Helping the Mentally Ill Help Themselves

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					Helping the Mentally Ill Help Themselves
Anyone who has worked in the mental health system can recite a litany of
patients who spin through its revolving doors over and over. They become
familiar faces and stories, some loved, some disdained.
This subset of patients return again and again for a variety of reasons,
but the most common one is noncompliance with medications. This happens
often times because of money and access, other times because of flat-out
Misfortune often laughs at our weakest, and some of these people end up
floating face-down in a river after successful suicide, or mumbling in
the hallways of a state mental hospital where they are psychologically
buffed-up to competently stand trial for some bloody violence. The rest?
Well, they walk among us.
As I've written in posts past, the mental health system in America is
bleeding to death. The causes are most certainly legion, but the
hemorrhage can be stemmed by creating law and infrastructure to get the
most seriously mentally ill treated. How to do this?
Assisted Outpatient Treatment (AOT)
There's a prima facie impression that only a relative handful of us give
a damn about mental health. After all, last week Congress had to pass a
law just to push mental health benefits up to par with other medical
treatments. Psychiatrists are the lowest paid medical specialists in the
nation. Psychiatric programs are often relegated to the farthest corners
of medical centers. Mental health staff are often among the lowest
compensated employees. Indeed, it can feel like a service begrudgingly
Realistically, mental health's black sheep status is more a matter of
evasion than indifference, of exasperation than antipathy, although there
is a mix of all those. Sometimes they coalesce to create a perfect storm.
Kendra Webdale
On a rainy Sunday afternoon in January 1999, 32-year-old Kendra Webdale
was waiting on a Manhattan subway platform. A young man named Andrew
Goldstein approached her and asked for the time. Just as the subway train
screeched towards them, Goldstein plunged Kendra down to a gruesome death
on the tracks.
Andrew Goldstein was one of those caught in the revolving door of mental
health. His life had started full of promise as he possessed an
exceptional, perhaps beautiful, mind. It was a promise broken, though,
when he had first psychotic break as a college freshman.
Diagnosed a paranoid schizophrenic, Andrew went through multiple
psychiatric hospitalizations and, in spite of the fact he had assaulted
thirteen strangers without provocation-all of them women-and had
expressed fears he would act on his violent impulses towards even more
women, he was released, again and again.
As you might expect, Andrew had not been compliant with his medications,
mostly because of debilitating side effects, and was continually released
before he was truly stable.
In the aftermath of this horrific episode, New York passed an Assisted
Outpatient Treatment law for the mentally ill and named it Kendra's Law.
Not long afterward, another tragic incident would underscore the failures
of the mental health system, this time 3,000 miles away in California.
Laura Wilcox
On break from Haverford College in 2001, nineteen-year-old Laura Wilcox
was working for a few days at a Nevada County mental health clinic. A 41-
year-old client named Scott Harlan Thorpe showed up for his appointment
on January 10. But to the horror of all around him, he pulled out a gun
and opened fire, killing two clinic employees. Laura was one of them.
Scott then drove to a restaurant and shot its 24-year-old manager.
As with Andrew, Scott had not been compliant with his treatment,
including medications. By the time he went on his shooting spree, he had
descended into a delusional hell where he was being tormented and stalked
by the FBI. His family stood by, helplessly watching his unraveling,
unable to do anything to compel him into treatment.
Like Kendra, Laura did not die in vain, either. Lawmakers California
would enact their own AOT law, largely based on Kendra's, and call it
Laura's Law.
What It Is
Under AOT, patients with severe and persistent mental illness can be
court-ordered into outpatient treatment, rather than leaving it up to
them. If the patient fails to show up for treatment, peace officers or
field clinicians can bring them to an emergency room. The patient is
evaluated for a possible 72-hour involuntary hospitalization (a 5150 in
California). For a complete detail of these otherwise complex laws,
please visit The Treatment Advocacy Center.
Flaws in the Laws: Comparing New York and California
The New York and California versions of AOT are almost identical, save
for one risky difference. Kendra's Law allows the refusal of outpatient
treatment to be sufficient grounds for an involuntary hospitalization.
Laura's Law, on the other hand, expressly forbids this. So what's the
One longtime patient I know goes off his medication regularly and
methodically to purge his system so he can go on a "tweekend" of crystal
meth and sex. We know when this is happening because he disappears from
his outpatient therapy. In a drug-induced psychosis he will reenter the
hospital to endure the depressive crash to come. A few days later he's
released and the cycle repeats itself over and over.
If he were in New York, his plans might be foiled. At the first notice of
his absence from therapy, he could be collected and hospitalized. But in
California, he could be detained for assessment then promptly released to
party on.
This is not to say that Kendra's Law is substantially tougher than
Laura's. A blemish in both of them is that neither allows non
participation in treatment to be grounds for contempt of court. But this
is precisely the kind of consequence that needs to be established, if for
no other reason than as a deterrent to professional patients who are
abusing the system.
I'm reminded of a man who has virtually lived in Los Angeles County's
psychiatric hospitals, floating from one to the next, costing taxpayers
millions of dollars in the process. Is he mentally ill? Aside from being
deranged enough that he elects to chill in psych wards, the answer is no.
What's his game, then? Simple arithmetic.
By crashing in hospital beds and not his own, he has amassed enough cash
from his disability checks to cruise around in a Mercedes Benz and buy
untold other something-somethings. I can tell you therapy isn't one of
Imagine that AOT law compelled him into treatment for his phony mental
maladies and found him in contempt of court if he was a no-show. I don't
think we'd ever see him in Club Psych again, freeing up the bed and the
monies to someone else who actually needs help.
It is money that is the decisive difference between the New York and
California AOT structures. New York has a well-organized and funded
program. California's is a little-known legislative mandate with no
finances to implement it. For the Golden State, it's all talk and no
action, at least for now.
Meanwhile, the investment has paid off handsomely for New York, both in
societal costs and the toll of human suffering. To wit: A 59% reduction
in repeat hospitalizations, a 75% reduction in incarcerations, a 57%
reduction in homelessness, and a 53% increase in medication compliance.
If that's not enough, the Office of Mental Health's web site features
even more impressive data.
Patient's Rights
A subtext, perhaps, to the lack of political and financial will to
enforce Laura's Law in California is simple complacency. It has been 36
years since the well-meaning but fundamentally flawed Lanterman-Petris
Short Act effectively tied everyone's hands. Compulsory treatment for
even the most seriously mentally ill was sacrificed in the name of
patient's rights. Hence, a floridly psychotic patient who believes he's
the King of Macaroni on a Moon that's made of cheese is considered
legally competent to refuse antipsychotic medications. Mind you, I'm not
suggesting that we violate or disregard constitutional rights in any way,
but to allow severely ill patients to dictate their own treatment appears
ludicrous at first blush, and then downright ridiculous in practice.
If you're a patient who has chronic paranoid schizophrenia, 20 or more
psychiatric hospitalizations over the last two years, and a pesky
penchant for dope on which you spend your entire monthly government
check, do we as a society not have a vested interest, if not moral
obligation, to force you into treatment? Or, perhaps we just really don't
care if you end up dead at 35 behind some Skid Row trash dumpster. One
less loser to worry about, right?
Final Thoughts: Rights Can Be Wrongs
The irony is that patient's rights can also be their undoing. Folks with
severe mental illness carousel through mental hospital doors because they
can't function in monitored settings. They take easy escapes like alcohol
and drugs that lead to hard falls such as homelessness and incarceration.
They are essentially children and adolescents in adult bodies. They need
us to structure their lives, to support them, to help them make
decisions, and to give them a time-out when they are spinning out of
Continuing with a business-as-usual approach is, in fact, the greatest
violation of a mentally ill person's rights we can commit. The AOT laws
may not be perfect, but they are a good first step for our patients'
Michael Jones, LMFT, helps people stop feeling scared and worried. His
psychotherapy practice is located in Glendale, CA. For an appointment,
call (818) 974-2158 or visit him at