Responding to “The Case Against AOT”—Next Steps for Change

Robert Nikkel, MSW
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Robert Whitaker and Michael Simonson produced an essential review and critique of forced outpatient interventions in their July 14 report, “Twenty Years After Kendra’s Law: The Case Against AOT.”

Bob has sometimes been criticized for not advocating more on the issues he raises. The way I see it, that is not his job as an investigative medical journalist. That is the job of readers of Mad in America. My interest lies in analyzing the “so what next?” steps that should be considered. For better or worse, my perspective is that of a person who has worked at every level of the mental health (and addictions) systems in the US. And it has evolved especially from my relatively long tenure as a state mental health commissioner. I tend to sort out the problems that have been identified and then suggest options to consider. These include policy, program, training, oversight, regulatory, finance, and legislative initiatives, and finally, the advocacy needed to enact the changes that are needed.

My overall reaction to the issues raised in “The Case Against AOT” starts with this—the states abuse their own regulations by not following them. This is not to say I think AOT (or as has been pointed out, we should be speaking of it in a more direct manner as “Involuntary Outpatient Commitment” or IOC) should even be a legal option. The three states that have refused to enact it into legislation—Massachusetts, Connecticut and Maryland—are to be commended and supported in maintaining this position. Advocates in the other 47 states have an incredibly challenging proposition to confront the elimination of IOC. It will be a time-consuming, intensely demanding political endeavor. It would be extremely important to learn from advocates in the few states that have blocked outpatient commitment laws from ever being enacted.

Colleagues like Tom Behrendt, Kathy Flaherty and others in Connecticut who have so far successfully fought the introduction of outpatient forced treatment bills have an incredible amount of history and information that would be best for them to share directly and in detail. But my summary of it is as follows: They were able to organize a powerful grassroots movement to speak to both the state mental health office and legislators when bills were introduced to start involuntary outpatient commitment. They monitored hearings. They helped draft testimony and made sure that it was well-organized with cogent arguments concerning all of the negative effects of passing such a law. They worked closely with the state mental health office to get them to change their initial support for the legislation. They involved key and well-known advocates, even from out of state if they could be available. They prepared alternate language to be inserted as proposed amendments to the bills they were opposing. For example, one of their proposals was to develop a program to train clients about advance directives and to create “peer engagement specialists.”

Perhaps Bob and Michael have given us one of the most powerful tools in future efforts of all kinds. Their report provides the most reliable and comprehensive guide to what research tells us about the ineffectiveness and dangers of involuntary outpatient commitment. We haven’t had this before. There will be many who will direct their efforts toward repealing IOC statutes in their states—an extremely challenging and uphill battle. Their arguments will be strengthened immensely by the findings in this report. But everyone who works on reforming the abuses of IOC will find this information invaluable too.

In curtailing the use of existing practices, I would like to point out that Saul Alinsky’s Rules for Radicals may apply here—make the system follow its own rules. As Bob and Michael make clear in telling of the tragedy of Andrew Rich, the basic standards for extending outpatient forced treatment can be and were disregarded. The only reason given for extending Andrew’s commitment was that he disagreed with his psychiatrist that he was “mentally ill,” which was not a criteria that, under the law, could be used to justify an extension.

What follows from here are suggestions to stimulate thinking about what kinds of interventions can be considered. They are far from comprehensive and some are far more likely to be enacted soon rather than later. Most will require not only advocacy but additional funding. If it’s going to continue at all, it must be recognized that Involuntary Outpatient Commitment cannot be respectfully much less anywhere near effectively used “on the cheap.”

Each problem in how IOC is currently practiced is listed below with examples of what can be done to counteract the harmful practices.

  1. The courts are inconsistent in following the legal standards for outpatient civil commitment.

One proposition to consider is that courts and so-called psychiatric experts must be intensely monitored. One step would be to engage each state’s Protection and Advocacy agency to try to get them to prioritize this area of human rights abuse. My experience is that different state disability organizations will have varying degrees of interest in the issues.

How to do this:

Advocates should begin taking an active role in attending hearings. They must pressure their court systems to ensure that competent defense attorneys represent the expressed interests of the person for whom the hearing is being held. Simply having legal representation does not meet the need—it must be skilled, independent, knowledgeable and assertive.

  1. The use of psychiatric drugs forced on people subjected to Involuntary Outpatient Commitment orders is largely out of control.

Like the practice of prescribing psychiatric medications in general, these medication orders are mostly inconsistent with unbiased research on outcomes and oblivious to the destructive and health damaging effects. They are especially blind to the dangerous effects of polypharmacy.

How to counter this:

To counteract these abuses, each state’s process should require the court to track what each person is being prescribed, at what dosage, for how long and by whom. The courts should then identify patterns and prescribers out of the bounds of standards of unbiased research-based clinical practice. The courts should be required to identify true experts in psychiatric drug prescription practices. This process would identify those persons who are being prescribed more than one psychiatric drug and those who are on even moderate, much less high dosages. This information should be made available at each court hearing for recommitment.

  1. Individuals under Involuntary Outpatient Commitment orders are virtually alone during the time between commitment and recommitment hearings.

How to counter this:

A peer rights advocate should be offered and made available to each person who desires it. These peer advocates would be independent of the courts and mental health treatment providers. They would spend time with each person on a regular basis to provide support and gather information about how the interventions are working or not. They would watch for infringement of rights, and assist the person in expressing her or his desires to the court. They would also assist the person in moving the commitment process toward self-directed decision-making.

  1. Involuntary Outpatient Treatment practices are based on a chronicity model which rewards only obedience to forced treatment orders. Destructive abuses occur when there is no attention to the process of moving beyond the outpatient commitment period and into a recovery mindset.

What to do:

While it may appear to be an oxymoron, the entire commitment system should be grounded in and feature the likelihood of recovery rather than chronicity. All of the forms of peer support can make this part of the court monitoring process, whether or not an individual judge or the so-called expert witnesses agree.

  1. The psychiatric profession is mostly uneducated when it comes to the mid- to long-term effects and outcomes for medication. There is virtually no attention given to providing true informed consent—including what can be expected when withdrawing from the drugs.

What to do:

A court could be required to monitor not only the prescribing patterns noted above, but behind this, the knowledge base of prescribers. Are they taking continuing education courses and receiving CMEs that demonstrate competency and knowledge from courses that are far different from the pro-medication biases of most existing CME resources? Resources like the Mad in America Continuing Education project should be provided with funds to market and purchase the relatively expensive CME applications for these kinds of courses.

  1. Courts and mental health administrators are largely unaware of the relative ineffectiveness of psychiatric drugs, what dynamics like dopamine super sensitivity are all about, and which withdrawal approaches will most likely lead to improvement in life satisfaction and safety rather than what is interpreted as relapse.

What to do:

Require court personnel and mental health administrators to attend educational sessions and seminars that provide unbiased information similar to what prescribers are required to take in continuing education for professional credits.

  1. Like the courts, prescribers and mental health administrators, county and state officials and legislators are unaware of the risks, the lack of effectiveness and the violation of rights that currently accompany Involuntary Outpatient Commitment. What they hear and understand comes almost entirely from NAMI and pharmaceutical lobbyists.

What to do:

The steps outlined here can be achieved only by advocacy at the state and local levels. The purpose of making legislators aware of the problems is to get them to build the solutions into policies, administrative rules and negotiated agreements. Many will require legislative interventions at some point. Advocates must establish working relationships everywhere they can. Often, certain state legislators will take more interest than others in mental health issues—sometimes for better, sometimes for worse. It is essential to know who’s who and which legislators have more influence than others, such as chairing human services committees. Likewise, state offices of mental health vary greatly in their receptivity to these kinds of human rights issues. Participating on planning and advocacy councils is often critical. Other times, less formal approaches will work better. State officers can be highly defensive, so going at it carefully and as respectfully as possible is key. Confrontation is needed sometimes but generally to be avoided when a softer approach can be used over a period of time.

  1. Advocates have yet to establish the increased costs, find ways to quantify them with credible fiscal analyses or learn how to manage the costs over time.

What to do:

As noted above, most if not all of these suggestions will require additional resources. In recognition of this, persons seeking change must be able to conduct credible fiscal analyses. Budget and fiscal staff from local and state agencies can be asked to provide coaching on how to do this. Some will be better at numbers than words, so identifying who can do which of these types of tasks is something to be worked out at every local and state advocacy level. One approach to minimizing fiscal impacts is to determine whether a pilot could be used to demonstrate effectiveness at a lesser cost than full blown changes.

Conclusion

Clearly, most of these suggestions are incremental in nature. Some would have greater impacts than others. I would suggest a two-pronged approach where effort is devoted to both repeal of IOC laws and these admittedly reform-oriented propositions. But it seems essential now to begin taking advantage of the incredible information assembled by Bob and Michael in their analysis of Kendra’s Law. It’s really up to us now.

27 COMMENTS

  1. Thank you, Bob, for these practical recommendations for opposing involuntary out-patient laws. I believe they are also relevant for involuntary in-patient commitment as well and also for out-patient behavioral health court practices. In addition, your recommendations are very relevant for “voluntary” services where the absence of accurate informed consent is typical. In the state where I live, Pennsylvania, the state legislature passed an “AOC” legislation which was optional for counties to institute. After strong advocacy from multiple sources, every county (67) opted out of “AOC.” I think this shows that clear messaging about how the legislation would work locally, especially given the absence of additional funding for community supports, was effective locally where groups which might have disagreed about many public policies, could still unite about this “AOC” legislation. It was my experience that writing to my state legislator did not change his vote or increase his understanding. Unfortunately on the federal level Pennsylvania enabled the Murphy Bill, which later merged into the “CURES” bill which President Obama signed. After public exposure of his personal behavior, Murphy has since resurfaced as a professional lobbyist. Corruption, obfuscation, and coercion support business as usual. Perhaps organizing locally can bring results with fewer barriers than state and federal organizing. It’s important to continue bringing Whitaker’s reporting, non-corporate backed research, and individual and family stories to the attention of those who legislate policy on all levels; to educate systems providers; users; and our communities to work for human rights. Yours and Saul’s recommendation to use their laws and regulations to accomplish this sounds strategic.

  2. We have to start putting at least some psychiatrists and some psychotherapists out of business.

    This will not be that hard. I have forced the closure of other types of businesses.

    Closing a business is a visible thing, it draws attention, it makes heroes, and it makes for enemies.

    But once we have this visibility, it will be easier to get more lawsuits going, easier to do sidewalk protests, and then easier to get critical laws changed.

    Forced treatment is of course unthinkable, but many Americans seem to believe that it is sometimes necessary. But the exploitation which is psychotherapy, and the chemical assault which is voluntary drugging, are very common. Many many people have been effected by these. Really, all should be entitled to sue and obtain compensation.

    So mostly it is just a matter of drawing attention by engaging in consequential actions against psychiatrists and psychotherapists.

  3. “Advocates in the other 47 states have an incredibly challenging proposition to confront the elimination of IOC. It will be a time-consuming, intensely demanding political endeavor. It would be extremely important to learn from advocates in the few states that have blocked outpatient commitment laws from ever being enacted.”

    I agree, and am curious when these oppressive IOC laws were enacted. Were they all enacted rather recently, in the past several decades?

    “Colleagues like Tom Behrendt, Kathy Flaherty and others in Connecticut who have so far successfully fought the introduction of outpatient forced treatment bills have an incredible amount of history and information that would be best for them to share directly and in detail.”

    I hope they choose to do so, since your synopsis and solutions, in as much as they are much appreciated, will take several readings and much more of a game plan to try to implement. And as you mentioned will need well organized and informed groups of people to accomplish on the local level. Perhaps MiA could help organize activists by state, in some manner?

    Especially since some of us actually had to move out of a state, to get away from the criminal psychiatrists, who for years illegally listed us with the health insurers as their “outpatients,” when we weren’t. Like never arrested criminal psychiatrists, who were also the “snowing” partners in crime of criminal doctors, like this now FBI convicted doctor:

    https://www.justice.gov/usao-ndil/pr/oak-brook-doctor-convicted-kickback-scheme-sacred-heart-hospital

    https://chicagoist.com/2013/04/16/chicago_hospital_owner_doctors_arre.php

    And having to move out of a state, that one has lived in for decades, does leave one with less local social connections. And especially since our mainstream religions have totally adopted psychiatry’s beliefs – to the point the DSM “bible” is now being taught in our local seminaries – so our religions stand 100% in support of the psychiatric “bible,” rather than the real Bible. Largely, no doubt, in part because the psychiatrists and psychologists have been covering up the child abuse and rape problems of the mainstream religions for over a century.

    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

    https://www.madinamerica.com/2016/04/heal-for-life/

    As even the appalled, ethical insiders within those religions are documenting in books, and the child abuse covering up crimes other religions are pointing out in articles.

    https://www.amazon.com/Jesus-Culture-Wars-Reclaiming-Prayer/dp/1598868330

    https://virtueonline.org/lutherans-elca-texas-catastrophe-coming-lesson-episcopalians

    Not to mention the multibillions psychiatry’s iatrogenic illness creating DSM system is bringing in for all the “religious” doctors and religious hospitals.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    https://en.wikipedia.org/wiki/Toxidrome

    I do think it’d be great if MiA could help organize activists by state. And help educate us how to legally fight against the massive in scope psychiatric crimes being committed against millions of Americans, together.

  4. THANK YOU, BOB!!

    It is truly up to us, the many people watching with very critical eyes what the system is doing.

    Difficult? Uphill? Of course!

    But look, resources in the form of testimony, investigation, research, medicine… and now, more and more, advocacy planning.

    Thanks to people like you who help us lead and lead us too. MIA keeps me at my work when the road looks rough and exhausting – I’m very excited to bring this with me to my new home state where IOC programs are legal… we are everywhere, and it’s time to get organized and effective on the local level. THANK YOU.

  5. I think a point is really being missed in your arrangement of steps to follow. People are NOT placed on IOT because of a worry about the “chronicity” of any “sickness”. People ARE placed on IOT because of a perceived threat of violence to the general public, that is, this worry is over the little matter of guilt and innocence rather than sickness and wellness. People are drugged not due to their supposed sickness but because of events like Columbine, Virginia Tech, etc. This being the case, the best argument is the argument provided by the facts, statistics. In drugging this population of people, you are drugging a population that is more likely to have violence done to it than to do violence. That is not a good argument for drugging people as a violence prevention measure. Next question, if you restored any of these drugged people to “normality”, er, “health”, are they going to be more, or less, prone to commit acts of violence against other people afterwards? The facts simply don’t support drugging people as a violence prevention measure as that is going to mean you are going to drug many people who are not violent in any way, shape, or form just to keep a minuscule fraction of that population in line.

  6. Very good Bob!

    For number 2 I wish people would acknowledge the drugs the person is forced to take on AOC can make them weirder than ever. Abilify has 4 warnings about “odd behaviors” as a potential side effect and has been linked to an increase in poor impulse control.

    Yet Abilify seems to be a favorite for AOT. How is this supposed to help people act responsibly and obey the law?

  7. There is no way any of these wonderful changes are going to be brought about by an analysis based on making reasonable arguments to the system. They simply fucking don’t care, it’s about POWER for Chrissake! The only strategic approach which will ultimately work is to build a people’s movement against psychiatry which is in synch with a movement to bring all systemic oppression to a halt. Appealing to “reason” is a completely and demonstrably failed strategy, as nothing this system does is based on reason, other than as a means of maximizing profits.

  8. Arguing with psychiatrists and “mental health” professionals is indeed futile.

    While I agree with Bob Nickel that these changes would be an improvement, I also agree with Oldhead. The “MH System” is too invested in preserving its own money and power to reason with survivors.

    Rather than waste time and energy debating shrinks, we need to win over the kind but deceived people who honestly think psychiatry helps its victims. A lot of people I know fall in this category.

  9. There is no mention among the above steps of the need to develop an underground railroad to aid people in escaping forced drugging. We are down to 3 states without forced outpatient drugging laws. A present danger is that IOC, if all states succumb to its seductions, might be legislatively mandated across the nation. This makes it essential that some people possess the necessary bravery and fortitude to defy the authorities, and risk imprisonment by sheltering people threatened with state drugging. As it was for people escaping slavery in the 19th century, so it is for people escaping forced drugging in the 21st century.

  10. Forced drugging is the most outrageous of all civil rights violations. It is essentially an assault and battery. That this is even a thing is incomprehensible. Informed consent should preclude forced anything. The people who engage in forced drugging should be subject to arrest.

  11. I agree with most of what the other commenters say or imply. The ideas the blog poster Mr. Nikkel mentions are complex and seem impossible to implement in our current society.

    When will we see a valid, scientific publication in a psychiatric journal that documents proven ways to ween from multiple psychiatric medications that have no proven efficacy or safety and are often prescribed on top of each other?? This is just one of many concerns with what the poster has to say.

    As far as the male in the 2nd AOT article, he killed himself because he was so distraught with what happened to him. How will our current psychiatric system prevent that?

    Information is important but action that the money driven system will implement is essential.

    How, and more importantly “when” will that implementation happen especially with our current political process that has very very much on their hands.

    “Slowly” is simply not good enough for those who are currently suffering, including their families, and people who everyday are beginning to suffer.

  12. Thanks for this article, Bob. I agree that it is up to us. Here are some things I would like to add:

    Jim Flannery’s recent film on how to escape forced treatment is very good. It is called Voices for Choices (on YouTube).

    Secondly, just because a state doesn’t have AOT does not mean they don’t use force. Yes, they do. Does a state hospital count? Yes, they use restraints and they force needles into you. If you refuse drugs they will put you on guardianship or just keep you locked up.

    Thirdly, force (whether it’s called AOT or not) is used as retaliation against activists and used to silence people, for the good of the institution.

    Those of us who have escaped or somehow ended psych “care” should now take heed to live well, to illustrate that we are fine without their “treatment,” that we can thrive once we are free of it. We can be careful about our use of language and make sure to use our words, not theirs.

  13. I spent 10 years doing legal work for the Farm-to-Consumer Legal Defense Fund. That group provided legal counsel to farmers who were being harassed by the government. It also did policy work, advocating for change in state and federal laws that restricted food freedom. I’d like to work with a legal nonprofit group to organize something similar for victims of involuntary mental health treatment. We could have a core group of attorneys knowledgeable in mental health law, which would support a national network of pro bono attorneys to help people in all 50 states. We could also operate a hotline 24/7 for both legal issues and non-legal peer support. We could organize a network of experts (psychiatrists, psychologists, and researchers) who understand the destructive and health damaging effects of widely prescribed psychotropic medications. These experts would be called upon to provide testimony in commitment hearings via videoconference. These are all things I was able to do as lead counsel and executive director of FTCLDF. I think I could secure a grant to fund some of this. Please let me know if you have a suggestion for a nonprofit I could work with.

    • Hi, I would contact MindFreedom or Jim Gottstein of Psych Rights.

      I always wanted to sue my former providers. I’m always hoping I can have a chance. I don’t want to nail them, I only want them to realize that what they did harmed me, and to promise not to do something like that again. Publicly. Oh, and stop claiming I’m psychotic when they know I am telling the truth.

    • You seem prepared to do some serious work, and to understand the enormity of what you’re proposing. You could start a 501(C)(3) nonprofit on your own, it’s not harder than any of the other stuff you mention. But again, it is an enormous task. Limiting it to involuntary psychiatry would be a good way to narrow down and focus specifically on this, which is undoubtedly our greatest legal need. But you would be starting from scratch, don’t expect any established groups or individuals to provide much critical assistance at this juncture. Just being realistic.

      • Thanks for the input. I did form a nonprofit, andrewsvoice.org (V.O.I.C.E. stands for victory over involuntary commitment excesses). I set it up as a 501(c)(4), because I also registered as a lobbyist and there are limitations on doing that as a (c)(3). My plan for the (c)(4) was to take on Wisconsin’s version of Kendra’s law; and ultimately attack it in the other 46 states that have enacted it. It took Torrey and the Treatment Advocacy Center 20 years and millions of dollars to get those laws in place, so I’m under no illusions about the task ahead of me. But in the process of getting in the trenches and representing people like Andrew, trapped in an endless cycle of forced treatment, I’ve become aware of the huge need for zealous, informed advocacy of people who are struggling, and dying, in this broken system. Maybe I can’t do it all, but I will keep trying until I draw my last breath.

    • Problem is there are precious few lawyers who can argue AP (anti-psychiatry) cases from the perspective of the victim, rather than simply adhering to the paternalistic assumptions of the system. Lawyers need to be able to argue AGAINST “diagnoses,” “treatments,” etc. from the understanding that psychiatry is fraudulent and unscientific, not fight for the best “treatment plan.” This will take lots of education and I’m not sure where it’s going to come from.

  14. One of my best friends is a VICTIM of “AOT/IOC”, and it is heart-rending to watch. The staff at the local “community mental health center” regularly IGNORE my friend, and LIE about her. They LIE, and claim that she said things she never said. They claim she does things she’s never done. And, they FORCE DRUG her.
    The State either doesn’t care, or else doesn’t know, which is almost the same thing.
    As valuable as Robert’s work here may be, it’s also pointless. Only “oldhead”, of all the other commenters here, (and Julie & Rachel), even seem to have a clue. The MENTAL ILLNESS INDUSTRIAL COMPLEX is about **ONLY** MONEY, POWER, and CONTROL. Helping people is NOT part of their game plan. Job security is their only real goal. These evil, delusional people will NOT listen to reason. If they could, or would think logically and rationally, then we wouldn’t have the screwed-up system we have, in the first place!

    • We human beings are very good at deceiving ourselves, when ignoring certain problems has immediate pay offs for us. Especially when others sustain all the damage from these problems.

      Read “The Banality of Evil.” Evil is not inherently sexy, spectacular or mind blowing. Most people behind atrocities are not sadists with maniacal laughs but calm, methodical people who just don’t care.

      They willingly serve as little cogs in the Big Machine instead of becoming monkey wrenches to stop It. Understandable since the monkey wrench will be bent out of shape and the little cog can work safely. Until the machine stops.