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“Assisted” Outpatient Commitment Advocates Manufacture Consent Via Manipulation

There is a battle currently raging to convince the few states without involuntary outpatient commitment laws to give in.

Although people with psychiatric histories are often perceived to be a danger to themselves and others, research doesn’t support that assertion.

Most people in the United States claim to value freedom and civil rights for all citizens. Wherever their biases may lie and whatever other limitations they feel should be in place, relatively few would openly admit to believing that any particular group should be locked up when no crime has been committed. Yet, for the same majority, that changes the moment so-called “mental illness” enters the picture.

Locking up people in crisis “for their own good” is simply seen as a different conversation altogether. It’s almost as if a psychiatric diagnosis makes one an alien subject to different laws. There are few situations in which this is more true than involuntary outpatient commitment (IOC).

IOC is better known as “assisted outpatient treatment” or community treatment orders. It typically amounts to placing someone who has committed no crime on a sort of “probation” where they are required to comply with a number of requirements under threat of detention in a psychiatric facility.

Although people with psychiatric histories are often perceived to be a danger to themselves and others, research just doesn’t support that assertion. This truth is rarely named and becomes further distorted by the fact that any time someone with a psychiatric history commits a crime, that history is cited as explanation, even if there’s little sign it’s related.

In fairness, most proponents of IOC do not suggest that it be applied based on diagnosis alone, but rather on a track record that might include repeated hospitalizations, ongoing suicide risk or even past history of violence in some cases. However, we already have a legal system (as problematic as it may be) to address actual infringements on the law. Any other removal of liberties based on potential “risk” would be unprecedented in any other community of people, at least as something cosigned through due process.

When laying out the facts, it’s hard to deny the injustice of IOC, yet there are several manipulations used by IOC proponents, the media, and others seeking to support them that obscure the realities of the issue and serve to convince the public it’s the “right thing” to do.

Euphemizing Force

A name can be everything.

IOC exists in most U.S. states and territories. However, most use the language of “assisted outpatient treatment” (AOT), and they do so without realizing they’re participating in a marketing scheme comprised of euphemisms.

The language of AOT was chosen intentionally to hide the fact that the practice is rooted in force. Not only does the name make it sound like a kind support, few people realize that many of the treatments that AOT has notoriously used have an incredibly poor track record with questionable long-term outcomes and even brain shrinkage.

This kind of linguistic manipulation doesn’t stop at AOT. Based on a geographic review, at least six states and territories have moved beyond AOT and instead named forced intervention after a particular tragedy. In Michigan, AOT is called “Kevin’s Law.” The law was named after Kevin Heisinger, a 24-year-old white man, who was murdered in 2000 by a person in crisis in a bus station bathroom. His murder was used to create a law intended to force people into psychiatric treatment without having to actually “wait for someone to do something dangerous.”

In Kentucky, the same sort of law exists but is named after Tim Morton. A bit of an outlier, he was 56 when he died of neglected health issues related to ongoing struggles with emotional and mental distress. The law there indicates that someone may qualify for forced outpatient treatment if they are seen as “lacking insight” into their own struggles and have been hospitalized “at least twice in the previous 12 months.”

In Louisiana, we have “Nicola’s Law,” named after Nicola Cotton, a 24-year-old police officer shot to death in 2008 by a man with a schizophrenia diagnosis. (She appears to be the only nonwhite person to have been memorialized in this manner.) Meanwhile, in Guam, there’s the “Baby Alexya Law” named after Alexya Esser, a 10-month-old baby, who was punched in the face by a 44-year-old woman with a psychiatric history in 2015. (The baby was not seriously injured.)

Even more convincing than threatened babies, it appears, are tragedies involving young, conventionally attractive white women. For example, one of the most well-known IOC laws is “Kendra’s Law” in New York. Kendra’s Law is named after Kendra Webdale, a 32-year-old woman who was pushed in front of a train in New York City by Andrew Goldstein, a 29-year-old Queens resident who was in crisis at the time.

Even more well-known — and arguably the most frequently referenced IOC law — is “Laura’s Law” in California. The law is named after Laura Wilcox, one of three people murdered in 2001 by Scott Thorpe, who had been undergoing monthly mental health counseling for agoraphobia. Individuals who dig into the details will find lesser-known facts such as that Thorpe had no prior history of violence, no one suspected he was likely to be violent, and that Wilcox was actually murdered at the site where Thorpe was actively engaged in treatment. All particularly interesting points given that the focus of IOC is to force people into treatment based on assumption of risk.

Regardless, the bottom line here is that it is much harder to argue against IOC when someone is advocating for it in the name of a horrific event likely to call upon people to put emotion over logic.

Media Manipulation

Tragedies aren’t just useful when it comes to naming these laws. They’re also used as an ongoing strategy to discuss them in the media, too.

Reporters regularly become complicit in manipulating public opinion by using often unrelated tragedies to push positive positions on IOC. For example, Deborah Becker of Boston-based news station WBUR published an article about IOC in March of this year in which she shared the story of Brad Cappucci, a 33-year-old man struggling with a psychiatric history, who died of exposure in Yellowstone National Park in 2021. His sister has reportedly theorized that an IOC law might have helped save his life were it available in his home state of Massachusetts.

Yet, the story glosses over the essential fact that Cappucci didn’t even qualify for involuntary inpatient commitment under state law, and so would never have met the criteria for IOC. Perhaps even more importantly, he moved out of Massachusetts to a state where IOC was on the books at least a year before his death, further demonstrating that such a law would not have saved him.

Stories truly are far more memorable and convincing than anonymous statistics for the average person. Yet, few are talking about why stories of pro-IOC family tragedies are relatively easy to come by while stories demonstrating the harms of IOC are much harder to find. Even if we look beyond the fact that many pro-IOC stories are misapplied, there are a number of other reasons for the disparity.

For example, in the same WBUR story, Becker did do some work to find accounts of individuals who had been harmed by IOC. However, in email communications to advocates at the western Massachusetts-based Wildflower Alliance, an advocacy, peer support and training organization where I serve as director, Becker communicated that there was a preference for people based in Massachusetts. When Wildflower connected her to someone living in neighboring Connecticut who had experienced IOC in Illinois, Becker replied only that she did not include that person because her editor felt their story was “too removed.” (That individual, Eliot Olson, later appeared in an Associated Press article on IOC in the Boston Herald.) How does a person find a story about someone negatively impacted by IOC within the confines of a state where IOC laws do not exist?

Further, even if geographic limits were taken off the table, it’s essential to bear in mind that individuals subjected to IOC have already been profoundly negatively impacted by the loss of their liberty. As such, they’re rarely eager to go public for fear of retaliation that could further restrict their rights, and some are simply too dulled by forced drugs or too demoralized by their losses to consider speaking up.

To mask these omissions, many reporters will throw in a few quotes from folks with opposing perspectives. But, sandwiched in between tragic stories, they remain practically invisible.

Medical Manipulation

As if euphemisms, misused tragedies and ruled-out counterpoints weren’t enough to convince most people, IOC proponents go for the kill with those who shall not be questioned: doctors.

There are all kinds of “industry secrets” and standard practices in the media of which outsiders are simply unaware. Most know that what gets reported as “facts” in the news can be skewed by any number of things ranging from implicit bias, to social capital, to who pays the bills. Yet few know that, unlike most other areas of reporting, journalists who write on medical topics aren’t typically supposed to question experts. Rather, they’re simply expected to accept what doctors say at face value.

Enter “anosognosia,” the linchpin of the pro-IOC argument. Anosognosia was first coined by neurologist Joseph Babinski in 1914 to explain what was happening when someone was unable to use or feel the left side of their body, typically following a stroke or other conditions affecting the right parietal lobe of the brain. However, decades after it was recognized as a neurological condition, psychiatrists appropriated anosognosia to describe individuals in their care who they perceived to be in denial about their diagnoses.

Lack of correlating evidence in brain scans didn’t stop psychiatrists from making this convenient argument, nor have counterarguments from other psychiatrists calling their bluff slowed them down. Some doctors even have the nerve to claim their psychiatric patients “suffering from anosognosia” go on to thank them after being forced into treatment, although journalist Rob Wipond has done a thorough job of dispatching that argument.

It’s probably safe to say that most times someone is alleged to be thanking the person who’s stripped them of all their freedoms, there might be something else going on beyond their being grateful.

The best marketing strategies are the ones where people don’t even realize there’s something being sold. Each recent buyer becomes an unwitting purveyor in an ideological pyramid scheme. Our best defense is to raise the veil and shine a spotlight on the inner workings. Once we can see what operates invisibly, at least some power is lost. That means calling things for what they are, shunning attempts to prey on our emotions, thinking critically, calling out disparities and asking tough questions — even of those who hold advanced degrees.

Of course, real change requires multilayered efforts. Yes, demystification, public education and exposure to new perspectives is needed, but so are collaborations with disability rights attorneys to address injustices, and perhaps most of all, the creation of new alternatives. This aligns with the “Transformation Triangle” as described by attorney Jim Gottstein who describes this framework as laying out a process for real change. For example, in Massachusetts, at the same time as advocates are battling to keep IOC out, they’re also fighting to reallocate funds to crisis alternatives like more peer respites and nonpolice responses to people in distress. Soteria Houses, Living Rooms, Hearing Voices and Alternatives to Suicide groups are included on the growing list of alternatives there and beyond, as well.

Involuntary outpatient commitment strips people of power and control in their own lives for reasons rooted largely in bias against individuals with psychiatric histories. There’s no need for us to become complicit in that by giving up power to manipulative tricks designed to inhibit our ability to determine what we actually believe for ourselves.

If we’re going to debate the merits of IOC at the risk of extreme loss of liberty for some of our most vulnerable citizens, let’s at least play fair and do it based on facts.

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