On Wednesday, June 15, alarms were sounded across the state by disability rights groups when proposed amendments were published as a part of a response to a House version of the following Senate Bill: ‘An Act Reducing Barriers to Care for Mental Health’ (S.2584). The alarms rose because Amendment #13 represented yet another attempt to push through Involuntary Outpatient Commitment (IOC, more commonly referred to as “Assisted Outpatient Commitment’ or ‘AOT’).
IOC represents a formalized way to force people who meet certain criteria to take psychiatric drugs, and potentially to live in certain places, attend certain therapies, engage in other treatments, and so on. The criteria for being subjected to that type of force can include being seen as high risk for acts that would be harmful to one’s self or others, or even just a cycle that includes what are deemed as too many times going into an inpatient psychiatric facility. As things currently stand, Massachusetts is one of only three states left that have not put such a law on the books.
At first glance, many people—even very progressively minded people— can be quick to say, “Why wouldn’t we want to help ensure that people who are struggling so much get the help they need?” Proponents of this sort of legislation play on that tendency by making IOC sounded like something supportive rather than involuntary. In fact, that is one of the main reasons they call it “Assisted Outpatient Treatment”; To make it sound like a helpful support, rather than what it actually is: Forcing someone to do something against their will.
This represents a dangerous misunderstanding of this sort of legislation. What follows is a quick summary of a handful of the key misconceptions about the potential benefits of these types of laws:
MYTH: Involuntary Outpatient Commitment (AOT) is applied fairly: The mental health system has a long history of being used oppressively against marginalized groups. For example, “homosexuality” showed up
as a diagnosis in the Diagnostic and Statistical Manual for many years. Popular belief is that the diagnosis was removed in 1972. While that is true, it was actually replaced by ‘sexual orientation disturbance’ which, in turn, did not come out until 1987. Another example: As many as 275,000 people were murdered during the Holocaust as a part of the T4 project due to what were seen as psychiatric disturbances. And, prior to the 1960’s, white women represented the group most commonly diagnosed with schizophrenia in the United States, and some of the ‘symptoms’ cited were not taking care of household chores or the children as expected.
Now, when we look at data from other states that have implemented some form of IOC, we also see this trend continue. Black and brown people are substantially more likely to be subjected to orders of force including IOC, and once under those orders they are much more likely to see harsher terms on those orders and harsher measures to enforce them.
Myth: People subjected to IOC orders must have done something really bad to get put on such an order. We already have systems in place to deal with actual criminal activity. On the contrary, IOC is often used to prevent criminal or other dangerous activity. While this may sound like a worthwhile goal, here’s a question to consider: For what other group is it legal to restrict their freedoms because of fear of what they might do?
If we look at the actual data of who is committing some of the most dangerous acts with the highest negative impact on the largest group of people, their characteristics skew heavily toward young, white, and male. Would anyone tolerate restrictions on people who meet those criteria for fear of their potential to cause harm? Probably not. Worse still, (as aforementioned) with IOC orders, ‘harm’ is sometimes interpreted as including something as mild as too many visits to the hospital.
Myth: Force has been proven to be a useful and effective tool at getting people the help that they need. A growing body of research is telling us that when people are forced into psychiatric facilities for any reason, their suicide risk goes up (and stays up for as long as two years after discharge). One recent study found that even the perception of coercion at the point of admission to a hospital can lead to elevated suicide risk upon release. Where problems with substances are found, the same trend exists: People who are forced into substance abuse treatment have an increased risk of overdose when they get out.
For anyone familiar with the Adverse Childhood Experiences (ACE) study, this shouldn’t come as a big surprise. ACE tells us—in no uncertain terms— the more trauma someone experiences as a child the more likely they are to face all sorts of bad outcomes as an adult. This includes problems with the legal system, physical health problems, lower income, and yes, emotional distress and problems with substances. And if you have a good understanding of trauma, you’ll already know that just about every type of trauma boils down to a loss of power and control. In other words, losses of power and control compound one another. The more experiences someone has of that type of loss, the more likely they are to struggle moving forward.
Given that being forced into a psychiatric facility (along with the forced drugging, restraints, and so on that can accompany that experience) so clearly represents a big loss of power and control and that so many people subjected to such force already have experienced significant traumas in their life, it should come as no surprise that force in the psychiatric system can lead to increased risk of all sorts. This includes increased risk of exactly the sort that the IOC orders are trying to prevent.
Myth: The treatments that would be forced under an IOC order are generally effective: Sometimes people who argue against IOC or participate in any other advocacy of this kind get labeled “anti-medication.” Rarely is that an accurate label. In reality, many people who advocate against IOC would love to see availability of highly effective psychiatric drugs that adequately address people’s pain, and assist them in overcoming a variety of challenges. Unfortunately, for the most part, those drugs don’t exist.
While we won’t argue that psychotropics aren’t effective for anyone, their rate of efficacy is surprisingly low, and too often confused with the impact of other things in someone’s life. For example, drugs routinely given to take away distressing voices someone may be hearing actually only successfully eliminate those voices a minority of the time. For far too many people, they only quiet or slow them down a bit. While that might seem desirable enough, for some folks that only makes the voices harder to understand which, in turn, may actually prevent them from understanding why those voices are there or how to navigate them successfully. And for still others, the voices can sometimes become angrier or otherwise worse. This is just one of several reasons why Norway determined that forcing people to take neuroleptics (the class of drugs often referred to as ‘antipsychotics’) was not lawful: Because the chance of them being effective simply wasn’t high enough.
Worse still, there’s also a growing body of research (e.g., Martin Harrow’s studies) demonstrating that long-term use of psychiatric drugs can actually lead to increased negative outcomes in just about every area in which the drugs were intended to help. Those negative outcomes include significantly shortened lifespans. It is widely recognized that people in these psychiatric systems die on average 25 years sooner than people in the general population, and that mortality gap is only growing.
Unfortunately, the success of other conventional clinical treatments don’t have too much better of a track record. Outcomes for conventional mental health treatments as a whole haven’t improved in
several decades. That truth is illustrated by the Massachusetts Department of Mental Health’s data on ages of people in their treatment. As this 2017 slide shows, people don’t typically enter the system, get help, and move on with their lives. Instead, they much more commonly enter young, get stuck in the system, and die young or transfer to nursing homes.
Help that hurts isn’t help at all, and certainly shouldn’t be forced on someone.
Fortunately—after a loud outcry from the community— Amendment #13 was withdrawn. But IOC is going to keep showing back up (one disability rights attorney recently referred to it as the ‘Zombie legislation that keeps coming back from the dead’), and its going to take all of us keeping an eye out and being prepared to speak up whenever it resurfaces. So, get educated, share what you know with others, and stay on the ready to fight back.
For more on IOC, click here for a handout!