Four days after the shootings at Isla Vista, Rep. Tim Murphy, a former practicing psychologist, was taking to the pages of The Guardian to talk tough about mental health legislation. In a piece titled “Dear Washington: take mental health seriously. It’s a matter of life and death” Murphy mentions Elliot Rodger, Jared Loughner, Adam Lanza and several other well-known murderers, Murphy derided the current state of mental health treatment in America: “We've found it easier to focus both the discussion and public resources on gauzy programs for ‘behavioral wellness’”, he said. He then proceeded to promote his own Helping Families in Mental Health Crisis Act, which would radically change the way the American government funds research and treatment.
This sort of tone, closer to a conversation on national security rather than health treatment, is new to the relatively staid world of mental health legislation. The last big Congressional fight over mental health, 2008’s Mental Health and Parity Act was fought over over fairly predictable lines: insurance companies wanted fewer diagnoses to be covered under the law, mental health advocates wanted more. Both sides optimistically called the deal a “compromise”. Murphy’s tone, which takes the stance his bill must be passed or the mentally ill will kill again, can be linked directly to December 21, 2012, when the NRA’s Wayne LaPierre would give a speech that would alter the conversation about mental health in America.
asked, “A dozen more killers, a hundred more? How can we possibly even guess how many, given our nation’s refusal to create an active national database of the mentally ill?” This was the only mention of mental health within the twenty minute speech, which focused more on armed guards and violence in video games. But as with many influential speeches, the smallest part turned out to be the most significant.
According to a Sunlight Foundation analysis of the NRA’s proposals a year later, “the initial fervor for increasing armed security in schools has died down” and the video game industry has “been upping its political profile with significant campaign contributions to Democratic members and a seven-figure lobbying budget”. While those two areas were stuck in the mud, “the National Alliance on Mental Illness (NAMI) found that a years-long trend of diminishing budgets for mental health had reversed in 2013, citing Newtown as a key mitigating factor”. The trend spread to more than budgets: Nevada and Nebraska established programs to provide for more screening and mental health training for children. Despite successes on the state front, the NRA still struggled: a quick search of it’s press releases show it mostly playing defense on a variety of bills, and it’s NICS Reporting Improvement Act of 2013 (a direct attempt to create the “active national database” LaPierre spoke of) went nowhere.
While the NRA is relatively new to the world of mental health legislation, Murphy, who is endorsed by the guns rights group, has adopted their tactics: the need to sign legislation comes from attack prevention. The bill currently has eighty-six co-sponsors, including fifty Republicans and thirty Democrats. Murphy’s office said that it was “unable” to comment on this article by its deadline, and the NRA did not respond to repeated interview requests.
The Helping Families in Mental Crisis Act covers many things in its 100-plus pages. But one current runs through the legislation: a consistent belief in the highly controversial technique known as Assisted Outpatient Treatment, known by its opponents as Forced Outpatient Treatment. Assisted Outpatient Treatment, commonly known as A.O.T, is “radioactive” within the psychiatric community, according to Jeffrey Swanson, Professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine who has studied the procedure, in which a court can compel someone into commitment against their will. In practice, the core of an A.O.T is forced treatment and medication. A.O.T affects “not everyone with a mental illness, not even everyone with a serious mental illness”, says Dr. Swanson, but it has become the focus of Murphy’s bill. The Helping Families Act would start fifty pilot programs for it throughout the country, and guts both the power and the purse of the government’s main outlets for mental health research and legal advocacy, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Protection and Advocacy for Individuals with Mental Illness Program (PAIMI). Both have consistently opposed A.O.T.
Outpatient commitment is frequently advertised as a last-ditch effort to stop violent offenders. New York’s version of the law, which is commonly seen as the Cadillac of A.O.T programs, is known as Kendra’s Law, named after a woman murdered by a schizophrenic who had gone off his medication. A study by Dr. Swanson highlighted the aggressive funding of the law, with New York State giving over $125 million to the procedure. It’s expensive: from start to finish, a New York A.O.T keeps a patient hospitalized for up to six months and is followed by assertive community treatment, “where the services are wrapped around the person” in their community, Dr. Swason says. “There’s a doctor, there’s a case management component with things like home visits to the person to make sure they take their medication. In addition, there is a connection to services and support which may include housing, helping a person become eligible for and actually receive a subsidized housing unit, which can be really important. I think that’s probably one of the reasons the A.O.T program in New York has succeeded.”
Success in an A.O.T can a variety of things: a 2005 report on Kendra’s Law measured the before and after effects on everything from violent measures, such as property destruction and suicidal attempts, to abuse of alcohol and drugs. While no one challenges the success of Kendra’s Law, critics are not willing to call it an endorsement of the forced commitment that defines an A.O.T: In most service systems, many people can’t get those services, so they aren’t offered”, notes Jennifer Mathis, Deputy Legal Director of the Bazelon Center for Mental Health Law. “Some of the studies, when they look up commitment, ‘Oh, those successful outcomes!’ Sure. When you give people the services, they will have better outcomes. But there’s nothing about the studies that show that it’s the force rather than the services.” Dr. Swason’s 2013 study, which focused on the cost-effectiveness of A.O.T, confirmed this, noting in its abstract that “voluntary participation in intensive community-based services may also reduce overall service costs over time, depending on characteristics of the target population and local service system.“
Bazelon was founded in 1972 by lawyers looking to challenge inadequate treatment in psychiatric institutions, a civil rights fight which became known as “the Consumer Movement”. Mathis sees the organization’s fight against A.O.T in similar terms: “there are the same types of concerns that motivated the consumer/survivor movement to focus on getting people into their own communities”. Discussing the claim that coercion is necessary for treatment in some cases, Mathis says “there are often reasons that are understandable about why people may be reluctant to seek help themselves. They may have had bad experiences with the mental health system before. We have such services that are designed to reach folks that are harder to reach, and they don’t rely on force. Sometimes it takes a little time, but services like ACT [assertive community treatment] have been very, very successful in reaching people and engaging them in services. It tends to work better when you offer services on a voluntary basis and people are more engaged than when you use force. Force drives many people away from the service system”.
There aren’t many examples of A.O.T programs not being adequately funded, although the Helping Families bill creates the potential for it. A 1987 paper by Susan Stefan, a Bazelon employee, titled “Preventive Commitment: The Concept and Its Pitfalls”, appearing in Mental and Physical Disability Law Reporter, describes the efforts of a pilot A.O.T program in Maryland, similar to what the Helping Families Act would create. Out of twenty-two participants, “[a]n interim report noted that three people have been rehospitalized, two have dropped out treatment, nine continue to be monitored, and eight have completed their treatment. The report also identified provider frustration at not being able to enforce treatment recommendations against participants who did not meet inpatiet civil commitment standards.” When asked if an A.O.T program could be successful without the severity of New York’s investment in the program, Dr. Swanson offered up a metaphor: “Imagine a person at the bottom of a staircase, and you pass a law forcing them to go up the stairs but you’re not going to give them a ramp. That doesn’t make any sense. That’s what you’re doing if you just pass an AOT law without investing in any of the services. It’s an access problem.”
Advocates for A.O.T are among the Helping Families Act’s biggest supporter. The Treatment Advocacy Center, run by Dr. E. Fuller Torrey, is amongst the most prominent supporters of the practice worldwide, promotes the bill front and center on its website. Writing for the Arizona Star, Dr. Torrey directly invoked the shooting of Gabby Giffords while describing flaws he saw in the Helping Families Act’s main opposition, a bill by Rep. Giffords’ successor, Rep. Ron Barber by saying that it did not add provisions which would allows for additional beds in mental hospital. Critics, such as Ms. Mathis of Bazelon, say that “[p]eople will go to hospitals for short-term acute care, but I don’t think that the priorities of a mental health service system should be having people in hospitals long term, or building more hospital beds”.
Dr. Torrey is also supportive of the NRA’s involvement within mental health policy. “[P]ersonally I would welcome such interest from any group because I think that untreated mental illness is the heart of the problem”, he told AlterNet over email. When asked specifically about the NRA, Ms. Mathis of Bazelon, an organization never afraid to throw punches, grew nervous. “Uh , I’d rather not get into that here,” she said. “But yes, public statements that people with mental health issues are monsters that need to be controlled do not help the debate.”