An inconvenient truth that needs to be addressed in a Murphy/Barber compromise: Assisted Outpatient Treatment versus individual choice

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We were pleased to learn that a bipartisan group in the House of Representatives has been meeting to look for some common ground on two mental health bills introduced this Congress – HR 3717 (Rep. Murphy, PA) and HR 4574 (Rep Barber, AZ). While there are similarities in the two bills, one of the lightning rods that distinguishes the bills from each other, and is dividing the advocacy community, is the issue of self-determination and individual choice in treatment decisions for those with a serious mental illness.

A bipartisan meeting focused on compromise is a positive development and gives us hope that some useful steps toward mental health reform can come of this instead of two competing bills both dying in committee.

However, in the spirit of compromise, we hope our elected officials will not shy away from one of the most contentious elements of the Murphy bill that is not in the Barber bill – Assisted Outpatient Treatment (currently, forty-five states permit the use of assisted outpatient treatment). The concept of “forced treatment” raises a host of concerns and has put the mental health advocacy community in opposition to each other, which is the last thing we need if we are serious about improving mental health services in America.

In an interesting critique of the Murphy bill by John Grohol of PsychCentral, he states:

And there, likely unintentionally stated, is the inconvenient truth of this debate. Yes, there are families with young adult children who are in crisis – today. And we are hearing from these families that they can’t wait for the promise of prevention programs that may provide great things, but not today. What happens today? What is their recourse today? How do they deal with the gut-wrenching worry of not being able to keep their young adult children safe from harming themselves or others today? How do parents who are ardent advocates for self-determination and individual choice resolve the internal conflict of knowing inside that their child needs help, but not being able to provide it? How do they resolve the conflict of doubt – second-guessing their internal intuitive compass that tells them there is trouble afoot?

There are no easy answers to these questions, but to deny the existence of these struggles is as wrong as it is to say that everyone has the right to choose, and that is that. Unfortunately, overlooked in much of the debate about the Murphy bill in particular, is an inconvenient truth – there are families with young adult children who need help now, today, not sometime in the future.

Strip away the personalities of members of Congress involved in this debate, national advocacy group position statements either for or against, and the research data that both sides of the issue present to provide viability to their positions. Strip away the inevitable stigma promoted in the press that individuals with serious mental illness are violent. Strip away the raging debate on the effectiveness and appropriateness of the use of medication. Strip all of that away and you still have an inconvenient truth that is festering like a burr under the saddle:

There are families with children in deep crisis who need help now.

The Children's Mental Health Network is a huge proponent of the recovery movement and has written about numerous examples of successful strategies for helping individuals take a self-directed approach to getting better. But what does that mean for those families and youth who are in a different, more dangerous place? How should we respond to parents who are frightened by their child when he or she is in a psychotic state, scared for the safety of siblings, others, or themselves? Where is their voice being heard? I am increasingly hearing from parents that national advocacy groups are muting the discussion of this inconvenient truth.

We need to embrace the voices of families of young adults in serious crisis just as fervently as we do those families who have young adults with less serious challenges or just as we do with young adults who are doing amazing, self-directed things on the path to recovery.

Is one perspective more valid than the other? Should we discount the clarion call for individual determination that so many against the Murphy bill have spoken about? Of course not. Should we discount the pleas from family members to have more options in front of them when dealing with concerns about a loved one? Of course not – but in many respects, during this debate we have.

The unfortunate irony in all of this is that there is a plethora of smart, knowledgeable people on both sides of the issue. What we need is for these smart and knowledgeable people to be reasonable and come together in a calm and coherent manner to truly address this inconvenient truth. Whether that looks like a designated commission or committee, I don’t know, but the members of Congress working on compromise solutions between these two bills are in a great position to make it happen.

Representative Murphy, Representative Barber, you were elected to represent the interests of the people in your respective districts and to model collaborative efforts for the nation on how to address difficult issues. We expect you to do just that. We are thrilled to see a dialogue beginning about what parts of each of your bills can be crafted to result in meaningful legislation, but please do not shy away from this issue. It is real; it is uncomfortable, it is not politically correct, but it may be the most important area of focus you could embark on.  


Scott Bryant-Comstock
President & CEO
Children's Mental Health Network


  1. Leah Harris's avatar
    Leah Harris
    | Permalink
    Wouldn't it be wonderful if there was a powerful "mental health industry" of peer support, crisis supports, Housing First, supported employment, Open Dialogue, etc. that was heavily funded from many sources to make a real difference for people and families in their communities. Most everyone I know who works in the "mental health industry" barely is able to make ends meet. These folks do the work they do out of the kindness of their hearts, and belief in hope, recovery, and dignity for all. We sure do need a dialogue to stop the demonization going on. It's a product of stigma and ignorance. Dialogue could change that.
  2. Psych Survivor's avatar
    Psych Survivor
    | Permalink
    DJ Jaffe, a well known promoter of civil rights abuses in the name of so called "mental health", takes his readers here and I comment here because he bans his critics from his facebook page (his prerogative, of course, but it goes to show his intolerance as well, and the type of mindset that embraces coercive psychiatry).

    The issue of self determination is well understood when we compare it with other areas of "public health", regardless of the argument on the validity of psychiatry (I for one think psychiatry is a quackery).

    The Cuban experiment shows that coercive HIV polices, namely, campaigns of forced testing and forced medication for those found out to be HIV positive achieve the result of lowering the HIV rate. Cuba, despite being a well known destination for sex tourism, is a country with one of the lowest HIV rates in the world. Recent studies show that forcing all gay males, IV drug users and sexually promiscuous people on Truvada would accomplish the same result in the US. Yet, nobody is suggesting taking away choice from people who could benefit from being put on Truvada forcibly.

    So why is it rational to refuse to use condoms "in the heat of the moment" as well as to refuse to take Truvada -in spite of the science that says that HIV transmission risk increases when none of these two measures are implemented-, but it is not rational to refuse neuroleptic drugs? Are we making "mockery of civil rights when we ignore people " whose life could be saved if they were to be forced to take Truvada? Why do we " leave them on the streets until they do something" that results in HIV transmission, thus assuring that they will die of a condition that could have been prevented had they been forced on Truvada? See, I have a huge problem with this double standard, but apparently people as totalitarian as DJ Jaffe or Tim Murphy do not.

    This "double standard" has a name: bigotry. The same kind of bigotry that was used against blacks (drapetomania), then against gays (before the APA removed homosexuality from the DSM in 1974) and now against the rest of us. And something else to address DJ's insidious double standard.

    Nobody would dare to implement an HIV policy without the input of those groups who, according to the CDC, represent 75% of all HIV infections: men who have sex with men, IV drug users or both.

    It begs repeating that AOT, as implemented everywhere, is for people who HAVE NOT BEEN legally deemed incapacitated. So we have people who, under the law, are deemed as having capacity to make their own decisions but AOT forces, or "compels them" as DJ and the like say euphemistically, to take drugs.

    Please name me another group of so called "patients" who would accept to be forced on so called "treatment" while not having been declared legally incapacitated. The answer is there is NONE.

    And yet, DJ Jaffe wants to impose that double standard on the people the APA targets with its DSM bigotry. It cannot be more evil and bigoted than this. And in fact, it cannot be a more direct violation of the equal protection clause either.
  3. Sarah's avatar
    | Permalink
    Thank you for this very thoughtful response. This is a fantastic articulation, and appreciate the "today" mantra, and acknowledging that there is room, and need, to have solutions for those who are in recovery, and those who are not yet, and may need something like AOT in order to even have a shot at recovery.
  4. DJ Jaffe's avatar
    DJ Jaffe
    | Permalink
    It is unfortunate that Children's Mental Health Network wants to limit treatment only to those who are well enough to ask for it, and not allow treatment for the others. It is true that the 'mental health' community is divided over AOT in that many support it. But that is a tempest in a teapot. The public, police, parents of SMI, and even those in AOT support it. As the recent vote in SF shows, politicians need to stop listening to the mental health industry which wants federal funds absent an obligation to treat the most seriously ill.
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