By Sera Davidow
Senator Chris Murphy of Connecticut (and his legislative co-pilot, Senator Bill Cassidy) released a new ‘Murphy Bill’ this past week. It’s called the ‘Mental Health Reform Act of 2015,’ though it has yet to be assigned an official number. While many words appear in its more than 100 pages, it’s worth noting that the term ‘evidence’ (most often paired with ‘based’ to form the familiar and supposedly scientific phrase, ‘evidence-based’) appears 27 times. Never to be outdone, the almost 200-page House version (‘Helping Families in Mental Health Crisis,’ H.R. 2646) from Representative Tim Murphy uses the same word 38 times.
This makes sense. Why wouldn’t anyone want anything to do with… well… just about anything… to be, you know, based on research and evidence? I mean, evidence is certainly better than wild guesses, right? Apparently, the most commonly used definition for ‘Evidence-Based Practice’ is this:
“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett et al, 1996).
Most people will hear ‘evidence’ to mean confidence and rigorous standards. They’ll hear that someone has really taken the time to figure things out and get it right. In a most basic way, it (sounds like it) means safety and that inspires trust. Most will read the use of ‘evidence-based’ in these documents in that way, and few will disagree that it’s a good thing, but here’s the problem:
At least in the realm of ‘mental health,’ evidence-based means something more akin to:
The use of current evidence as developed by individuals who had enough funds at their disposal to engage in the bolstering of their own favored ‘best practice’ – often to the exclusion of other evidence to the contrary and commonly more or less in alignment with the dominant paradigm (hence the availability of said funds) – and all too frequently based on research conducted upon such an extraordinarily narrow and contrived group of people and characteristics that it is unlikely to be particularly meaningful or replicable in the ‘real world.’
Furthermore, ‘evidence-based’ practice is frequently measured against outcomes that are defined by a clinician or scientist rather than someone whose life is directly impacted. For example, a scientist might interpret reduction in hospitalization as a primary and positive outcome, but ignore the fact that the person no longer hospitalized is so sedated that they have lost their day-to-day ability to function in anything resembling a healthy manner, and will soon begin experiencing medical complications as a result.
Twenty-seven (or 38) uses seems excessive for such a hollow word, particularly in a document that has the potential to change so many lives in such a dramatic way. But, ‘evidence’ is not alone. Alas, there are many words in the Murphy Bills that serve little purpose other than to mislead or fluff up the grand illusion that these legislators are on to something good. Others include (but are not limited to):
- Assisted Outpatient Treatment
- Peer Specialist
Assisted Outpatient Treatment
The ever-euphemistic term, ‘Assisted Outpatient Treatment’ (AOT) appears prominently in both documents, although in slightly different ways. While Murphy 2013 sought to penalize states that did not take sufficient steps to implement so-called AOT, Murphy 2015 in the House claims only to want to incentivize the states that do. Meanwhile, the Senate’s Murphy Bill takes arguably the most timid approach, claiming to only be continuing existing AOT demonstration projects to 2020.
However, the fact is that all three versions essentially seek to expand (in one fashion or another) the practice of forcing psychiatric drugs and other ‘treatment’ on people who may have done little more than be hospitalized too many times for someone else’s liking, and they are simply experimenting with which version of expansion might be most palatable to the general public so as to allow it to slip by. And, while they’re doing so, they’re calling it ‘assistance.’
Personally, when I picture someone providing ‘assistance,’ it conjures up images of helping an elderly individual across the street, or maybe offering a grant to a young person entering college. I certainly don’t ever imagine forcing someone to take chemicals into their body against their will, attend appointments they don’t wish to attend with clinicians they do not trust, or telling them they must engage in any other activity under threat of hospitalization if they refuse, and then smiling and calling it ‘assistance.’ I might as well commit armed robbery and suggest to the bank that I’m simply ‘assisting’ them in correcting my personal financial woes.
Yet, once again, what impression is it that these bills leave with the voting public? Not only are we kindly assisting someone with what they need, but we’re doing it based on evidence! (Never mind that there’s a great deal of evidence that what I prefer to call Outpatient Forced Commitment [OFC] does not work unless simultaneously implemented with an influx of other improved and voluntary services, in which case it is still not likely to be the OFC that is actually leading to any documented improvements.)
Peer Specialist & Recovery
Perhaps the greatest issue with the newly included (and nearly identical) ‘peer specialist’ sections in both current Murphy Bills is the implication that there is actual goodwill toward and belief in peer-to-peer support. Personally, however, I’m brought back to various conversations I’ve had about drug legalization with individuals who otherwise are staunchly opposed to drug use but feel that legalization is the best way to control and regulate it. In other words, the inclusion of ‘peer specialist’ rings of a desire to scrutinize, limit and control these roles rather than to support them.
Both documents define a ‘peer specialist’ (a problematic term all on its own and the only ‘peer’ role recognized therein) as someone who must be working in collaboration with and under the supervision of a clinician. It lists documentation and assessment as among the primary tasks. Perhaps most frightening, it states that such individuals must not work outside of the ‘scope of their expertise.’ Although it does not specifically define what the supposed scope of a ‘peer specialist’s expertise might be, the implication is that when it is defined, it certainly will not be by the ‘peer specialist’ or anyone they are supporting.
To be clear, this is less ‘peer-to-peer support’ and more co-optation giving way to mandatory assimilation. It represents an uprooting of firmly planted principles already struggling to thrive in many environments. It devalues the potential of people in peer roles to be change agents, ties their hands as ‘advocates,’ and disregards the importance of their operating within the system without being precisely ‘of’ it. The ‘peer specialists’ of a Murphy’s world would be less ‘peer specialists’ and more moles, administrative assistants, and ‘right hands.’
This brings me to perhaps one of the most interesting and overlooked points in the entire document: It also defines a ‘peer specialist’ as someone who has been in active ‘treatment’ for the last two years. Furthermore, in a separate section of the Senate version, when describing a committee to be formed, it designates one seat to a ‘peer specialist’ (as defined above) and another to someone who has been not only in ‘active treatment’ for the last two years but who has expressly ‘benefited from’ it. (The other 21 seats are largely, of course, allotted to various academic or clinical types.) What on earth does any of this say about either Murphy’s actual belief in the word ‘recovery?’
Now, I’m not a particular fan of the word ‘recovery’ (see my blog, ‘Recovery Trap’ for more on that), but for very different reasons. It’s certainly not because I don’t believe in the potential of people who have been given psychiatric diagnoses to heal, move beyond the need for ‘treatment,’ and get on with their lives.
The word ‘recovery’ appears 12 times in the Senate-driven Murphy Bill and seven times in the House version. But, what could it possibly mean to legislators who have written a proposal that so explicitly and intentionally eliminates the voice of anyone who has ever been given a psychiatric diagnosis but is no longer in ‘treatment’? Lifelong ‘treatment’ is certainly not my vision of ‘recovery’ for myself.
Evidence. Assistance. Peer Specialist. Recovery. The linguistic imagery this Murphy duo paints looks kind of pretty at a distance. It’s like one of those paintings that form a beautiful, scenic horizon when one is standing far away enough to see it in that light. However, up close, one can see that the larger image is built on millions of tiny tears and specks of blood.
At a glance, the public will assume that the Murphys intend to prioritize a ‘gold standard’ of treatment – only the very best, most ‘evidence-based’ ‘assistance’ for all. They’ll assume they believe in the potential of treatment and ‘recovery’ so whole-heartedly that they’re even going to invest in bringing in ‘peer specialists’ as living breathing examples of that future-oriented vision.
But, the truth is ugly. The truth is about control, obfuscation, and a game where political careers and appearances reign supreme over the actual issues at hand. These bills pose an unprecedented threat to so many people and organizations engaged in the most innovative efforts, who may be rendered invisible for their lack of ability to fit into the superficial definitions and re-worked meanings that inflate these bills.
What happens to innovative efforts like Recovery Learning Communities, peer respites, Soteria projects, the Hearing Voices Movement, Alternatives to Suicide groups and so many more when they don’t have the money to pay for an ‘evidence-based’ status? When some newly appointed official is told it’s their responsibility to award grants to only those who ‘fit’ a very particular set of standards?
What happens to the others when they call ‘Assisted Outpatient Treatment’ out for what it really is and fight against force? When they fail the newly branded ‘peer’ litmus test for lack of clinical supervision or practicing outside of what someone else has decided their scope should be? Are we ready to let all of these efforts die, in spite of the hundreds of thousands of people who say (‘official’ research studies be damned) that they saved their lives?
And, what happens to those of us (myself included) who stand up to speak but are silenced because we are no longer in ‘treatment,’ or want to share how it didn’t work for us?
It’s funny how these bills and their associated Murphys are claiming a desperate need for great change, and yet what their legislation would seem to most readily accomplish is a narrowing of the field to a lot more of what’s already most strongly represented. I don’t know of anyone who would say the current mental health system is a success (or even vaguely acceptable). However, nor do I know anyone who would say that the mental health system of several decades ago was either, and, at least in part, that’s where the Murphys seem intent on sending us. The only question remaining is who is up for signing on to that ride.
Change is needed, yes. But, why would we trust overworked and under-informed legislators with divided interests to design that change for us? And, since when did change become heaping piles of more of the same?
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ: British Medical Journal, 312(7023), 71.
Sera Davidow is a mother, an advocate, an activist and a filmmaker who devotes much of her time to the Western Massachusetts Recovery Learning Community (http://www.westernmassrlc.org). She entered the mental health system as a teenager and cites “non-compliance” as part of what saved her from a very different path that surely would not have included the freedom she now enjoys from all psychiatric labels and medications.