I’ve said it before and I will say it again. 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 length of stays at both local and state psychiatric hospitals across New York State. I am also a Licensed Clinical Social Worker (LCSW), professor of Social Work, and seasoned psychotherapist and private practice owner. In spite of 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 a necessary evil. I do not believe it is the best fit for treatment or a practice that should be considered the gold standard for mental health treatment as a long term “go to” model for this population. Instead, we need to be constantly revising our practices, moving studies and research forward to move into a era where forced treatment is obsolete.
As for Kendra and day when the very ground floor of modern mental health treatment trembled and collapsed on itself. We will never forget it. For patients whom have and continue to fall through the systems cracks, Kendra’s death marked a new beginning for many violent and chronically mentally ill patients facing possible incarceration, legal issues, and jail sentencing. That moment I am speaking of was that day in the year 1999 when Andrew Goldstein pushed Kendra in front of a train. Well, that is now all history now. But, we must never ignore the implications of that violent act which changed the face of mental health treatment forever in New York and states adopting forced treatment laws.
Kendra died for us. Yes, she did!
What do I mean by that? I mean Kendra’s death will not be in vein. Because of her tragic ending, the fate of so many violently mentally ill people changed forever. Now, there is hope and available treatment for this population. There is treatment instead of incarceration and re-entry into the criminal justice system. Her death signaled to the world that we need to radically shift our methods and approach to treating people whom are violently and persistently mentally ill if we are to truly help people have a real chance at survival from their condition. This signal did more than gesture that we need to make radical changes and now before more people suffer tragic and avoidable loss. This signal was the sonic boom that called upon legislative bodies, advocates, and allies of people with a diagnosis to realize our paradigm for treatment of VSPMI wasn’t working.
I am not suggesting forced treatment works perfectly. I have seen it first hand as an ACT (Assertive Community Treatment) practitioner. I’ve see the law fail clients and forced treatment 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. Indeed, the stigma that evolves from an AOT (Assisted Out Patient Treatment) label under the county department of community mental health radar is demoralizing to say the least. The label is humiliating, infantilizing and demeaning for many connected to an AOT service.
Today, and until the day we devise another approach to treating this population of the mentally ill population we need to truly push hard and persist in our creativity, clinical prowess and research to build a new paradigm to supplant this existing AOT structure to treating the V-SPMI folks mandated to mental health treatment. I do not agree however with the manner in which this treatment paradigm is sold, packaged for consumption by organizations like SARDAA and The Treatment Advocacy Center. These organizations sell these treatment modalities and legislative imperative as client centered and in the best interest of the patient with a diagnosis. That couldn’t be more misrepresentative of what is happening and what is put into motion in the lives of those mandated to AOT laws.
These people instead lose a part of their independence, their autonomy and relative status as citizens equal in the name of the law. The law confines, restricts, and places limitations on the movement and personal freedoms of people under the AOT regulations. Travel, medication administration, choice in treatment staff and frequency of contact with mental health staff and treatment teams. All of these domains of mental health treatment are prescribed, mapped out, and monitored closely by the county government whom can at anytime, when it’s rules are violated, pick you up in your home and take you to the hospital for forced treatment.
The real and more immediate problem exists in client centered care for V-SPMI people. Practitioners working with mandated clients believe in many documented cases that they can engage in client contact aggressively, without any client input, and without regard for the personal beliefs and values of their patients. It is an unspoken trend with all too many workers charged with the provision of care of people with an AOT status. These psychiatrists, nurses, therapists and mental health clinicians will go about treatment without any regard for client centered care and harbor an attitude that this is punitive measure. The fact of the matter is even TAC and SARDAA make it clear this is not punishment. This is a measure to avoid further ineffective and inappropriate legal measures and sometimes criminal charges or jail time. Mental health treatment is never and will never be the right fit for V-SPMI folks if the system understands it as a punishment for people with a diagnosis.
Kendra died for us. Her departure from this Earth and the loss felt by those she loved will never be forgotten by everyone with a mental health diagnosis whom has flirted with the need for AOT treatment. We all feel the threat and loss in freedom or potential for loss in our right to choose our own care and treatment for our diagnosis. The loss of Kendra, was subsumed by people carrying a mental health diagnosis, and we will never lose that scarlet letter that labels us and marks is as eligible under the law to lose our right if our conditions worsen. Our fate after Kendra’s death to make decisions for ourselves and care will ultimately, until a new paradigm arrives, be under the provision and care of the law. Instead, our personal beliefs on how we want to manage our own mental health affairs will continue to be unjustified and privilege the provider.