Today, I received a private email from a mental health advocate whom I had met at the Kendraâ€™s Law State Assembly hearing a few weeks ago. She pointed out to me that my article did not sufficiently highlight how Kendraâ€™s Law is a â€œdumping ground programâ€� and â€œa symptom of the hypocrisyâ€� of a â€œbrokenâ€� mental health system, and she criticized my quoting from the â€œsame old playersâ€� in the mental health community.
I imagine I was equally likely to receive a letter from a Kendraâ€™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 donâ€™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 â€œAssisted Outpatient Treatmentâ€� was questionable and drew attention to an interesting gray area: the use (and misuse) of language in law and psychiatry. Though Iâ€™m sure numerous doctoral dissertations exist on this topic, it wonâ€™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 â€œAssisted Outpatient Treatmentâ€� because that is how the Kendraâ€™s Law statute characterizes it. Upon closer scrutiny, though, itâ€™s quite an ambiguous term. How is this treatment â€œassisted,â€� and by whom, and why, especially with respect to something that is supposedly good and necessary? â€œAssistedâ€� as opposed to â€œunassisted?â€� Or â€œassistedâ€� as opposed to â€œcoercedâ€�?
â€œAssistanceâ€� under Kendraâ€™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 â€œassistanceâ€� is a code word for â€œimposed.â€� They prefer the terms â€œinvoluntary outpatient commitment,â€� â€œforced treatment,â€� â€œinvoluntary treatment,â€� â€œcoercion,â€� or some configuration of those words, to denote what they feel is the unjust aspect of the lawâ€”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 â€œleast restrictiveâ€� means of treatment. Theoretically, a patient can enter an â€œenhanced services agreement,â€� 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 â€œvoluntaryâ€� contract, a court order could be issued.
Again, what is the assumption behind the word â€œvoluntary?â€� A backdoor draft is â€œvoluntary,â€� 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 â€œvoluntary.â€� In fact, supporters of Kendraâ€™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 â€œvoluntaryâ€� treatment. According to the testimony of the anonymous interviewee, as transcribed by the Mental Health Empowerment Project, the patient â€œagreedâ€� 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 â€œresistantâ€� to her treatment about a year later, and since then, sheâ€™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 â€œvoluntary,â€� yet still refers to himself as â€œactively on AOT,â€� 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 â€œbest interestâ€� of the patient and the public.
Iâ€™ve lived with a family member with mental illness and seen how it impacts oneâ€™s relationships with others. But in listening to the stories of advocates and mental health consumers, Iâ€™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 processâ€”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 themâ€”I could only use my observations to forge a composite portrait of the lawâ€™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 youâ€™re a patient, a service provider, a judge, or simply an observer.