JESSE: When we started this podcast we were focused on learning as much as we could about involuntary in-patient commitments. It became quickly apparent however, that there is another type of commitment that we should also be talking about.
Involuntary outpatient commitments.
Outpatient commitment laws vary from state to state, but for the sake of this conversation we are going to broadly describe them as a court order requiring someone to engage in treatment outside of an inpatient hospital setting. Outpatient commitment laws also come with different terminology. In some states, they are called outpatient commitments. In some states,
they are called mandatory outpatient treatment. And in other states, like New York state, they are called assisted outpatient treatment.
To learn more about assisted outpatient treatment.
BRIAN STETTIN: Sorry about my barking dog, I’m sure that’s ruining your recording.
JESSE: I spoke to Brian Stettin.
BRIAN STETTIN: My name is Brian Stettin, I'm the policy director for an organization called the Treatment Advocacy Center. We're a national nonprofit group that works to remove barriers to the treatment of severe mental illness.
JESSE: I started by asking Brian, what is assisted outpatient treatment?
BRIAN STETTIN: Assisted outpatient treatment, or AOT, is the practice of providing a person with severe mental illness who has a history of disengaging with community-based treatment for that illness, uh, with an opportunity to receive care in the community under a court order.
And we use the court order as a means of helping a person understand their need for treatment and have a period of receiving treatment under controlled conditions to the point where they can, uh, hopefully recognize that being engaged in treatment is something that makes their lives better.
JESSE: A court order can sound intimidating, can you walk through the basic process of reaching that point where a court order is issued?
BRIAN STETTIN: Sure, and let me say even before I do that, that any sense of intimidation a person might have about the idea that we're placing someone under a court order I think comes from differences in the way we apply this court order, then the way it ordinarily works in other legal contexts, right?
So, he reason people tend to be intimidated by the concept of a court order is we think about the person being held in contempt of court. That is under normal circumstances if you don't obey a court order, a court can hold you in contempt and you could wind up in jail, or fines could pile up. In most states, we have provisions in the law that say the person can not be held in contempt of court for violating this particular order.
We're not trying to create a new way to get somebody into a jail cell, just the opposite. So, uh, that's not how this is enforced. Nor would we say a person gets automatically recommitted to the hospital because they haven't obeyed the order, if you don't meet criteria for hospitalization that can’t happen. Nor do we go into the community and involuntarily administer medications to people who are not taking them as directed by the court.
You know, that kind of involuntary medication through restraint is something that only happens in a hospital setting, and only under certain conditions that just aren't part of what AOT is about. So the kind of traditional teeth you might associate with being under court order are just not part of how this works.
There is no punishment associated with not doing what the court said, so every state has a set of criteria that have to be met for the court to find that this is appropriate. This is not for everybody with severe mental illness. It's only for people with severe mental illness who have demonstrated historically that they have difficulty engaging with treatment on a voluntary basis.
So there are legal criteria that a hospital, or a doctor, or a county mental health system has to allege and then prove in court before the court can be satisfied that, yes, this is someone who is stuck in the revolving door of the mental health system, who has a demonstrated need for this kind of assistance in order to survive safely in the community. Uh, and so all that through due process must be established in court before we can put this order in place.
JESSE: My understanding was with the court order, you are not automatically sent inpatient if you stop engaging in treatment, but it does trigger an evaluation, is that correct?
BRIAN STETTIN: Yeah, that's right, so it would trigger a short-term hold in a hospital for a person to be evaluated. I don't wanna give the impression that it's not going to interfere with the person's liberty at all. It will, to some extent under most state laws, again, these vary from state to state, and it's all determined by what's in the law of a particular state.
But the typical process is that if the treatment provider determines the person is not adherent to the treatment the court has ordered, and has made good faith efforts to solicit that adherence and it just isn't working, that gives that provider authority to go to the court and ask for an order directing the person be held for up to 48, or 72 hours, again, varying by state, so that the person can be evaluated to determine whether it's necessary to move them up to a more restrictive level of care.
We think this person might need to be hospitalized at this point. We won't know unless we bring them in for an evaluation, so that gives the court the authority to have the person held for a short time to be evaluated, and then we'd come back for another hearing. And if during that evaluation it's found the person doesn't meet inpatient criteria that person has a right to be released back to the community. Hopefully we'll get them back before the judge to have just a, kind of a sit down with the treatment team where we say, “Hey, Right now we can't hold you any longer but we all kind of know where this is headed because, let's just look at the history that got you into this program, you've been in the hospital eight times in the last two years, because you have had trouble engaging with treatment, and we know you don't like to go to the hospital. So let's all work together to make this court order effective.” And that's really all the teeth we have and it's all the teeth we need to make these programs worthwhile.
JESSE: Do you think it would be theoretically possible to restructure healthcare, or maybe reform it in the U S in a way where AOTs were no longer necessary?
BRIAN STETTIN: I don't, and I'll tell you why because, you know, AOT is designed to address a problem that isn't going away, which is lack of insight, right? Clinical term for that is anosognosia. The inability of some folks to recognize their own need for treatment.
And, you know, I am ready to lock arms with anybody who feels that we don't do enough to provide treatment for people who are desperately wanting it. And I absolutely think there are lots of people doing poorly today who don't need AOT, who would do much better if we simply built up a better system of community-based care.
But I think we also have to recognize there is a population for whom that is not enough because they don't believe they have an illness. It's a corollary of their illness that they can't see, no matter how desperately obvious it is to the people who love them, they can't see they have an illness and have a need for treatment.
And it's just kind of common sense that no wonderful system of community-based care is going to be attractive to someone who doesn't believe they have the issue that that system is designed to address. And so that is why I do believe we're always going to need this kind of involuntary mechanism. It's not something with most people it needs to stay in place for very long, about a year seems to be the sweet spot for most people to get to a point where they, even if they don't come to recognize they have an illness, cause that's just not possible for some people, but they do recognize that their lives are a whole lot better now that they are engaged with treatment and they develop habits of treatment engagement.
I think we're always going to need that mechanism for people who have that particular deficit.
JESSE: Anosognosia is typically simplified as being “lack of insight,”. Essentially, that someone believed to be displaying symptoms of a diagnosis isn't aware, or refuses to accept, that they are displaying symptoms and that the diagnosis is accurate.
But it's more complex than that.
In part, because this term is primarily associated with conditions that involve identifiable damage to the brain. But in these conversations it's being used in reference to S.M.I., or, Serious Mental Illness. To clarify this term, a serious mental illness is not determined by the type of diagnosis, it is determined by the severity of the diagnosis.
Years ago I was more than once given a diagnosis of severe anorexia and I remember being in a hospital while a physician suggested that I lacked insight into my illness. I remember being told that and knowing that it wasn't true. In that situation I did not deny that I had severe anorexia. I did not deny, or refuse to accept, that I had a serious mental illness. In that situation
I was emotional, I was scared, and I was trying to communicate that I disagreed with the treatment.
But the physician either wasn't aware of, or refused to accept, what I was trying to say.
When it comes to mental illness, lack of insight is not determined by objective information about a person's state of mind. It is determined by a clinician’s interpretation of the symptoms that they believe to be present. Lack of insight is an opinion. And anosognosia is a complicated diagnosis, primarily attributed to people with an underlying physical condition, that can only responsibly be given to a person who does not want to engage in treatment after every other reasonable explanation for why that person might not want to engage in treatment has been ruled out.
But AOT is designed to help reduce in-patient commitments.
All of the commitments I experienced were in Massachusetts, one of only three states in the US that does not have some form of outpatient commitments. To better understand why some people in Massachusetts continue to be passionate and active advocates against outpatient commitment laws I spoke to Sera Davidow from the Western Mass Recovery Learning Community
SERA DAVIDOW: My name is Sera Davidow, and I'm the director of the Western Mass Recovery Learning Community.
JESSE: What is assisted outpatient treatment?
SERA DAVIDOW: Assisted outpatient treatment is a euphemism, we'll start there. It is a euphemism for involuntary outpatient commitment.
The reason I say it’s a euphemism is because it's a phrase designed to make it all sound really nice and helpful. You know, we're just going to assist you with your treatment. So I hesitate to use either the word assisted or the word treatment because assisted, you know, if I'm looking for assistance that's a voluntary sounding sort of thing, a supportive sounding thing.
And in fact this is forced that we're talking about, um, treatments.
You know, we're trained to hear treatment as generally a good thing and desirable thing and in fact many of the things that so-called assisted outpatient treatments forces ends up being quite harmful and really designed to protect society, or people's idea of what's right rather than actually supporting someone. In its essence though, assisted outpatient treatment, which you'll also hear referred to as AOT or what I would refer to it is again, involuntary outpatient commitment. What it is is a court order against a person that is perceived as being at risk of, sometimes of potentially harming others but sometimes it's just of harming or not taking care of themselves in the way that society or a particular treatment team believes that someone should. It's a court order that allows for the forcing of particular psychiatric drugs.
It can also, however, you know, I think a lot of people understand it to be around psych drugs, but it's not just, it can also be used to force someone to go to a day program, or to live in a particular area, or any number of other things that influence their day to day life. What providers they should be seeing, that they should be seeing particular providers at all. All of that can become a part of these involuntary outpatient commitment orders.
JESSE: What is it about a court order that might make this problematic?
SERA DAVIDOW: So many things about it being a court order make it problematic. In pretty much every other part of the way our society and our legal system is designed you have to have committed a crime to be forced by the court to do something that you don't otherwise want to do.
And so this is a strange sort of way of putting someone essentially on legal probation when they haven't committed a crime. In many instances it's simply based on the idea that some group of people is worried you might commit a crime, or that you might not take care of yourself, or you might try to kill yourself, what have you. And that's a lot of projection and a lot of fears that need to be owned by the people who have them and not necessarily forced on someone else.
There are many other situations in our society where we would be reasonable in having fears that something is going to go wrong and yet there's no other part of society, that I can think of any way, where you can go say, “Hey, I'm really afraid that over her there's going to be violence that happens, or this bad thing will happen.”
And that you can actually force something on someone. There's just so many situations where, in my world, I could be reasonably based in reality to have worries that something might go wrong but I don't have that power. So, why do we have that power over people when it comes to psychiatric diagnosis? For me, that is based in discrimination and psychiatric oppression and we need to take a look at why we've given our legal system that power. It's a power that has existed in many ways in the past, in more obvious ways that we've gotten rid of. For instance, you used to as a man in this society be able to commit your wife simply because you disagree with how she was raising your children, or her religious beliefs, or what have you.
But we got rid of that, so why are we still stuck here in general with psychiatric diagnoses?
JESSE: In mental health care there's something referred to as the revolving door where someone is committed, then discharged, committed again, discharged again and again, again. What other than involuntary outpatient commitments would you recommend someone try to get out of that revolving door?
SERA DAVIDOW: So I think there's two answers to this question. So, one is how have we defined, how have we decided as a society, what is too many times in the hospital? And is that always bad?
i really was impressed with there's a psychiatrist, Sandy Steingard who works out of Vermont, who at some point in her writing said something about, you know, when did we decide that the ultimate goal is to keep people out of the hospital forever?
Now I don't want to go in the hospital and I'm not saying like, “Hey, it's a cool place to be.” I too would like to support people to stay out of the hospital. However, the way she lined it up and with the example that I've carried with me for a long time, is that, would it be better to say for someone to avoid being in the hospital once, a couple of times, even a few times in a year, but otherwise be living a full life, versus being drugged so much that all they can really do is kind of sit on their couch and drink coffee, eat a lot, smoke cigarettes and not really be able to do much with their life. Like which of those is actually better?
So how did we as a society get to the absolute belief that number one goal is keeping people out of the hospital? A lot of it's about money, you know, who has the power to drive what is right, what is needed. So, there's that assumption that I don't think we should be operating off of as a starting point, but then let's assume that many people do want to stay out of the hospital and that it is disruptive to people's lives, and not particularly helpful when you're in there.
Then I think we need to look at what is our voluntary system looking like, you know, how do we put money into a voluntary system that actually hears what people want and what they find helpful and offers that?
I can tell you right now that I generally steer clear of the mental health system for myself but I do have a child who I think would benefit from talking to a therapist at the moment because there's been a disruption in her life and the people that she trusts and I've been looking for a therapist for her. I cannot find one. The best I can find is like maybe in a month or two someone might have an opening for my nine year old daughter who's struggling right now.
So there is my effort to enter voluntarily into this system that I generally avoid and I can't. So, perhaps if we focused on choice and making those sorts of supports readily available, so that we don't push people into such states of desperation and mistrust of the system that we then have to force them to enter it when we suddenly decide that they should, we’d be in a better place.
And I think we also need to look at the reality that we're operating in a system where it's extremely hard to find a therapist or a psychiatrist who's not white. And so why would people who aren't white trust the system? And there's so many problems that we should be looking to address in a voluntary system that supports real peer support, real alternatives, more peer respites, more living rooms, all of these different things that we could be offering.
And instead we get so wrapped up in psychiatric drugs, hospital, therapists, that's it, and people if they don't want them well at some point we might try and force them. It's just not a functional way of being.
So . I’ll tell you most, most people who enter these systems have experienced some degree of loss of power and control in their lives that have put them into these places of distress.
So continuing to strip away more power and control isn't generally any sort of answer.
JESSE: In outpatient commitments if someone chooses not to comply with the court ordered treatment plan then legally speaking the worst thing that should happen to them is that they are detained inpatient for evaluation. Are there any risks with mental health care professionals, and judges, just trying an outpatient commitment and detaining the person for evaluation if it doesn't work?
SERA DAVIDOW: If someone decided, “Hey, Sarah is not following through with her therapy and psychiatric treatments, we're going to send her to the hospital.” They’re not thinking about what happens to my child. They're not thinking about what happens to my job. Who's paying my bills? What happens to the place I'm living? People lose their homes, they lose their children, they lose jobs, they lose relationships that are meaningful to them. And on top of that sometimes what we're seeing is that people are on some of these types of orders and they're suffering neurological damage. So, they're being ordered to take psychiatric drugs that are causing them to twitch, and fall, and experience things like tardive dyskinesia that can become permanent if not addressed quickly.
And some other person has decided, “Hey, whatever risk we perceive of them not being on the psychiatric drug is a greater risk than this neurological damage they're experiencing. So let's keep going.” More than once I've seen people who are having those kinds of symptoms, those medical symptoms that can be really devastating and long term, and are just kept on these orders.
JESSE: I asked Sera if there is anything else about involuntary outpatient commitments that is important to know.
SERA DAVIDOW: I think one thing that's really important for us to pay attention to with outpatient commitments is how it is reflected in terms of racism and other forms of systemic oppression. So, we have tons of research at this point that says you are more likely to get a more severe diagnosis if you are a black or brown person. And then in turn you are more likely to be subjected to orders of force. Once those orders of force are in place, you're also more likely to see them enforced. We have seen that repeatedly through all these systems and so how we can get to a place where we think that something like an involuntary outpatient commitment order could ever be applied fairly, I don't know how we could hang on to that belief because all the evidence says it's just not possible.
Even if it were something that we believe was somehow helpful, which I don't, then I still don't know how we could get to the point where we as a society are ready to implement it fairly in a way that's not rooted in racism.
JESSE: In 2009, Marvin Swartz and Jeff Swanson led an independent evaluation of assisted outpatient treatment in New York.
A section of that evaluation attempted to address questions about racial disparities in AOT. Here is Committable contributor Brian Patrick Williams reading an excerpt from that 2009 independent evaluation.
BRIAN: Since 1999, about 34% of AOT recipients have been African-Americans, who make up only 17% of the state's population. While 34% of the people on AOT have been whites, who make up 61% of the population. We find that the over-representation of African-Americans in the AOT program is a function of African-Americans higher likelihood of being poor, higher likelihood of being uninsured, higher likelihood of being treated by the public mental health system, rather than by private mental health professions, and higher likelihood of having a history of psychiatric hospitalization. The underlying reasons for these differences in the status of African-Americans are beyond the scope of this report. We find no evidence that the AOT program is disproportionately selecting African-Americans for court orders. Nor is there evidence of a disproportionate effect on other minority populations.
JESSE: If you are aware that systemic racism has horrific impacts on the lives of African-Americans, making it more likely that African Americans will struggle with poverty, more likely that African Americans will be uninsured, and more likely that African-Americans will have a history of psychiatric hospitalizations.
If you are aware of all of that and then design that law, can you really claim that you are separate from the broader system? Can you really claim that your law has no part in the continuation of systemic discrimination?
While making this episode I was more than once asked, “Why does this matter to you?”
I struggled to answer that.
I have never been court ordered to treatment and I don't currently meet the criteria for an outpatient commitment, so why?
When I was first committed I was a 19 year old college student committed for anorexia and then released with a few conditions. I was not allowed to attend classes, I had to move back into my parents' house, and I could not leave that house without permission.
And every week I had to go to three appointments; a therapist, a physician, and a nutritionist.
The therapist actively tried to convince my parents to have me committed again.
The physician told me to go to my parents' house and do nothing but think about food and gaining weight.
And the nutritionist decided that it would be too much work for her to create meal plans or calculate the calories of what I was eating, so she taught me how to count calories and insisted that I keep a detailed record of everything that I ate.
And if I resisted this treatment? It was strongly implied by the treatment team that if I resisted treatment I could be sent back to the hospital for evaluation.
So, I did what I was told.
Within a few weeks the direction that I stay at home thinking about nothing other than food and gaining weight drove a manageable eating disorder into a disabling obsession.
And the detailed records that the nutritionist insisted I make were later used in court as proof that I deserved to be committed. The thing that the treatment team insisted I do after my commitment was used in court to justify that commitment.
So why does this matter to me?
Because I know what it's like to be coerced into treatment, I know what it's like to be harmed by treatment. and when treatment causes harm, and disagreeing with the treatment team is dismissed as lack of insight, and lack of insight further empowers that team to exercise their authority, what then? How do you navigate society after an experience like that knowing that the argument that persuades legislators to make new laws is not that those legally authorized to force treatment need to be held accountable for their mistakes. Instead, the argument that compels legislators to act is that treatment teams need more ways of forcing people into treatment.
So when asked, “Why does this matter to you?” Perhaps what I should say is, “Why doesn't this matter more to everyone else?”