I’ve said it before, and I will repeat it. I am an overweight Jewish man from New York State with an active schizophrenia diagnosis. I have been committed to involuntary treatment numerous times for different lengths of stays at both local and state psychiatric hospitals across New York State.
Despite all these hats I wear in the mental health community – or perhaps because of them – I am also a firm believer that forced treatment for V-SPMI (Violent Severe and Persistently Mentally Ill) people is justifiable. I do not believe it is always the best treatment fit or practice that should be considered the gold standard for mental health treatment or the long-term standard milieu. Instead, we need to be continually revising our rules, moving studies and research forward to move mental health treatment into an era where forced treatment is obsolete.
Forced treatment may be obsolete.
As for Kendra and the day when the very ground floor of modern mental health treatment trembled and collapsed on itself, we will never forget it. For patients who have and continue to fall through the system’s cracks, Kendra’s death marked a new beginning for many violent and chronically mentally ill patients facing possible incarceration, legal issues, and jail sentencing in New York. I am speaking of that day in the year 1999 when Andrew Goldstein pushed Kendra in front of a subway train. Well, that is now all history. But, we must never ignore the implications of that violent act, which forever changed the face of mental health treatment in New York and states adopting forced treatment laws.
Kendra’s death was not in vain. Because of the tragic fate surrounding Kendra’s premature death, the lives of so many violently mentally ill people will be changed, altered, and, in many cases, protected by new laws governing the provision of mental health treatment. Now there is a glimmer of new hope and available treatment for this population incarcerated without a second thought by the court system, instead of inappropriately incarcerating V-SPMI people in jails and prisons, where all evidence points towards their ultimate re-entry into the criminal justice system due to further offences or new crimes rooted in the mistreatment of a current diagnosis and aggravated symptoms from their jail sentence.
Kendra’s death signalled to the world that we need to radically shift our methods and approach to treating people who are violently and persistently mentally ill. If we genuinely help people with a real chance of survival from socially unacceptable and violent mental health conditions, this signal must be more than a gesture to the public. We need to make radical structural adjustments to the mental health system before more people suffer tragic and avoidable loss. Indeed, Kendra’s loss was more than this signal. It was the sonic boom that called upon legislative bodies, advocates, and allies of people with a diagnosis to realise our paradigm for the treatment of V-SPMI wasn’t working.
I am not suggesting that forced treatment works perfectly for everyone in this category of mental health disorders. I have seen it first hand as an ACT (Assertive Community Treatment) practitioner. I’ve seen the law fail clients and forced treatment to create animosity, anger, and self-shaming cognitive distortions above and beyond the original altered perception of clients without being enrolled in compulsory care and treatment.
The law places limitations on people’s movement and personal freedoms under AOT (Assisted Out Patient Treatment) regulations. Indeed, the stigma that evolves from an AOT label under the county department of community mental health radar is demoralising, to say the least. The title is humiliating, infantilising, and demeaning for many connected to an AOT service.
V-SPMI patients under the AOT structure are mandated for mental health treatment. Instead, these people lose a part of their independence, autonomy, and relative status as citizens equal in the name of the law. The law confines restrictions and places limitations on people’s movement and personal freedoms under the AOT regulations.
Travel, medication administration, choice in treatment staff, and frequency of contact with mental health staff and treatment teams are required by AOT. These mental health treatment domains are prescribed, mapped out, and monitored closely by the county government who can, at any time when its rules are violated, pick you up at your home and take you to the hospital for forced treatment.
The loss of Kendra was subsumed by people carrying a mental health diagnosis. We will never lose that scarlet letter that labels us, and marks are eligible under the law to lose our right if our conditions worsen. After Kendra’s death, our fate to make decisions for ourselves and care will ultimately be under the provision and maintenance of the law until a new paradigm arrives. Instead, our personal beliefs on how we want to manage our own mental health affairs will continue to be unjustified and privilege the provider.
The right to fail, to live our lives as flawed, diagnosed, mentally ill people the way we see fit to do so. In New York State and many other states in the US, unless you are mandated, or in an AOT or forced treatment programme, you can fail out of society and be admitted to a hospital for psychiatric rehabilitation. Unless you have been labelled V-SPMI, you can cycle back into the system, from hospital to independent living, and the converse, over and over again.
I don’t think it should be any other way. This is a privilege not all of us have in the US. Some states operate differently, offer fewer freedoms, and offer less supportive services to people who want to live on their own. We must protect this privilege. The endorsement of this freedom and dissemination of this privilege must be defended at all costs. We can never give it up. Next to the modern mission of dignity, hope, and recovery by NY-OMH and other state mental health regulatory bodies, we must write into law and inscribe it with the right to fail.
This addendum in the history of our mental health system must read clearly. It should reflect the all-important pendulum; some might even call it a continuum. This is the abstraction, the theory underpinning a right to fail put into practice. Professionals have another name for it. It’s called ‘dignity in risk, and risk of harm’. This expression has been debated for years, and the debate still rages on. Since the de-institutionalisation, people just aren’t sure about the future of people living with diagnosed mental health conditions living out in the community.
Whenever you hear, should this person or that person be allowed to live independently or be discharged from a hospital, it boils down to nearly where the identified patient falls on this continuum of being more of a risk or maintaining stable living? But what does a regular living look like? What does failure look like? Clinicians can do their very best to assess and predict outcomes, but do we never really know what people are capable of, do we? I truly wonder.
And yet, still, I wouldn’t have it any other way. Sure, clinicians assess for lots of concerns. Discharge planners in hospitals look at a person’s full clinical picture before they are released into the community. Depending on the identified patient’s precipitating event, the length of stay in the hospital will be different. Lethality, homicidal ideation, violent ideation, suicidal, strengths, weaknesses, and past history are assessed, right? But is this enough? I am a licensed clinical social worker with a mental health diagnosis, and I still wonder about the answer to this debate.
I have done unfathomable things during the tenure of my mental health disorder. This is why I genuinely wonder. I have done things I still cannot express regret for, or live down. And yet, I always, even as a clinician, wouldn’t want the system to be set up any differently. This is because I have also done wonderful, beautiful things in my lifetime, since my diagnosis, and would never forget these memories. The light simply outshines the darkness, every time my freedom is involved. This is why we cannot ever give up this privilege.
Image credit: Freepik
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
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