drugs do not, and certainly can not, stop people by being violent beyond that of just simple sedation which may only be enough to stop sudden agitated violence, but not pre-meditated violence. I personally would love to have such an event to refer to when people claim that AOT can prevent violence.

        • ““Another bad effect of such an event is that the public will turn against our cause, as violence scares people.””

          I do have one more thing to say regarding this, and it’s the ultimate error in that sort of thinking. On one hand it will indeed scare SOME people, but those are indeed the same sort of people who fear the mentally ill anyway and support these laws one way or another. It would however work to convince other types of people of just how serious a violation of human rights these laws are. I’ve come across many people over the years, mostly libertarian and conservative types, who would be much more opposed to forced drugging if they didn’t think that the people being forcibly drugged were thanking them later. They often see it as a means of getting drugs to the druggies and not as an assault again’st a group of people.

          Or to put it another way: When people resort to extremes, some people are indeed afraid of them, but there are certainly others who say to themselves “Wow, they must have really been violating those people for them to have taken it that far.”

          • Just imagine if hundreds if not thousands of people who have abused by the system became violent, even without causing immediate harm, but rather even just by declaring violent intentions if their rights continue to be violated. Of course mainstream psychiatry and much of the people would want to take it even a step further, but that’s exactly when it could all hit the fan so to speak. I can imagine you would have people on one side going “We need to round up all the angry psychiatric patients and ex patients, and lock them up for life” and then of course would come the realization that this is the year 2014, and I highly doubt they could ever do that. It might finally just tip the barrel and authorities might begin to wonder, “Well what has been done that is pissing them off so badly, and how might we rectify it?”

            Could you seriously imagine the supreme court allowing hundreds if not thousands of people to be locked up for life in the year 2014, for forming a unionized threat again’st people that they contend are causing them harm and violating their rights? I cant.

          • To be honest, if you could mobilise the entire class of psychiatric surviviours to do anything in a coordinated way then it really would not matter if it’s violent or not. If individual people will start threatening violence the next thing you’ll see is them being rounded up and treated accordingly and likely you’ll see new anti-terrorism laws against the “terror of anti-psychiatry”. You can see this with other movements like the animal rights. Violence will likely alienate the public and we need the public on our side. I mean, what are you proposing: bombings of psychiatric clinics as the pro-life fanatics do? I am sorry, but I don’t like the idea of hurting people. I can understand the person fighting back when they’re in the process of being violated and I consider this reasonable self-defence but I don’t think that will work as a strategy and I also think it’s not morally OK. Maybe we should take a lesson from the LGBT movement who managed to push their agenda against the bias and discrimination without resorting to violence? They now have the majority of people on their side and they completely changed the discourse.

        • But you have cases like that – look at the mass shooters who were on meds. The only answer they would give you is that these people were not sedated enough and would likely result in drugging everyone to the point that they are literally catatonic. You’re expecting logic to enter this discussion and I can tell you that in case of dramatic events, such ones you describe logic is the last thing that would enter public discourse.

          • But in all the cases of mass shootings, the mass shooters were never put on drugs to prevent violence. Thus, society figures that if they were put on the “right” drugs, there would have been no violence.

            In any case, I totally agree with you. It’s a pipe dream of justice that most probably will never happen. But considering how many people diagnosed with serious mental illness are often street people, and how street people tend to respond to being so violated… I really think it would happen if education efforts reached them and taught them of the corruption in psychiatry and the drugs causing brain damage. I think psychiatry thinks this too, and is why they have always treated that information as being “dangerous”.

          • “The only answer they would give you is that these people were not sedated enough and would likely result in drugging everyone to the point that they are literally catatonic.”

            But that was another one of my points, is that this isn’t the 1930’s and they cant do that. Even now they have to pretend that they are serving a medical need that is in the best interest of the patient. And the very reason that Torrey and his goons have had to go for AOT laws in the first place is because there’s no way the supreme court would allow them to start locking people up again.

          • There is no more reply options so I’m answering myself (clear sign of, I don’t know, shizophrenia? ;P) but it’s to JeffreyC:
            I see your point “this isn’t the 1930′s” but I disagree. Remeber, right now they control the narrative. they get to decide what is being told the public about the reason someone died. Look at cases of police brutality, prisoners abuse and so on. They only ever get prosecuted when someone happens to release a video and even then it’s kind of a lottery. I think you’re naive in thinking that they will get scared of public outrage, when they can do whatever the hell they want to any kind of protesters (look what happened to Occupy) and use violence willy-nilly. Add violence on out part to it and then they even likely don’t get outrage at all because the person was clearly asking for it. It’s just not a way to go.

          • I’ll give you an example:
            https://www.youtube.com/watch?v=6tpAZObNZfI
            This guy only had a small knife or that is at least alleged. Sorry, but no one can defend themselves if they face the force like that. I mean, sure you can and with a degree of luck you manage to wound or kill one person before they turn you into a bloody mess. It’s morally wrong and counterproductive to advocate for violence.

      • “If their protests had been violent, the results would have been very different.”

        Their protests often were violent, and violence certainly works when study history without a liberal bias. In fact, violence appears to be the only thing that ever has worked. Peaceful protests and logical arguments are certainly not the reason why the media refuses to show images of muhammad, and certainly peaceful protests never stopped the nazi’s either.

    • I know it is only natural for a person who is a victim of any violence, let alone legalised, institutional violence to have feelings of aggression, need for revenge or simply self-defense. However, even though one could see it as a justified reaction, it’s in fact counterproductive. We can see how the instances of mass shootings are used to introduce the more draconian, coercive measures although it is clear that they are either causally linked to psych meds or at least not prevented by them. So I fear that if the people targeted by these programs were to oppose them violently it would only be used as a justification to paint them as “criminally insane”.

  7. “This damaging effect on staff who forcibly treat people is why I personally wouldn’t want to be involved in it.” Yes I agree. And being on the receiving end of it, with no choice but to accept it, is even worse. Because we can’t walk away and choose a different path if experiencing mental distress and drugs are the tools of coercion.

    In Scotland we’ve got a new initiative, the Scottish Patient Safety Programme in Mental Health which has the aim of “educing the harm experienced by individuals in receipt of care from mental health services, with a focus on adult psychiatric inpatient units (and forensic inpatient units)”. They are looking at restraint and seclusion, among other topics:
    http://www.knowledge.scot.nhs.uk/spspmh.aspx

    However I am convinced that we need alternative ways of working with people in psychoses and altered mind states that don’t involve psychiatric drugs being forced into them. Rather than accepting the only road is an assertive one to manage and control the mad people in our society. For I think they’ll only get madder the more we restrain them or that we are restrained. It’s a vicious circle.

  8. The representatives who argue for these laws always use the same tired slogan for these laws. They are making sure the “mentally ill have access to the help they deserve” or it’s their “moral imperative.” I disliked these types of laws to begin with because it’s all based on a lie. There is no way to predict what crimes could have been stopped had this law been in place, but they insist on rattling off some arbitrary number anyway. If they are so set on us having access to the help we deserve, maybe they should bother to inquire as to what we feel is helpful. This is somewhat like my psychiatrist assessing my quality of life… As far as a moral imperative, have you ever noticed this phrase only comes up when the people involved intend to stray as far from anything considered “moral” as humanly possible? I was first institutionalized in the mid nineties. I was fourteen, my family was wealthy, and my mother had no urge to ever see me again. This was a magical combination back then. It would be five years before I was free again. As a minor, I would never see a lawyer or a judge. I won’t tell you what I went through because it’s horrific and because it tends to overshadow my point.. See, the one thing I learned very well in the years that followed was that treatment cannot and does not prepare you for the reality of the outside world. The only effective aspect of these programs was their ability to instill fear. It has been nearly twenty years since I won my freedom in a court, but that fear has never left me. In my mind, laws like this one, mental health courts, and the like are nothing more than political propaganda, and our Western version of political psychology is very dependent on having a scapegoat. Having said all that, if you find yourself in a position where you need help, you should seek it in any program that offers you the help you need, but let’s face it, we already tested this method of treatment for effectiveness… starting with Bedlam. It has never worked, and the few good things it has delivered are always outweighed by the damages it leaves in its wake.

  9. “The time for contentious advocacy aimed at stopping AOT has ended and the time for collaborative advocacy aimed at implementing AOT as well as possible is upon us. ”

    I have absolutely no interest in supporting your Vichy-type regime, that is, I have no interest in collaborating with you or anybody else who supports, proposes, promotes, or encourages psychiatry between non-consenting adults. First, AOT, actually involuntary outpatient commitment, invariably means forced drugging, and it means forced drugging with chemical agents that have been proven to be more damaging than they are therapeutic. This being the case, people’s security of person is being violated whenever they are being drugged against their will and wishes. Second, these forced druggings are a gross violation of the 14th amendment of the US constitution. You have to remove due process and equal protection under the law to force drug (violate the civil liberties) of law abiding citizens. It would be a shame if in the 21st century people were reduced to, as run away slaves were during the 19th century, following ye ole’ north star to freedom, given the lack of basic human rights in a country that used to pride itself on the degree of freedoms it permitted it’s citizens. Get somebody else to collaborate in enslaving people, I want no part of it, unless that part be one of assisting in the liberation of people from this ingratiating and dehumanizing slavery that you advance.

  10. “The time for contentious advocacy aimed at stopping AOT has ended and the time for collaborative advocacy aimed at implementing AOT as well as possible is upon us. ”

    I don’t believe the battle for our children’s rights has even begun. Not till every psychiatrist who has forcibly medicated and harmed individuals using the devise of AOT has has apologized to the victims and their families, and made amends for the lives they helped to ruin. When the evidence clearly stated from the time of the late Dr. Mosher that the majority of young adults experiencing a psychotic break could heal naturally with compassion, protection and support without neurotoxic medication and this evidence was ignored for decades and now we have a generation of drug damaged, permanently disabled individuals.

    I and other mothers who are in the awful predicament of having to drug out children as a condition of their release, our hearts are breaking. The longer she stays on medications, the lower her chances of a full recovery. Shame on AOT!

    My daughter has been in psychiatric state hospital/prison for over a year. I have to sign an agreement whenever I take my daughter on a pass that we will keep her drugged. It is heart wrenching. And all the while, she is learning helplessness. This bright intelligent daughter of mine used to help cook gourmet meals and work vigorously in the garden, ride her bike, etc. Now, she sits in her room all day, heavily medicated, mumbling to herself, when it is meal time and she sits at the table waiting to be served, as at the hospital chow line. She has become institutionalized, expecting others to wait on her hand and foot. She takes her meal and goes to her room. She doesn’t offer to help with household duties. What kind of ‘hospital’ would condition people that their highest purpose is to be waited on in such a manner? This is a shameless system and its costs my daughter, our insurance, and the taxpayers over $100,000 grand/annually to create this pipeline of disabled people!

    I am in agreement with Frank, that there is no room for compromise on human rights. There is no good way to execute AOT. It is wrong, even if there are billions of dollars to be made from keeping people like my daughter in a helpless and diminished state.

    • Madmom

      The pain you feel for your daughter is very apparent. I am sorry about what’s happening to her. I can affirm all of what you say here about “treatment” in “hospitals” being nothing more than learned helplessness since I work in one of those so-called “hospitals” and witness everything that you talk about here. The system is making sure that it never runs out of people to keep it running because people come to the point of never being able to take care of themselves. Many people entered the system as young children and know nothing else. It’s heartbreaking and horrible. One good thing is that your daughter has you and you have her best interests at heart.

      It is amazing to me that Americans have totally forgotten some important facts. Prior to the advent of the toxic drugs into the arena of “mental health care,” at least 60% of people experiencing first episode psychosis recovered and went on with their lives. Some experienced a second episode but it was a small number. Only about 30-some % continued to have issues for life. Bipolar was a rather rare thing and most people experiencing their first episode of this recovered and went on with their lives.

      With the advent of the drugs what was once episodic became chronic! Now what does that tell you? Now, only about 15-16% of people ever have any real chance of recovering their lives and moving on.

      So, the wonderful “treatment” that these people think everyone should be subjected to whether we want them or not is no treatment at all but the serious cause of the problem. Anyone with access to a computer and the internet can find all of this information in no time. Why is it that the American public is such a bunch of dunces who are willing to listen to this drivel? All the information that’s needed to show that this is nothing but a dog and pony show run for the benefit of psychiatry and the drug companies is available to everyone and yet no one seems to know this. What was once episodic is not chronic and it’s caused by the so-called “treatment!”

      • Excellent points, Steve, and so well summarized! And I join you in affirming Madmom’s caring and support for her daughter. Another heartrending thing I’ve witnessed is how few people in these locked psychiatric wards get visits from family or friends from “the outside”.

        I always appreciate your comments here at MIA, Steve. If you want to make another try at shedding some needed light on these issues at the next NASP convention, I’d be honored to join you in that venture if you’d like…but first I’ll have to re-register and pay my dues!

    • Madmom, I know very well the pain you’ve described so well. I witnessed and experienced very similar things during each of my daughter’s several hospitalizations. It’s so maddeningly frustrating when you have to watch your loved one decompensate under psychiatric “treatment” that is so damaging; and then to have to “go along with it” as a parent, because if you don’t you’ll be cut out of the picture entirely and then have no ability to at least have continued contact with your loved one and perhaps some ability to influence the “treatment”. The irony is, those in charge believe they’re reducing the severity and chronicity of “the brain disease” by medicating quickly, aggressively and continuously; in fact, the long-term studies (such as that recently published by Dr. Martin Harrow) indicate just the opposite! These biopsychiatric zealots always use “anosognosia” of people in extreme emotional/mental states as a justification for forced drugging. Why don’t we hear more about “anosognosia” of hospital staff?? In my experience most seem oblivious to the clearly evident damage being done on a daily basis to the victims of their “treatment”. My wife and i witnessed very clear symptoms of continuing akathisia in our daughter during her second lengthy hospitalization; however, it was never identified or mentioned by hospital staff, and we only became familiar with the term much later when her outpatient psychiatrist identified it from our description. And every week when I have lunch with my friend (diagnosed with schizophrenia) it is heartbreaking to see how physically and/or emotionally debilitated most of his fellow SRO residents have become–and, of course, they’re all well trained to dutifully line up for the meds that assure they will remain in this diminished state! Thankfully, my daughter has been out of the hospital for over 20 months and has recovered very well in many ways. However, she remains dependent on these substances which have clearly been very toxic, with no medical support to taper responsibly and instilled with the fear of relapse and re-hospitalization if she tries to “go off the plantation”.

  11. Mark, I can not even begin to tell you how offensive it is for you to dictate to me and others: “The time for contentious advocacy aimed at stopping AOT has ended and the time for collaborative advocacy aimed at implementing AOT as well as possible is upon us.” You’re certainly free to give up the battle. After all, as a highly regarded psychiatrist, you’ve nothing to lose. However, my worst nightmare is someone knocking at my door with a loaded syringe. I consider the potential for that quite high and it is the worst sort of intrusion, into my body. How dare you tell me or anyone else to stop fighting and play nicely and collaborate. The Vichy government were great collaborators too.

  12. I know someone who killed herself, and although she left no explanation for why she did this, she was on a Community Treatment Order and resented the effect of the drugs on her.

    There are lots of arguments against involuntary treatment, one being that psychiatry is not very effective, damaging, dangerous, bad. Which is largely why people do not, “Comply.”

    I’m not in the USA but I think the appropriate response is to organize effective opposition, advocacy and protection of people threatened with these laws. That is the only thing that has the only chance of minimizing the implementation and in the long term getting the laws reversed.

      • Advocacy definitely, because if you look closely at any of the procedures, you’ll find the rules are broken, sometimes to such an extent that the original ‘diagnosis’ doesn’t stand up.

        For example how many psychiatric staff would pass a mental health test themselves, or maybe a drugs/alcohol test?

        What about eye contact or body language, these can be really dodgy in psychiatric professionals.

  13. Was the battle to end slavery in the US “contentious?” How about the women’s rights movement? Or Ghandi’s effective effort to achieve Indian independence? Just because those in power agree to do something doesn’t mean we have to collaborate or cooperate. Contention is necessary when intended or expected evil and bad outcomes are likely to result from some action taken by those in power.

    You suggest that one of the “pro” arguments is that AOT results in a decrease in imprisonment or re-hospitalization. First off, I don’t have any stats or studies showing this to be the case. Second, even if this is true, this is a pure and simple social control argument that has NOTHING to do with the mental health of the “recipients” of enforced treatment. Locking everyone in a dark basement or dropping them to the bottom of the river in “cement overshoes” would reduce the incarceration and hospitalization rates, and be a much cheaper intervention. Point being, medical treatment, as this claims to be, should not be aimed at reducing social costs, but at enhancing the health of the individuals being treated. It is notable that none of the listed arguments in favor address the long-term health and well-being of the individuals being forced into “treatment” against their will.

    Additionally, the controls you suggest over the system are inadequate, not to mention they are unlikely to occur. I don’t know who you intend to have on your oversight committees, but unless they are packed with a majority of mental health consumers/survivors, such committees will become just as much a rubber stamp as the Courts are now. Plus, they cost money, and since most of our money will now go to enforcement rather than to engagement, these ideas will never be funded for more than at most an initial “show” period to shut up critics.

    The “immediate risk of harm to self and others” standard was developed only after years of intentional and widespread human rights violations among those identified as “mentally ill” and some very “contentious” advocacy by the consumer/survivor movement in its infancy. It represents an absolute minimum standard to even think about justifying taking away someone’s constitutional and civil rights, and even with that standard, rights violations are rampant (look at the Pelletier case). To loosen the hard-won protections (however inadequate) that do currently exist is extremely dangerous, and not just to the so-called “mentally ill,” since the ever-expanding and increasingly subjective DSM definitions will soon allow almost anyone to be forced into “treatment” for offenses like grieving too long or being “too disturbed” about even a genuine medical condition. We need to resist this concept with every fiber of our beings, and it would really help if inside people like you, Mark, would join in condemning any loosening of the current already-too-vague standards for involuntary commitment and enforced treatment, rather than providing an “out” for proponents by proposing safeguards that won’t work and probably won’t ever be enacted.

    —- Steve

  14. Mark said, “A key argument has been effectively made by the proponents of AOT that it actually reduces the amount of coercion these people experience because without AOT they are hospitalized and jailed more frequently.” The problem is that involuntary outpatient commitment always includes psychiatric medications. AOT considers it less coercive to allow a person’s body to remain free rather than locking it up. However, I consider it a greater intrusion to force medications, sometimes toxic, sometimes lethal, into a person’s body. Remember the notion of a chemical lobotomy? What good is it if the body remains free but the mind is lobotomized? Are you unfamiliar with this because you’re one of the good guys who never forces meds? Otherwise, how’d you miss this?

    • And I don’t buy that “mentally ill” labeled people are hospitalized or jailed more frequently in the absence of AOT – I don’t think the stats show any difference. Look at Wunderlink or Harrow. It’s a lot of money spent to humiliate and traumatize people that doesn’t even accomplish the questionable social control goals that it is supposed to meet.

      —- Steve

  15. The fact that the drugs cause chemical lobotomy is no mystery to people who use them (or should not be if they paid attention during their studies). The dean of the medical university I studied at and a renown neurobiologist used this very phrase “chemical lobotomy” to describe the effect of these drugs during a lecture.
    You’re making a great point: it’d rather be locked up in basement but retain my ability to think and my personality rather than walk around in a zombie-like state. Another aspect of the drug (and ECT) side effects is that some of them cause memory loss. Benzos cause anterograde amnesia, which means that if you keep a person on them you basically turn them into a patient zero for hippocampal removal (the poor soul Henry Gustav Molaison). One would think that the psychiatrist would notice something as dramatic as that but if they can fail to spot it while the patient in on the ward for several days (true story) what are the chances that they will realize while giving them the drug in an outpatient setting (I anyway give them the credit of “not notice” as opposed to “ignore”).

  16. Mark – I think you go along with the way AOT fanatics intend to dumb down the conversation because that dumbing down suits you. You then enter into the fray as an expert, and no matter which side of the aisle you are patrolling you can throw your weight around and lay claim to wanting first to do no harm and care, care, care.

    I’m not cynical, and it’s not bad to care, care, care. But laying claim to it has its own purposes, and advertising it as you main purpose when your deeds say it’s secondary to the purpose of “keeping society in order” is approaching cynicism.

    For instance, Mark, the “vicious” historical debate? That wasn’t the point of the anti-psychiatrists or Thomas Szasz, to get vicious. Szasz in particular was damned polite and wrote explicitly about the importance of good manners and polite conduct.

    And, for instance, you know full well that the merit to the argument equating lock-up here with lock-up there is its power as a diversionary tactic, since, of course, people care about who they are taken to be, since the question of constitutional rights isn’t reducible to that kind of pragmatic double-talk.

    • Mark, Also, you aren’t involved in a genuinely medical enterprise, but a pseudo-medical one. So, since I didn’t need a doctor, if I were one of your charges, I wouldn’t like your bothering me all of the time. This isn’t some mere emotional reaction, and isn’t to be equated with disrespect. I would feel sure, I believe, that you had plenty of arrogance for overcoming disrespect shown to you in person, the arrogance of your mission, which included bothering me. Genuine dislike most of the time for your bothering me would be how I felt in the detention setting. The game you set-up with society at large, that natural social groups do well to exclude people who need to see a doctor keeps you in business.