Five Strikes Against Assisted Outpatient Treatment Laws

Margaret Altman, MSW
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Only five states remain in which Assisted Outpatient Treatment (AOT) laws have not yet gone into effect — Massachusetts, Maryland, New Mexico, Connecticut and Tennessee — and the pressure to start these programs in CT and NM is now very heavy. This article will address the push towards forced treatment for vulnerable populations who are at a high risk of being re-traumatized by these laws. It will also attempt to put a human face on the issues of stigma, labeling and the downward spiral that distressed individuals can get locked into when positive rather than punitive pathways are not made available to them.

In New Mexico, the AOT law came up for debate recently and wasn’t passed. The proposal was fueled by a rash of police shootings (more than 40 since 2010), with officials claiming that 75 percent of the suspects shot suffered from some sort of mental illness. One such case was that of Duc Mihn Pham who shot a police woman in 2003 and then was shot to death by police. The officer recovered and went on to speak on behalf of the AOT legislation. A rather revealing comment of the officer’s was picked up by the media: “mentally ill you don’t know what their thoughts are.” In yet another statement during the Department of Justice investigations into the shooting, she said that officers meet up with people dealing with mental illness often and that those deemed dangerous can be unpredictable. We can only wonder how this perception influenced her decision to shoot.

Following the incident, the female police officer and her attorneys, backed by the Department of Justice, the Treatment Advocacy Center and the National Alliance for the Mentally Ill, continued their massive pressure for a New Mexico Assisted Outpatient law to be on the books. In 2004, NAMI recognized the police officer with a national award for her bravery and congratulated her at length in their newsletter for supporting the AOT legislation.

To move forward to the current situation: Duc Mihn Pham has become the poster boy for the DOJ, NAMI and other supporters of the Assisted Outpatient Law. This man — a Vietnamese-American with a very troubled childhood, a head injury and years of homeless despair on the streets of New Mexico — may not have appreciated this acclaim and its direction towards AOT legislation, given his personal situation. This is what we need to hear. Although his voice has been silenced, his story should not be ignored or dismissed.

Pham’s story comes primarily from reports derived from a close friend as well as the Albuquerque hospital and court records. Pham’s friend is Mr. Montoya, the director of the community Multi-Service Center in Albuquerque. This is a place that Pham frequented, where he was able to receive warmth and kindness from Mr. Montoya.

Pham was born in Vietnam to an American soldier and a Vietnamese woman. His biological father left Vietnam, never to return, and as a young child Pham was in an orphanage and wandered the streets. He suffered from stigma as the son of an American, and his friend said he was ostracized in that country for most of his early life. He was alone and unsupervised. One day at age 5, he was struck by a vehicle and suffered a massive head injury. He was in a coma for 3-4 months but survived.

In his early 20’s Pham came to the U.S. where he picked up odd jobs to sustain himself. He lived in New Mexico and then moved to Arkansas where he married and had a child, then relocated back to Albuquerque in 1994. When he returned, his friend Mr. Montoya gave him some money for food but Pham declined the offer of a hotel room. Instead he went into a Buddhist temple where he was arrested for trespassing. We don’t know much about his emotional state at this time, but his trespassing behavior was the first of many such minor infractions that led to a 6 month stay in jail. He was evaluated and labeled “mentally ill” — in all of his court appearances the judge found him to be incompetent to stand trial due to his “mental illness” and Pham was released to the streets. During this period he was also hospitalized, where he was diagnosed as “schizophrenic” and prescribed medications. At some point he was assigned a social worker who was to find housing and “mental health treatment.”

Thus began months of a terrible cycle of medication, minor offenses (such as trespassing), incarcerations, hospitalizations and court hearings where the judges deemed him “mentally ill” and incompetent to stand trial for his minor crimes. Unfortunately we do not know what prompted the psychiatrist to diagnose him with schizophrenia, but his friend Mr. Montoya has a descriptive account. He remembers that Pham stayed around the community center a great deal of the time when he was not in jail or in the psychiatric hospital. Pham found comfort in that environment, and clearly had attached to his friend who witnessed Pham’s deterioration from the medication and the cycle of hospitalizations and incarcerations.

Of great importance are Mr. Montoya’s descriptive statements as follows: “Pham told me that he was just given drugs to calm him down. He became progressively worse. He was on and off his medications.” Mr. Montoya stated that by April 2003, just prior to the confrontation with the police, Pham had totally deteriorated. In the literature there is a great deal of information about the side effects of psychiatric medications, and Pham was, by his friend’s account, suffering from the debilitating effects of medication and by withdrawal symptoms. Many homeless individuals and impoverished individuals are forced into this cycle. When they are involuntarily incarcerated or hospitalized they have to take medication, but when released they cannot access either the medication or any help in safely withdrawing from the drugs.

This is a multi-layered story that brings up questions and issues that are being passionately discussed and debated. Among these are the issues of continued stigma and its prevalence across multiple domains including corrections, the media, legislative bodies and communities in general; the concerns about psychiatric medication and its efficacy; the lack of comprehensive evaluations of individuals in emotional distress who have had head injuries; cultural insensitivity in relation to Asian and other populations who have different and significant perspectives on emotional distress; and, of utmost importance, the failure to address the needs of our most emotionally distressed population for compassionate, non-medically based care.

Pham’s lived experiences with the neglect, stigmatization, abuse and physical head injury were highly significant factors that were ignored and dismissed. As a consequence, being labeled, diagnosed, medicated and incarcerated led to his complete deterioration. While we cannot presume to know what Pham’s emotional state was just prior to the final incident that led to his death, we do know that Pham had never been violent, his “crimes” of trespassing and shoplifting were minor and he was not deemed a danger to himself or society. What we do know from his friend’s account, from the lived experiences of individuals who have taken psychiatric medications and from the research, is that his emotional and physical state was likely very fragile and vulnerable. What I know from my own personal and professional experience with people who have been traumatized in childhood is that they often continue on to adulthood with an extreme fear and sensitivity to any verbal or behavioral situations that they view as “threatening.” He was on that treacherous covert list of individuals who are considered by an uninformed society to be “mentally ill,” “dangerous,” “unpredictable.” Given this reality his fate was sealed — as it would be if he were alive today.

From professional experience as a social worker I have witnessed all of the conditions that Pham suffered through, and I have seen the stigma and pain of withdrawal symptoms in the emergency rooms where I have worked. It all plays into the evaluation process that an individual goes through when they walk in or are brought into the emergency department. The stigma has an impact upon the disposition of the individual. More likely than not, an evaluation will be done, and in order to quickly resolve the case an involuntary hold will be initiated without addressing the history or circumstances of the individual. Most of what the person says is ignored while the evaluating person only probes for any sign of “dangerousness”. And that term is not clearly defined. Here we have a statement from another social worker with strong feelings about the damages done:

“Most people have never participated in an involuntary mental health commitment. As a social worker, I have, a number of times. When you’ve participated in one, especially one that has gone awry, you see with crystal clarity the reasons for so many layers of protections for the detainee. When a civil commitment is authorized in the state of Pennsylvania, it becomes a warrant to take them into custody. People who go to psychiatric units against their will don’t go in ambulances, they go in paddy wagons.”

In Pham’s case, his history, his emotional attachment to Mr. Montoya and his frequent visits to the nurturing community services center should point to a course of events quite different from the one that individuals such as Pham endure when they are in emotional distress. However, standing directly in their path to alternative solutions are such statements as the following from TAC in their rationale for the AOT program:

“Extensive research since the early 1990s has revealed that some people with schizophrenia and bipolar disorder experience a neurological deficit called “anosognosia,” a condition also commonly found in people suffering other brain disorders such as Alzheimer’s or complications from a stroke. Anosognosia impairs the ability of individuals to recognize that their symptoms are caused by a brain disorder. A leading researcher detailed the severe consequences of this condition: [P]oor insight in schizophrenia is associated with poorer medication compliance, poorer psychosocial functioning, poorer prognosis, increased relapses and hospitalization and poorer treatment outcomes.

The most common reason that people with severe mental illnesses are not being treated is that they do not believe that they need treatment. A severe lack of insight into illness can “seriously interfere with [a patient’s] ability to weigh meaningfully the consequences of various treatment options.”

It is my belief that people who refuse “treatment” are not people who don’t want help. They are certainly not “unaware” of their distress, and most are able to tell of their life experiences with encouragement from a compassionate person. They may well be afraid of being labeled, stigmatized and diagnosed with a “brain disease” that will lead to medications and a cycle of pain and frustration. They may well be fearful of losing control over their lives and being told what to do, with threats of more medication or forced medication. They do not trust in the system that purports to help and yet does grave harm.

If we extrapolate from Pham’s life experiences and his needs, we can see that being targeted as a candidate for an AOT program could not have met his needs in any way and could have set him directly in the path for more hospitalizations. He would have been under judicial pressure to take medications that according to his friend and others would “calm” him down and probably create distressing symptoms. He would have been threatened with involuntary hospitalizations if he did not or could not comply. This would only have escalated his pain and further dehumanized him. Having never had a family, Pham needed a place and people to turn to in order to rebuild his trust and make him feel worthy and human. AOT does the opposite under the guise of protecting the individual and keeping society “safe” from “dangerous,” “unpredictable” people.

Unfortunately, all but five states have adopted AOT programs. The pressure is enormous; from NAMI, from the Department of Justice, from TAC and from members of the community who believe that punitive programs work. And that is why the jails are overflowing with individuals who are labeled “mentally ill” and who cycle through the hospitals and correctional institutions in a never ending stream of humanity.

The authors and commentators of MIA have spoken out loudly for respite centers that would provide individuals like Pham the compassionate and non-judgmental care that he needed. The fact that he sought out the community center convinces me that there is a positive pathway to health, and that we need to continue to advocate for it.

29 COMMENTS

  1. Assisted outpatient treatment laws are enacted under the false assumption that people with a mental illness which is treated would not choose to commit evil acts unlike people who have no mental illness do. This absurdity, if taken to the next logical step. would say that people with treated mental illness are better neighbors and citizens than those without mental illness. The fact is that social class is the best predictor of potential criminal conduct and society puts the mentally ill at the very bottom of the social-economic strata.

  2. Wow, this nightmare of force treatment would horrify even Gregor from Kafka’s Metamorphosis. Ironically, E. Fulley Torrey is in some sense less in touch with reality than the people who reject that their distress is caused by a brain disease.

    I’d like to share 3 brief stories of what is possible if psychotherapy and compassionate community support for psychotic people is available. These are the briefest adaptations of long case studies from the book Weathering the Storms, by Murray Jackson. It’s interesting to consider what could have happened if the man in this article had access to these services:

    Case 1:
    Anthony was age 18 when his brother died and a girlfriend rejected him. He experienced a breakdown featuring voices which ordered him to burn himself, and he believed his feelings had migrated from his brain into his left leg. He made a suicide attempt, and was then medicated and nonfunctional for the next 10 years, living alternately in hospital and parents’ basement.

    At age 28, he had opportunity to participate in a supportive outpatient program and 2x/week psychotherapy. At first, he was detached and out of contact, saying nothing meaningful to the therapist. However, he gradually began to discuss the fears and traumas which had contributed to his breakdown a decade before. He became increasingly attached to therapist, seeing them as a parent figure, an issue which had to be worked through. Over the next two years, his paranoid fears gradually lessened, and Anthony became increasingly secure in his attachment to the therapist and outpatient program.

    During the next 5 years, he gradually became able to work full-time, was helped to get his own apartment, and later found a girlfriend and married. He eventually tapered off all psychiatric medication, and remained well on followup at age 35.

    Case 2:
    Alec, age 22, came from an abusive, cold family. He had tried to work and function for several years but eventually heard alien voices attacking him and felt strong urges to kill his mother and sister. For the next 14 years, he lived alone in a shack near his parents, doing nothing during the day and wondering the streets at night. He occasionally attempted to work as a county road sweeper, but had to stop due to fears that he was killing defenseless vegetation.

    At age 36, he got a chance to do an outpatient program with 2x weekly psychotherapy similar to the first case. Despite all the years of torment, he was motivated to get help. The treatment team eventually helped hi to understand how his fears related to his past traumas and did not represent real threats in the present-day environment. He was able to experience some safety and attachment both with the therapist and the group program. He could now face his long social isolation and all the losses he had incurred.

    At age 40, he was for the first time living in his own apartment, had no psychotic symptoms, working in a sheltered/apprentice job, a good relationship with his sister, and was exploring relationships with women. Alec said, “I had made myself God, but God became lonely and I had to admit I needed other people.”

    Case 3:
    George was age 16 at his first breakdown. Coming from a cold, neglecting family, he became depressed after rejection by a girl, and then came to believe he was the devil and Hitler. He felt that others could read his thoughts. Very quickly he lost any ability to function at school, and then made a suicide attempt by jumping off a building.

    He was hospitalized, and later at age 19 got a chance to do 2x/weekly therapy plus outpatient work. For about a year, George spent most therapy sessions talking to himself, making no eye contact, and refusing to sit down in the office. Finally the therapist said something to George about how his fears of being retraumatized by the therapist were playing into his avoidant behavior in the office. This connected and allowed George to talk meaningfully about his fear. Over the next year, the withdrawal and muteness disappeared and George was able to engage in emotionally meaningful conversation about the events leading up to his breakdown.

    By age 24, George was working full-time in a supermarket, functioning well in his own flat, and on good terms with his parents. He also returned to college, where he was achieving excellent grades. Despite their continuing problems, his family were extremely happy to see George’s emotional and intellectual growth.

    —————————

    I have glossed over and shortened these cases considerably to present what were really arduous, harrowing processes of gradual recovery from a psychotic state.

    Obviously the crucial factors were:
    – Opportunity to get group support and long-term individual therapy.
    – A treatment team who believed that psychotic experience was meaningful and that recovery is possible with good support.
    – Gradual tapering down of medication (this occurred in almost every case in this book).

    In America, several factors make George, Alec, and Anthony’s journey of healing virtually impossible for many people labeled schizophrenic. Over-medication, the attitude that severe distress is a brain disease, and the lack of provision of long-term support combine to destroy the possibility of recovery.

    By supporting these factors, Torrey’s TAC is responsible for contributing to the murder of these people’s souls.

  3. Police violence is a growing issue in this country, and violence directed against vulnerable peoples. Given such violence, your defense of Duc Mihn Pham, in this instance, is both poignant and necessary. Involuntary outpatient commitment orders, if they do anything, are likely to increase the incidence of violence taking place. Desperate people do desperate things, and the problem is not an illness that possesses of the mind, or of the body, so much as the problem is the negative circumstances that they find themselves in. Drugging people is not a solution to the impossible living situations that people find themselves in, nor is it a solution to this nation’s gun problem. Never was, never will be. Do something about the social and economic straits that drive people to desperation, and you will be doing something about the problem. Pretend that the problem was created by a contagion of “mental illness”, and the problem is only going to continue to escalate. “Mental health” treatment and crime prevention are not synonymous. The misconduct of overzealous police officers, of which we’ve seen pretty much recently, illustrates the complete absurdity of leaving the policing of the police up to the police. What happened in New Mexico, as in other places around the country, just goes to show that law enforcement needs the kind of independent citizen oversight that it doesn’t currently receive.

    • “Desperate people do desperate things, and the problem is not an illness that possesses of the mind, or of the body, so much as the problem is the negative circumstances that they find themselves in.”
      If I were to be subjected to AOT I’d sure as hell become homicidal. It’s also known as “self-defense”.

      • As others have pointed out, Assisted Outpatient Treatment it ain’t, Involuntary Outpatient Commitment (forced drugging) it is. Referring to forced drugging as Assisted Outpatient Treatment is a stretch of the imagination.

        The news carries a lot of stories about patient on staff violence these days whereas staff on patient violence is sloughed off. I’d say people would have a great deal of cause for self-defense there, too, if it didn’t beget more violence. Ending the state sanctioned violence behind non-consensual treatment, rather than making attempted vengeance a part of the routine, that’s the challenge. If there had been no imprisonment in those psychiatric prisons euphemistically referred to as hospitals, there would be no forced drugging outside of such institutions today. Certainly such ‘enhanced interrogation’ techniques are not the kind of “progress” anybody needs.

  4. Only five states remain in which Assisted Outpatient Treatment (AOT) laws have not yet gone into effect

    I had no idea. If this is true it would seem that fighting Murphy would be an exercise in futility, as any victory could be trumped by state laws. Of course maybe that’s how they want us to think.

    To me this emphasizes the urgency of demonstrating to the masses that “mental illness” is a bogus concept and that “treatment” is a fraudulent euphemism for state control of our bodies and the most intimate aspects of our lives. We need to deconstruct the semantic tricks used to convince vast segments of the population that metaphors such as “mental illness” are to be taken literally, and that such figurative “diseases” can be “treated” with very real and debilitating drugs.

    It will take mass resistance on many levels if we hope to eradicate this scourge in our lifetimes.

  5. “The proposal was fueled by a rash of police shootings (more than 40 since 2010), with officials claiming that 75 percent of the suspects shot suffered from some sort of mental illness.”

    I love how the problem of people getting shot by police turns into the solution of using forced psychiatry against people who are getting shot. How about doing something with the out-of-control cops? It’s essentially the same problem as the black community faces – it’s always our fault and never the police.

  6. Thanks, Margaret, for pointing out the ineffectiveness and one of the injustices resulting from AOT. No one, IMO, should ever have a right to force (or coerse, especially with lies like the “chemical imbalance theory”) drugs onto other human beings, especially since their is zero scientific proof any of the DSM disorders are actually real “brain disorders.”

    And I’m quite certain the reason some so called “bipolar” / “schizophrenics” don’t want to take the neuroleptics is because the neuroleptics, themselves, can indeed cause a person to suffer from both the positive and negative symptoms of “schizophrenia” itself. The negative symptoms resulting from neuroleptic induced deficit syndrome. And the positive symptoms resulting from neuroleptic induced anticholingeric intoxication syndrome, aka anticholinergic toxidrome.

    It is absurd to live in a world where anyone (including psychiatrists) have a legal right to force treat people with mind altering drugs known to create the symptoms of “schizophrenia.”

  7. Thanks for telling Duc Mihn Pham ‘s story.

    I think the most tragic part for me was that he had lived for so long in such difficult circumstances without incidences of violence, and then how soon after medication was introduced that a violent incident happened. I just imagine how different it might have bee if we could have had support enveloping him around his own ‘home’ – at the community center.

  8. I can relate to the “downward spiral” caused by mental health “treatment.” I lost 10 years of my life to “treatment,” stigma, and punitive psychiatry. The only reason I’m “in recovery” now is because of my upper-middle/upper-class family taking care of me after reconciling ( did I mention that the shrinks are part of the reason we were estranged?).

    Its crazy, being locked in the cycle of punishment, pain, and stigma. I feel for this individual, I do, and I hate the way Torrey is always seizing upon tragedy to make his case for controlling and drugging those deemed “severely mentally ill.” Brain disease? As I recall, in the 60s and 70s, Torrey tried his hand at being the next Thomas Szasz. Apparenly, there’s more money and prestige in his current breed of psychiatry than in his old one.

    • Yeah, same here. If I hadn’t been able to rely upon the patience and protection of my loving family during the years it took for me to struggle with and eventually succeed at detoxing from these addictive and harmful drugs, Pham’s fate could easily have been mine.

    • As I recall, in the 60s and 70s, Torrey tried hisfor example that hand at being the next Thomas Szasz. Apparenly, there’s more money and prestige in his current breed of psychiatry than in his old one.

      Yep. His arguments in The Death of Psychiatry were even used in the mental patients’ liberation movement to help demonstrate the bankruptcy of the “mental illness” con. He stated for example, that one can no more have a “sick mind” than he/she can have a “purple idea.”

  9. I don’t know about Torrey in the 60’s and 70’s; but in his current state; I should suspected Torrey when I read one of earlier editions of his infamous; Surviving Schizophrenia. In one of the editions; he stated that we should not stop the “schizophrenic” from smoking; because they don’t get much pleasure anyway. I guess not with all the toxic addictive drugs they throw down your gullet. So, the “schizophrenic” person suffers first from the drugs and then from their toxic side effects; t.d. weight gain, diabetes. Then, after all that he gets lung cancer or emphysema from the cigarettes no one wanted to help him quit; because they give him pleasure. In later editions, Torrey did change his tune a little in that he said the person experiencing “psychosis” should wait until he’s in “remission” to quit. When I read that earlier edition of Torrey’s Surviving Schizophrenia, a little inner light did go off in me; but it took a few years before it really took hold in my brain. Sadly, many people look on Torrey’s book on Surviving Schizophrenia to be almost like the Bible. He also wrote on Surviving Bipolar Disorder which is as equally as useless and demeaning. I threw all my Torrey books into the dumpster where I live. Although, I am fervently against book burnings and book censorship; I felt this book and several others were so damaging and gave such erroneous information as to truly hurt innocent people; especially young adults. I refused to donate to a library for a book sale or even to a used book store for exchange. Please forgive me those who believe in freedom of thought and publishing; like myself. I just don’t want anyone to get hurt like I did. Thank you.

  10. So Margaret, do you ever plan to tell the readers of this website and commenters of this article that you now retract this viewpoint and are in fact very much pro-AOT? I sometimes read DJ Jaffe’s facebook page for kicks and noticed Margaret posting over there quite frequently recently, praising him, which rather surprised me given articles like this. Yesterday, someone directly asked her about this article and she confirmed she is pro-AOT and that her perspective has completely changed. She also describes her time over here as a ‘research on anti-psychiatry groups’ (whatever that means). Not just on DJs page, but I then noticed several other recent FB posts elsewhere where it was made very clear that her perspective has radically changed. Care to enlighten us why the radical change in such a short period of time? Or was this really no change, but these articles were really just some sort of “research” to determine our responses?