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April 20, 2005

Semantic Games

Today, I received a private email from a mental health advocate whom I had met at the Kendra’s Law State Assembly hearing a few weeks ago. She pointed out to me that my article did not sufficiently highlight how Kendra’s Law is a “dumping ground program� and “a symptom of the hypocrisy� of a “broken� mental health system, and she criticized my quoting from the “same old players� in the mental health community.

I imagine I was equally likely to receive a letter from a Kendra’s Law proponent lambasting me for not sufficiently highlighting the statute as model legislation, which finally addresses widespread unmet needs, and for giving undue attention to clients who don’t understand their situation and to advocates who have yet to present a better solution.

In sum, writing this piece was a case study in the difficulties of balancing legal and clinical realities, on one hand, with the subjective analyses on both sides of the issue. I learned that, from the use of jargon to the presentation of outpatients as victims as well as agents in the system, writing about mental health involves learning when to step back from your subject and when to try to peer into a world that is, to most of the general public, inscrutable.

Questions of journalistic judgment frequently centered on the issue of language. The very term “Assisted Outpatient Treatment� was questionable and drew attention to an interesting gray area: the use (and misuse) of language in law and psychiatry. Though I’m sure numerous doctoral dissertations exist on this topic, it won’t hurt to add some of my insights into the public discourse, if nothing else to clarify some questions readers might have about the piece.

I decided to use the term “Assisted Outpatient Treatment� because that is how the Kendra’s Law statute characterizes it. Upon closer scrutiny, though, it’s quite an ambiguous term. How is this treatment “assisted,� and by whom, and why, especially with respect to something that is supposedly good and necessary? “Assisted� as opposed to “unassisted?� Or “assisted� as opposed to “coerced�?

“Assistance� under Kendra’s Law takes more than one form. The more popular aspect of the law is the provision of priority access to a select subpopulation of severely mentally ill people.

But opponents I interviewed told me “assistance� is a code word for “imposed.� They prefer the terms “involuntary outpatient commitment,� “forced treatment,� “involuntary treatment,� “coercion,� or some configuration of those words, to denote what they feel is the unjust aspect of the law—not the services it offered, but its forcing of those services upon those selected by the government to receive them.

Then there is the caveat of the “least restrictive� means of treatment. Theoretically, a patient can enter an “enhanced services agreement,� which is more or less the same plan, but instead of living directly under a court order, the outpatient is subject to a type of probationary treatment, with the understanding that if he or she somehow breached this “voluntary� contract, a court order could be issued.

Again, what is the assumption behind the word “voluntary?� A backdoor draft is “voluntary,� too.

Advocates I spoke with generally argued that the threat of a court order as punishment for non-compliance is basically the same thing as a court order issued outright, for the element of force is used as leverage in both circumstances.

The legal opacity of the AOT process further complicates the definition of “voluntary.� In fact, supporters of Kendra’s Law have even called for a codification of enhanced service agreements to ensure that if the treatment plan breaks down for whatever reason, the authority of the courts will again be invoked.

The experiences of the two AOT patients I described both entailed periods of this “voluntary� treatment. According to the testimony of the anonymous interviewee, as transcribed by the Mental Health Empowerment Project, the patient “agreed� to the treatment plan two years earlier, though she has consistently held that the court order was unfounded. Her official order was reportedly not issued until she was determined by AOT authorities to be sufficiently “resistant� to her treatment about a year later, and since then, she’s been trying in vain to wage a legal battle. She reported that in one court hearing, her court-appointed attorney basically sided with the service providers, resulting not only in the continuation of treatment but a period of hospitalization as well. Similarly, Derick Adams has had his official status reduced to “voluntary,� yet still refers to himself as “actively on AOT,� because his plan has proceeded virtually unchanged. As reflected in the article, both patients viewed the voluntary and involuntary phases as part of a continuum of imposed care.

It is a challenge to convey the civil liberties implications of mandated treatment against the widespread assumption that force is justifiable when used in the “best interest� of the patient and the public.

I’ve lived with a family member with mental illness and seen how it impacts one’s relationships with others. But in listening to the stories of advocates and mental health consumers, I’ve also had a glimpse into how in our society, a diagnosis of a mental disorder can preclude the ideas of individuality and personal autonomy that we often take for granted.

To provide some insight into the AOT process—from the perspective not of a legislative body or a psychiatric professional, but of a patient living under the surveillance of those with the power of the courts behind them—I could only use my observations to forge a composite portrait of the law’s impact on the individual.

The main idea that I humbly put forth in the article is that the law in practice betrays the ironies of the law in theory. The much larger issue behind that, to which I regrettably could not do justice in this piece, is that the rigidity of our public health and legal systems, and the intensely subjective, emotional realm of mental illness, are in many ways impossible to reconcile, whether you’re a patient, a service provider, a judge, or simply an observer.


aikanae: Semantic Games

The hard reality is that this law does force society to make choices. Some patients might initially benefit from court-ordered treatment, but that isn't true for most. Mental illness is more complicated than prescribing a pill for a single ailment. My own experience was that i languished in the mental health system for almost a decade, until becoming labled as "treatment resistant". No one questioned what my diagnosis or treatment plan was, despite I was having a hard time tying to comply with. My treatment was also considered "client-centered".

Fortunately, I was lucky enough to eventually discover my proper diagnosis and the resulting change with my treatment has made a night and day difference. Despite obvious improvements, I still had to overcome solid resistance getting it changed "officially". I also witnessed those responsible for prescribing my treatment, were comfortably distanced from having any sense of accountability for errors and continuing with ineffective treatments. Regardless of the years of life I lost, most of those treatments could've resulted in irreversible side effects - hardly worth the additional risk when not actually needed.

When a patient objects to treatment, despite immediate signs of symptom improvement, there is a reason. I'd like to see treatment approach, diagnosis, choices developed and actually offerred until something "works" for the patient as well. Science, nor behavioral health carve-out plans have invented any magic treatment plans which fit everyone even within the same disorder. I wouldn't expect a doctor to keep handing out aspirin for headaches, even with some immediate relief the headaches continued, and ignore other reasons such as migraines, cancer, or something else involved.

No one dreams of growing up to be labeled "seriously mentally ill" either. Patients are already motivated to recover. It's this motivation that clashes with the mental health community and some families, who are unwilling to hear them. Treatment resistance may be a patients' only way of saying "my treatment isn't working". This law successfully eliminates any need to continue developing more effective treatments and removes professionals and behavioral plans ever further from accountability to those who are supposed to benefitting the most.

Currently within mental healthcare systems, treatment is rationed based on demonstrable need, That means it's only offerred when someone is in crisis and only until the immediate crisis is resolved. There can be no substantial progress when someone is expected to live from crisis to crisis, floundering imbetween with few support resources until they end up in crisis again. This legislation is little more than a finger in a dyke, trying to stop leaks a little sooner, while ignoring the already strained, unresponsive system, bulging under pressure rather than demanding the reforms needed to actually make a difference to those they are supposed to be helping..

I feel for those who are witnessing an obvious need for mental healthcare with someone they know and love. I've seen too often that settling for temporary solutions, only creates a deeper money pit. I hope that the momentum this legislation has, will be added to the pressure for making some real reforms.

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The NewStandard ceased publishing on April 27, 2007.