Monday, September 14, 2015


In case you missed it, the billboard above, sponsored by designer Kenneth Cole, has been the source of a lot of angst.  Presumably, Mr. Cole meant to point out that people with difficulties have trouble accessing mental health care ( ~so true), but instead the message blames people with mental illness for gun violence.  It's both wrong and stigmatizing, and the American Psychiatric Association understandably asked to have the billboard taken down and started a #GiveStigmaTheBoot campaign.

I want to point out an inconsistency in the APA's endorsements.  Representative Tim Murphy has proposed an overhaul of our national mental health services from the top down.  Many of Murphy's proposals in his Helping Families in Mental Health Crisis Act are admirable and have the potential to decrease repetition of oversight, and hopefully to change the way psychiatric services are delivered to those who need them most.  However, the bill was put forth in response to the Newtown tragedy where a disturbed young man killed 27 people, including 20 young children.  Murphy repeatedly says that something needs to be done about our nation's mental health services before more such tragedies occur, and that this is his promise to the parents of the children who died at the hands of a disturbed gunman.

Murphy's bill creates incentives for court ordering patients to outpatient treatment, also called Assisted Outpatient Treatment or AOT -- a measure that has been used in some states for people with psychotic disorders who are repeatedly hospitalized for noncompliance with treatment.  Outpatient commitment is a tough one -- it may help some people to get help, but it also infringes on a person's right to determine their own medical care, a civil right we all value.  
  In an article in Behavioral Healthcare on September 4, 2015, "Murphy touts mental health bill on Cleveland visit," Julie Miller writes about Murphy's support of the controversial outpatient commitment bill.   Miller writes:

He believes that if the perpetrators of violent tragedies like Sandy Hook Elementary School and the Aurora, Colo., movie theater had assisted outpatient treatment, the tragedies wouldn’t have occurred. To those who oppose AOT on the basis of personal freedom, he says, “Go talk to the moms from Sandy Hook and tell them that.”

Personally, I'm at a loss here.  From what I've read in a variety of sources: the media, the report of the Connecticut Department of the Child Advocate, and live-streamed testimony from the Aurora hearings, neither of those shooters had ever had a single psychiatric inpatient commitment and neither had a history of violence.  No one knew these young men had planned these atrocities.  The graduate student in Colorado was going voluntarily to treatment, he stopped when he left school and his eligibility for services ended.  If his psychiatrist knew he was dangerous, there are laws in place that would have permitted his commitment.  Both young men were diagnosed with anxiety disorders, not psychotic disorders, prior to their shocking crimes.  Simply put, they weren't candidates for Outpatient Commitment, and by making the assertion that outpatient commitment can prevent mass murders, the implication is that the government could knock on your door to see if you are harboring a loner young man who plays videogames and behaves oddly.  These aren't the people who get captured by Outpatient Commitment orders.

Yes, we need better mental health access and more comprehensive services.  But we need them to help people live better lives and suffer less.   Everything about Murphy's Bill as a promise to the parents of the children of Newtown --- that better mental health services will prevent mass murder -- is stigmatizing.   And yet the APA has no campaign against this stigmatizing bill, in fact, the APA wholeheartedly endorses this form of stigma.  


withallmyheart said...

My doctor, who has known me for a few decades now, understands and accepts that I live with with chronic suicidality. At a hearing years ago, he testified that "she could slip away" at any time. That was one of the most courageous statements in the world I felt, that a psychiatrist could have ever uttered.
That is what I see in all this - the ineffable states of the human condition. How can we address the instability, the volatility of any human mind?
...I have been sick since I was a little girl. There is no stigma in it......just a willingness to be open and honest and help in any way I can.
And to clearly state that treatment has saved my life....
Thanks for listening. That is what gives stigma a boot.

Anonymous said...

Thanks to a handful of gossips on the Internet, I have been forced into some of the so-called treatments. It has destroyed both my family by marriage and my family of birth.

"Treatment" encompasses many different methods, and I am very glad that WthAllMyHeart found something that works for her. I am thankful that I was mentally healthy when the abuse started, in the name of helping me, so I could withstand the repeated cycles. I am wondering when the abuse will stop, and how many people have died because of the mis-treatment I have experienced.

Joel Hassman,MD said...

You end this post by noting the APA endorses this kind of stigma, and yet you continue to be a member. I am astonished you wrote that.

Inconsistent at least, hypocritical at most, and not much to say of legitimate defense to support your position at the end of the day.

As I continue to tell anyone interested. you let politicians set the bar for mental health care, it will end up being hideously mirroring the same way Nazi Germany handled their mental health population. I don't care how harsh the analogy, politicians hate mental health, and over and over again, the history of the way they have handled things only reinforces my opinion about it.

Think about it!

And, maybe start thinking about the way this guy Murphy really is trying to frame mental health as an alleged advocate!

Anonymous said...

Speaking of stigma. Here's what they do to people with depression in Texas:


Dinah said...

I'm not a my-way-or-the-highway soul. I continue to get something out of being both an APA and an MPS member, so I stay in the organization even if I don't agree with every stand they take. I register my displeasure when I disagree ~sometimes a bit louder than some some would like ~ but I believe change is more likely from the inside. And I only have a limited amount of energy for being indignant. That energy store seems to be depleting as I age.

Wow, now I have to click on french fries to prove I'm not a robot. What will they think of next?

Joel Hassman,MD said...

You really think you're going to make change from the inside, with an organization that has an entrenched hierarchy of people who will not leave the APA until they die?!

If you are not with them then you're against them, and you will be marginalized and minimized if not flagrantly ostracized. So I respect your outward interest to make change, but, these guys are just like the politicians of the American political system. They believe that they are the only ones who know better, they set policy and tone and if you don't march lock step with him, then you are considered expendable.

That's why I will never, ever join the APA again. They are just rigid and flexible people who superficially claim to care and want to make our profession better. And then they ally with people who just do the stupid crap that you read about at other sites that unfortunately have some validity to be complaining about.

So, good luck with that "change" stuff.

Anonymous said...


In all fairness, if I remember correctly, many DMS's also ask about whether someone is taking non psych meds as many meds whether they be psych or non psych can cause impairment while driving. By the way, I never realized how impaired I was on psych meds until I started tapering off of them so as much as I deplore anything that may seem like it is stigmatizing someone as in the case of the Texas teen, I do understand their concerns.

Speaking of stigma, it definitely occurs if you disclose your psych med history to regular doctors as many times, any complaint is seen through the lens of mental health and you cease to be seen as a credible member of your healthcare team. I am so frustrated that this is is constantly minimized by both psychiatry and the regular medical profession.

Anonymous said...

Anon, they already ask: "Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle?" That is sufficient.

If the psychiatrist feels a patient is unsafe to drive they can do the reporting, but we don't need the DMV investigating every person who seeks treatment for a mental illness. According to the question about mental illness even patients who are diagnosed with depression and receiving only therapy would have to answer yes since therapy is a treatment. Does that make any sense? All these questions do anyway is encourage people to lie. If every patient in Texas taking an antidepressant were answering yes to the mental illness question the DMV would not have time for anything else. I would bet money most people just lie. What is that accomplishing?


Anonymous said...

Thank you Dinah for pointing out this somewhat glaring contradiction.

I've found the scaremongering terminology around the Murphy Bill to be extremely disturbing. My main concerns are:
- It's (as you say) all framed around mass-shootings and people deemed to be "psychotic", which I think is deplorable in its own right and will never be effective;
- When you read the definition of "Eligible patient" it goes further than the above scenario to include people at risk of harm to self due to severe depression. Seriously? Such people aren't dangerous to others; have an entirely different diagnosis.
- Most frightening of all, is how much people just clearly don't give a damn about carving away the freedoms of a potentially very large group of people...all because of ignorance, fear and conflicts of interest.

@Joel, I take your point re: letting the politicians alone design this stuff, but isn't Tim Murphy also a clinical psychologist? Likewise the Congressional testimony on the Murphy bill included ye old faithful of Jeffrey Lieberman (whose main points seemed to focus on why Psychiatry is a real form of medical was weird) and then there's those really charming folks from the Treatment Advocacy Centre...(best not to get me started).

Anonymous said...


I totally agree with what what you said and didn't realize that the kid was being targeted specifically due to a depression diagnosis. And as I keep mentioning, where are the medical associations in all of this since they keep claiming that mental illness needs to be destigmitized?

Regarding lying, I hate doing it but sometimes, sadly, that is the only option.

Dinah said...

It's unfortunate that there is a question about mental illness on driver's license applications (or any application) -- the question should be simply 'do you have a health condition that may impair your ability to drive.' But the article notes that this was a misinterpretation by the worker --in other words a mistake -- and the teen got her license. I don't think we should make too big a deal about mistakes that get corrected, I hope they do change the question, there and everywhere else.

Anonymous said...

I think it is fine that we consider the roles of guns and mental illness in the level of violence in our society. But why do we not consider how much "normal violence" we allow? Violence plays a large part in our t.v. shows and movies. Instrumental aggression is a major part of most video games. "If it bleeds, it leads" makes sure that violence is rewarded with mass media coverage. Verbal aggression passes for political discourse. Toys ranging from plastic guns to paintball guns teach us that shooting people is good fun. Fantasies of "self defense" that demonize particular out-groups make sure that we live in a target-rich environment. Feelings of weakness and helplessness fuel gun purchases, fortification of homes, and paranoid fantasies.

It isn't mental illness that is the engine of violence; it is the "do unto others before they do unto you" mentality that pits us against each other. It is the well-known escalating cycle of violence and retribution that has ratcheted up fear and hatred in many communities.

Anonymous said...

It may not seem like a big deal to have to answer that question, and if I could honestly answer No to the question it wouldn't be a big deal to me either. It is a big deal, though, for many who are left to wonder what the government may end up doing with sensitive information or who feel like they have to lie on a government document to protect their privacy. It's just one more way those diagnosed with a mental illness are set apart as different from everyone else, but the good news is that I just read a follow up article that they no longer ask the question in Texas due to a new law. So, I guess I won't have to lie when I renew my license after all. Whew!


Steven Reidbord MD said...

I'm coming to this a bit late, haven't been keeping up with the psych blogosphere lately. The Kenneth Cole billboard seems directed toward the easy availability of guns, making the point that they're more accessible than mental health care. The comparison itself is unfairly stigmatizing, as it associates gun violence with mental illness. In reality, much more gun violence erupts from those without a psych diagnosis than from those with. (Limiting the discussion to non-politically motivated mass murders of strangers may tip the balance toward the diagnosed. Still, violence is the exception.)

In any case, I appreciate your pointing out the inconsistency in the APA's position on stigma. AOT may keep an occasional dangerous person "safely medicated," but it's absurd to advocate for AOT on the basis of public safety. Stricter gun laws, among other strategies, would have a far, far greater effect, as they would address the bulk of gun violence that is perpetrated by what passes for sane in our society. I imagine Kenneth Cole was trying to convey something along those lines.