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.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.