Where About Us But Without Us Leads

On 1 June 2010, E. Fuller Torrey MD wrote an op-ed column for the New York Times, “Make Kendra’s Law Permanent.” Dr Torrey is the founder of the Treatment Advocacy Center (TAC), a nonprofit group whose sole purpose is to lobby states for the passage of so-called assisted outpatient treatment (AOT) laws like Kendra’s Law in New York and Laura’s Law in California. The New York law is named after Kendra Webdale, who was killed by Andrew Goldstein in 1999.

Dr Torrey and TAC will tell you Mr Goldstein had untreated schizophrenia. They’ll tell you people like him are dangerous, they’ll tell you people like Mr Goldstein are often so sick they don’t understand they’re ill and need treatment, and they’ll tell you they know best. They won’t tell you that Mr Goldstein had been seeking treatment desperately and been turned away repeatedly.1

They’ll tell you there are no racial disparities in the implementation of assisted outpatient treatment despite 34% of AOT orders being imposed on African-American New Yorkers and 30% imposed on Hispanic New Yorkers; they make up 18% and 16% of the total population respectively, while non-Hispanic whites, who received 34% of AOT orders, make up 63% of the general population.2 The Services Effectiveness Research Program in the Department of Psychiatry and Behavioral Sciences at Duke University Center was awarded the contract to evaluate New York’s assisted outpatient treatment program under a requirement of the 2005 reauthorization of the law. (The Wikipedia entry on Kendra’s Law states, wrongly, that the Duke University study was independent.) Their findings were that there were no racial disparities — when the data were controlled for factors such as poverty and diagnosis with serious mental illness such as schizophrenia.

Which, if I’m reading that right, says that when they control for the effects of racism in society (poverty disproportionately affects non-white people) and racism in the mental health professions (non-white people are disproportionately diagnosed with schizophrenia when white people presenting with similar symptoms are diagnosed with less ‘serious’ mood disorders), the racial disparities in the implementation of assisted outpatient treatment disappear. It’s fucking magic. Okay, so this particular program may be following the same rules as everything else, but those rules are set up to have a disparate impact on non-white people already.

Make no mistake, the assistance provided in assisted outpatient treatment is the armed force of the state ensuring that persons who fall under the purview of this law and those like it comply with any and all aspects of the court-ordered treatment plan. Assisted outpatient treatment is strictly from Minority Report — the person needs have no actual history of violence and need not be judged to be in immanent danger of harming ouself or others.

I can’t get the actual text of the law (the site for the New York Legislature keeps giving me internal server errors when I try to get the Mental Hygiene Law) but here’s some excerpts from a summary on the law from the New York State Office of Mental Health3:

AOT Criteria

No person may be placed under an AOT order unless the court finds by clear and convincing evidence that the subject of the petition meets all of the following criteria:

  • Is at least 18 years old; and
  • is suffering from a mental illness; and
  • is unlikely to survive safely in the community without supervision, based on a clinical determination; and
  • has a history of lack of compliance with treatment for mental illness that has:
    1. prior to the filing of the petition, at least twice within the last thirty–six months been a significant factor in necessitating hospitalization in a hospital, or receipt of services in a forensic or other mental health unit of a correctional facility or a local correctional facility, not including any current period, or period ending within the last six months, during which the person was or is hospitalized or incarcerated; or
    2. prior to the filing of the petition, resulted in one of more acts of serious violent behavior toward self or others or threats of, or attempts at, serious physical harm to self or others within the last forty–eight months, not including any current period, or period ending within the last six months, in which the person was or is hospitalized or incarcerated; and
  • is, as a result of his or her mental illness, unlikely to voluntarily participate in the outpatient treatment that would enable him or her to live safely in the community; and
  • in view of his or her treatment history and current behavior, is in need of assisted outpatient treatment in order to prevent a relapse or deterioration which would be likely to result in serious harm to the person or others as defined in §9.01 of the Mental Hygiene Law; and
  • is likely to benefit from assisted outpatient treatment.

A court may not issue an AOT order unless it finds that assisted outpatient treatment is the least restrictive alternative available for the person.

There are other troubling parts to the law: damn near anyone can file a petition to have a person placed under assisted outpatient treatment, including any adult room mates, parents, spouses, adult children or adult siblings of the person. There are confidentiality problems with the way information is treated under the law, distributing clinical information about persons with AOT orders to mental health facilities across the state.

And it’s not necessary. Andrew Goldstein had been seeking treatment. The non-coercive parts of Kendra’s Law, the grants for community treatment and medications, those are helpful and helping. We need access to effective community treatment. Unfortunately in this age of budget shortfalls and funding cuts I don’t see access to community mental health treatment increasing.

This quote from Dr Torrey’s op-ed piece struck me as particularly telling:

The people who could be treated under Kendra’s Law account for only one in 10 seriously ill psychiatric patients. But when these people are untreated, they also make up one-third of the homeless population, and at least 16 percent of the jail and prison population. These people are ubiquitous in city parks, public libraries and train stations. And a small percentage become dangerous, even homicidal.

One in ten is not an only, one in ten is a very large fraction of any population. We — I am seriously mentally ill (and not compliant with every treatment recommended) — are over-represented in jails and prisons because we can’t get adequate treatment in our communities. We stop taking meds that make us sick because newer meds with fewer unpleasant side effects are, well, new. And expensive. Seroquel is still under patent; risperdal isn’t.

We are unsightly. We make parks and libraries and train stations unpleasant for non-mentally ill folk. We make things difficult for our families when we don’t take our meds. Dr Torrey and TAC and the National Alliance on Mental Illness and all the other family-of-but-not-mentally-ill advocacy groups out there want it to be easier to make us take our meds. So they play on fears and tragedies. Because we aren’t actually any more likely to commit violent crimes than the population as a whole. It’s just that when we do commit them we fit neatly into an existing and convenient (and heavily reinforced thank you ever so much every TV and film cop drama ever) narrative that mad people are violent and unpredictably so. Even homicidal!

But Dr Torrey knows how to save everyone from us. He just has to convince enough people that we shouldn’t have the same rights to due process as everyone else.

So far it’s not been that hard. Almost every state has some version of an assisted outpatient treatment law, largely thanks to the lobbying efforts of Dr Torrey himself and his organisation. He decries that the laws aren’t used enough. (Someone in his organisation is likely responsible for the ghastly Wikipedia entry on Kendra’s Law, which portrays opponents to making it permanent as anti-psychiatry and *gasp* liberals. Sheesh.)

And Andrew Goldstein has pleaded guilty to manslaughter, after one trial where the jury failed to reach a verdict, a second trial where he was convicted and sentenced to twenty-five years to life — but the conviction was overturned on appeal because a witness gave second-hand information — and I suppose he didn’t want to go through it a third time. He’s been sentenced to twenty-three years in prison plus five years supervision. I expect he’ll be forced to comply with court-ordered psychiatric treatment for the rest of his life.

13 Comments

  1. Doesn’t the term “mental hygiene” just send shivers down your spine? Because if you aren’t quite the way you’re “supposed to be” you’re “unclean.”

  2. And yet, when a “sane” person does something violent and deadly, the violence is not attributed directly to their sanity. That’s just an individual person doing something individually bad.

    But people with psychiatric diagnoses, their actions must be resulting from that diagnosis — despite their rate of crime being on par with the general average, making this assumption patently ridiculous once it is actually examined.

    But no one wants to examine it.

  3. Just a cognitive processing suggestion– it’d probably be best to have the acronym “AOT” next to the text “assisted outpatient treatment”, or vice versa. Maybe it’s just my reading patterns, but it took me far too long to correlate the phrase in the middle of the first paragraph with the unexpanded acronym in the 3rd paragraph.

  4. The Untoward Lady, it really, really does. It sounds positively Orwellian — especially the connotation that if we don’t keep clean (or at least quarantined) we contaminate others — and it’s frightening.

    amndaw, yeah. It’s one of the reasons these narratives* are so dangerous. Because they exist most people just slot events into existing kyriarchy-informed narratives and stop examining them. There’s no need for examination; they make sense already. As we know from experience and has been backed up by research once many people have done that they will defend it assiduously; being presented with accurate information contradicting their narrative sorting often strengthens their attachment to it.

    So it’s pretty typical human behaviour. Which doesn’t make it any less fucking depressing.

    codeman38, ah crap! I thought I had done; thank you for pointing out I’d missed that. I have a difficult time processing acronyms and abbreviations also; when they’re unfamiliar each gives me a little hit of noise in my head (which makes the internets super fun to navigate when my head’s already noisy). I try to make sure to define any I use in the text I use them in. It was kind of late when I was writing; it might have gotten excised in an edit?

    Anyway, how’s this?

    * There are similar narratives stemming from racism (violence involving black and/or Latin@ USians is gang and/or drug related) and sexism (men who go hunting women are seen as individual actors and not actors within a structure that informs and enables their hate) and trans*phobia (fucking us is so emasculating and traumatic killing us is the normal response) and on and on and on.
    .-= kaninchenzero´s last blog ..ow, continued =-.

  5. I’m studying clinical psychology and this is ridiculous. Very few people with schizophrenia end up hurting others. And the only way to determine risk (risk, not certainty) is to individually evaluate people. And that risk changes based on the moment and individual. And most people with schizophrenia know they are experiencing something troubling. It’s downright disgusting that even people who want treatment are unable to get it and then laws like this restrict the rights of an entire clinical population for no good reason.

  6. @k0: Much better, thanks! And understood about accidentally editing it out; I was wondering if that might’ve been what happened, in fact.

  7. if we don’t keep clean (or at least quarantined) we contaminate others

    I have felt like this my whole life any time I have ever talked about anything relating to my mental health with any of my friends who don’t have to deal with it daily.

    Thank you for writing this, K0. Smashing.

  8. The meaning shift on “hygiene” is an interesting one, and relatively new. Etymologically and in the really quite recent past, “hygiene” just meant “healthful art” (“way of living that promotes health”), or “branch of science to do with preventive health” – concepts that are problematic in their own way in conception and execution, but not ones that are exclusive to ideas and practices of washing and cleanliness. Hygeia was the goddess of health and daughter of Asklepios in Greek mythology. She is sometimes seen as the personification and embrace of a holistic approach to health and well-being, and identified with the divine feminine, rather than the narrower crisis/remedy “masculine” approach in Asklepian medicine.

    That meaning lives on in terms like “sleep hygiene” and “occupational hygiene”, which are not about cleanliness; but with the meaning contraction for “hygiene” that has occurred in general English discourse, the resonances with cleanliness and sanitation are disturbing.

    …I’ll shut up now.

  9. Torrey has never failed to make my blood boil.
    .-= Amanda´s last blog ..I have become a cyborg!! =-.

  10. I’ve always held a boiling hatred for New York State medical law—I go to college there, and it’s responsible for my being hospitalized against my will when my OCD-related violent obsessive thoughts were mistaken for real threatening behavior (the most traumatic experience of my life) and later, making me jump through all sorts of ridiculous medical/legal hoops just to get my meds; at times they’ve seemed so distant about it all that I’ve been reduced to tears. So honestly, this doesn’t surprise me at all. The fact that our medical system is so balkanized from state to state—allowing the officials to write whatever bigoted laws and rules they want—is exactly why we need a true national health care service.

  11. Well, not only must any bad deed done by someone with mental health difficulties be labeled as an effect of those, but very often bad deeds committed by perfectly neurotypical people are also attributed to a diagnosis. Such as “temporarily insane” or whatever the legal phrase is.

    Mere days ago, one of the news papers here in DK, wrote that Israel’s behaviour towards the global community and the flotilla attack was a sign of their increasing autism.

    In comments on their website it became a debate about which psychiatric diagnosis was the most accurate descriptor (schizophrenia, autism, sociopathy, etc), not about whether it was at all okay to use diagnoses as descriptors of neurotypical people doing bad things.

    I tried to turn that flow, but no such luck. I wrote the paper criticising their choice of words, but they defended themselves, saying that autistic is the most accurate descriptor of what Israel is doing.

    Thus, since diagnoses of all kinds are becoming a more and more accepted form of analogy and descriptor of bad deeds and the causes thereof, it is really no surprise that any bad deed by someone who does happen to have a diagnosis is attributed to that.

    It is a terrible development we’re seeing, and I don’t have a single clue what to do about it. Even writing the people at the news paper only resulted in me being told that they felt completely at ease judging that their misuse of a word is not misuse at all and is not at all damaging. In fact, it would severely limit the language, it would actually harm the language if we limited the use of certain words.

    In other words: language and privileged folks’ use of it is prioritized higher than the people affected by that use. Surprise, surprise.

    Those incidents reflect different levels of villification of diagnoses. Schizophrenia has been feared for quite some time due to bad reputation, created by completely haphazard use of the word. Autism has not yet reached that level, but some people are working very hard to get it there, it seems.

    And I have no idea how we can possibly turn that development around,

    And just for the record: I am autistic. And I have been fighting for over a year to receive qualified help and treatment. I have not yet succeeded. And I supposedly live in the country with one of THE best socialised health care systems in the world. Oh yeah, and I haven’t killed anyone – but damn, sometimes I want to.

    I blogged about the Israel = autistic thing on my blog, if you care to read more.

  12. Jemima, that’s absolutely ridiculous that that paper labeled Israel as autistic. Not only that but it doesn’t many any sense at all! Good on you for writing to them despite their indifference and lousy defense.

  13. Nice article. Well worth checking out the writings of Thomas Szasz and R.D Laing on the subject of mental illness and becoming a “non-person.”