Kendra’s Law and Treatment Resistance

Yesterday, The New York Times reported on a new study exploring the clinical and economic efficacy of Kendra’s Law. In brief, states like New York with variants of this law can, through court order, compel particularly treatment-resistant individuals to participate in mental health care even after discharge from involuntary inpatient hospitalization. Often called assisted outpatient treatment or AOT, these programs represent an interesting intersection of clinical judgment, human rights, and public safety. Can individuals who are below the threshold of involuntary hospitalization be ordered to participate in treatment they do not want? Is forced treatment beneficial to patients? Does compelling the state to provide and often pay for ongoing outpatient services for these individuals ultimately save taxpayer money? While the ethicality of AOT remains an open discussion, the new Duke University study suggests that the answer to the latter two questions is yes. New Yorkers ordered to comply with treatment tended to be hospitalized and arrested less than they were before the order was enacted. These are solid empirical indicators of clinical improvement as well as decreased economic impact on public systems.

How is it that people benefit from a treatment they ostensibly do not want, and in fact often fight tooth-and-nail to repeal? A major component, which the Times article emphasizes, is the amount of money and resources spent by the state on AOT programs. Not surprisingly, the most successful programs are those that were most heavily invested in. Looking beyond the economic to the clinical, another answer may be found in broadening the concept of treatment resistance. In psychoanalytic thinking, it is considered normative and even necessary for patients to resist aspects of psychological treatment. When the therapy environment becomes too intense or threatening, patients often act out as a means of preventing work from moving forward in order to protect themselves. This can manifest as missing or arriving late to sessions, avoiding certain topics or emotions, or even becoming romantically infatuated with one’s therapist. How the therapist works with such resistance may vary depending on the situation and the therapist’s theoretical orientation, but one thing is agreed upon: Resistance is universal. Furthermore, the presence of resistance does not necessarily mean that treatment is ineffective or should be discontinued. In fact, resistance often serves as an indicator of change ambivalence — mixed, often unconscious feelings about the changes that treatment may bring about — and therefore can rear its head just as the patient is nearing a significant breakthrough.

If at some point(s) in typical outpatient psychotherapy cases we would anticipate resistance to the treatment, it would stand to reason that in more extreme cases resistance would take on a more global, institutional nature. Rather than refusing to attend a given session with one’s therapist, the individual refuses to be engaged in any treatment whatsoever. This does not automatically mean that the individual does not need — or even unconsciously want — treatment. The rub, of course, is that speculation of unconscious desires should not give the justice system carte blanche to intrude on someone’s civil rights. This is a slippery slope that, taken to its most drastic conclusion, would result in a kind of psychologically-justified totalitarianism. But is it more ethical to assume that an individual’s conscious wishes are the inviolable truth, even if evidence points to the fact that some degree of coercion will likely benefit that person, as well as surrounding family and friends? The Times article points out the important fact that AOT compliance is often very good, even amongst the most objecting patients, despite the fact that the consequences for noncompliance are not particularly severe (usually a psychiatric evaluation to see if the person needs to be hospitalized). Perhaps compliance in the face of conscious objection does not only represent coercion by the court system (which it does) but also an implicit acknowledgment on the part of the patient that help is needed.

These are murky dilemmas with no clear right answer. The views expressed here stem not only from emerging empirical research but also my clinical experiences with patients on AOT — others may take a different stance based on divergent but equally real experiences. However, the inductive reasoning cited by one opponent of Kendra’s Law in the Times piece — essentially, “if AOT is so great why don’t all states already use it” — is counterproductive to this serious debate. The consequences of enacted policies (or the lack thereof) have profound and immediate implications for the lives of people living with severe and chronic mental illness. Therefore these programs must be carefully evaluated in an ongoing manner for their effectiveness and humanity.

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