#FreeBritney Shows Us When “Help” is Not Helpful
How our Mental Health and Legal System is Failing Britney Spears (and So Many Others)
She’s So Lucky, She’s a Star
This past weekend, I was spending time with some girlfriends- an eclectic crew all in their 30s or early 40s who grew up in the Britney Spears era- and the conversation inevitably drifted to her much-publicized conservatorship battle. One friend expressed frustration that everyone was so focused on a celebrity when there were many other vulnerable individuals being exploited and controlled around the world not making headlines. I got to thinking about why I, a Harvard-trained board-certified psychiatrist who does not read TMZ or Page Six, was taking such a keen interest in Britney’s troubles. The reason is simple: If a rich, famous and talented woman like Britney cannot disentangle herself from the tendrils of a dysfunctional mental health and legal system, what hope is there for the rest of us trying to get help for ourselves or our loved ones who live with mental illness?
Britney is one of 1.3 million Americans living under conservatorship/guardianship arrangements where an adult’s decision making power around their health, their life and their finances can be placed in the hands of someone else due to concerns around their ability to make these decisions on their own. This is murky and poorly regulated terrain, particularly when mental health issues are at play. They say sunlight is the best disinfectant so we held a panel discussion on our Clubhouse Creator First show, New Frontiers, with experts from the mental health and legal world as well as members of the #FreeBritney movement to shine some light on this “toxic” mess.
I’m a Slave 4 U
A pivotal moment in the case was Britney’s recent brutal 24 minute testimony in open court where she likened the arrangement where her father has total control of most aspects of her life and body to sex trafficking and deemed it and those involved, including her former psychiatrist, abusive:
Rachelle Dooley, the founder of the Deafinitely Inclusivity Club on Clubhouse, discussed that for people with disabilities, listening to Britney state in this hearing that she is not allowed to remove her IUD in order to try and have another child with her long-term boyfriend hits home. She described being told by her mom that because she was deaf she should not have children. While the attorney for the conservatorship has subsequently stated that Britney is allowed to remove the IUD but just does not understand how the process works, my experience as a physician with these types of arrangement is that the conservator or guardian does indeed need to give consent for any sort of medical intervention, including the removal of an IUD. The person living under this arrangement is treated the same way my 5 year old daughter is if she goes to the pediatrician and the doctor recommends a vaccine which I, as the parent, must (and do!) consent to in order for her to receive it.
In any event, many of my patients, especially woman, who are living with mental illnesses such as bipolar disorder hear from friends and loved ones about how they should not have kids either due to being perceived as “unfit”mothers or passing on “bad genes” or some combination of both. This is, as our panelist Dr.Amanda Tinkelman, a perinatal psychiatrist, declared “total horse hockey.” While we as a society have made major strides in de-stigmatizing mental illnesses like depression and anxiety, for individuals living with bipolar disorder, autism, psychosis, personality disorders and other severe and persistent mental illnesses, offensive, inaccurate and highly destructive ideas still are prevalent around having children. In the past decade in my career as a psychiatrist I have never once told a patient they should not or could not have children because of their psychiatric condition or psychiatric medications. Have we discussed when would be better timing? Or what medication regimens might need to change? Sure, but to tell an adult they cannot start a family due to mental illness is simply not a call I think anyone should make on behalf of someone else. Full stop.
Just because a guardianship/conservatorship allows a conservator to determine if an IUD should be placed or removed does not mean the conservator should stand in the way of the individual’s wishes as long as the person has capacity to make that specific decision. In medicine, we talk quite a bit about “capacity” to make medical decisions and a key point to remember is that someone may have capacity to make one decision but not another since each decision has different risks and benefits. For example, consenting to take an oral antibiotic for a urinary tract infection in the outpatient setting is a low risk, high benefit decision but declining to be treated with IV antibiotics for a severe kidney infection while in the ICU is much, much higher stakes. We want the conservator/guarantor to be able to appreciate this nuanced calculus and to default to allowing as much autonomy as is reasonable for each circumstance. That’s why who is selected for this highly privileged and challenging role is such a crucial decision. Unfortunately for many, a family member is often picked with little consideration of the ramifications for the individual and the family relationships and very little guidance for the parties involved.
Just Like A Circus
We invited one of our panelists, Hazel M, a transgender woman in her early 20s with a complex psychiatric history, to share her story about her parents being her guardians. She confirmed that similar to Britney’s account of her IUD situation, her parents needed to consent to her undergoing hormonal treatments to transition from male to female. She also discussed how even if one’s parents and the individual want to identify and appoint a new guardian who is not a family member, it is an uphill battle. One of our panelists, Prianka Nair, Esq. who is the Co-Director of the Disability And Civil Rights Clinic at Brooklyn Law School, echoed this sentiment and likened conservatorships to a “civil death”. There are hoops to jump through that can be expensive and if a suitable non-family member is identified, someone needs to pay for that person to serve in the guardian role for the duration of the arrangement. While Britney’s $60 million bank account can cover costs like that, for many people like Hazel and her family, this can be cost prohibitive. In my clinical psychiatric practice, I have encountered quite a few cases where guardianships are in place or are being considered. The vast majority of these fall into the hands of a family member despite us frequently recommending that not be the case as it can really lead to problematic family dynamics and forever alter relationships with loved ones. However, just as in Britney’s case, someone, usually a parent, ends up in that role like a tragic game of musical chairs.
But My Life Has Been So Overprotected
The many voices around the world chanting, tweeting and hashtagging #FreeBritney have played a major role in drawing attention to the plight of a vulnerable human being so many have admired for decades. The thing is that people who are vulnerable- to exploitation by others, to intrusive tabloids, and to the often mercurial forces of mental illness and other health concerns- do typically need some scaffolding in place to protect them. What could that look like in a case like Britney’s? While we don’t know all the details of her specific case, here are ten considerations for those who are directly involved from me- someone whose career as a psychiatrist has focused on helping individuals live to their fullest in their communities while living with significant mental illness:
Have a Neutral Third-Party as Conservator: If someone truly needs to be under a conservatorship/guardianship, the person(s) chosen as a conservator/guardian should NOT have significant personal or financial conflicts of interest in that role. A third-party known as a Professional Fiduciary who serves in this role as part of their routine duties for multiple individuals who is paid a fixed, modest amount is much less likely to create perverse arrangements than someone who stands to benefit from the proceeds of an estate or someone too close to the situation to see things objectively. Jodi Montgomery, for example, is a professional fiduciary and must abide by a code of ethics family members are not held to.
Default to the Least Restrictive Environment and as Much Autonomy as Possible: The person acting as a conservator/guardian should operate under the assumption that the least restrictive environment and conditions are the goal. Whenever the individual has capacity to make a specific decision about their health and body, they should be allowed to do so. This means the individual should be able to choose an attorney, a therapist, a psychiatrist, a gynecologist and so on and so forth that they like and trust. The treatment alliance is sacred. If someone gets on their knees and thanks God that their psychiatrist died, that is a red flag that we can and must do better by that individual to build a team of helpers that they trust.
Financial Guardrails Should Not be Draconian: The same is true of financial decisions. For example, if someone who makes millions of dollars annually wishes to get her nails done weekly and change the color of her kitchen cabinets, it’s hard to imagine a world in which a guardian should stand in the way. If someone hypothetically wanted to spend $150 million dollars on a dinosaur skull, pygmy heads and 2 European castles, that is a different threshold and different checks and balances can be in place at that level.
Arrangements Should Be Time-Limited and Reviewed:If a guardianship/conservatorship is in place, the burden of proof should be on the conservator's legal team to prove this arrangement is still absolutely necessary in an ongoing way. The default should be that these arrangements expire after limited periods of time and are not simply renewed unless the person under the arrangement contests it. I believe that this is the case in some states and has been my experience in NY but it seems in others they seem to just get rubber stamped and renewed indefinitely. There is no rule that someone must submit to a formal, lengthy and intrusive evaluation to end a conservatorship. Mental health and medical professionals who already know and work with the individual in an ongoing way can provide evidence and the court decides if the conservatorship should be terminated.
Everyone Needs a Health Care Proxy. Guardianships/conservatorships should be last resorts if other much less restrictive arrangements are deemed not effective. Notably, we have structures in place such as health care proxies where individuals collaboratively and proactively make decisions about their wishes should they find themselves in a state where they do not have capacity to make certain types of decisions. Everyone should stop right now and fill out paperwork to identify a healthcare proxy and a backup health care proxy if you have not already done so! Sometimes friends make better health care proxies than family members and on rare occasions even a doctor or therapist may be best suited for this role- it should be someone you trust and who has a good sense of what you want and the integrity to respect it if/when the time comes.
Psychiatric Advance Directives are Your Friend: If someone has a significant psychiatric illness that waxes and wanes episodically, something called a psychiatric advance directive can be a great way to collaboratively and proactively plan with someone what makes sense to enact for when they are in crisis. This can include everything from which hospitals are preferred (or to be avoided) to what medications have helped previously to the use of non-medication coping tools like weighted blankets when someone is in distress. They can also include conditional financial controls. For example, someone who is prone to excessive spending while manic can stipulate they want their credit limits changed or require a trusted individual to need to approve transactions above a certain amount if someone finds themselves in a state where they cannot make good choices around money. Psychiatric advance directives are underutilized in the mental health field despite being freely available, straightforward to create, great mitigators in a crisis and incredibly empowering for individuals living with mental illness.
Environmental Factors Should Support Recovery: People who are vulnerable to episodic mental health conditions need to be mindful of sleep, exercise, work stress, travel across time zones and other environmental factors that can influence the course of their illness. For bipolar disorder, for example, there is an evidence-based treatment called Interpersonal and Social Rhythm Therapy that helps people stay as much on track as possible and sometimes means people can rely less on medications with hefty side effect profiles. Of note, I am not aware of any evidence-based approaches for mental illness that involve working 7 days a week around the clock, constant performing in front of thousands into the late night hours with marijuana smoke wafting onto the stage and being responsible for the livelihood and experiences of a massive entourage. As a Harvard Medical School graduate, this “treat-patient-like-race-horse” approach must have been the ONE lecture I missed.
Assisted Outpatient Treatment Programs Exist For High Risk Individuals with Poor Insight : Assisted Outpatient Treatment (AOT) orders exist in many states, including California, as an alternative to more restrictive or sweeping arrangements such as involuntary psychiatric hospitalizations or conservatorships. These can place levers in place to ensure people follow outpatient mental health treatment plans around medication and therapy and minimize the use of involuntary commitments. These are still controversial and should be limited in use to extreme circumstances but do have a role to play in certain circumstances where the insight someone has into the high risks of their condition(s) is poor or non-existent. Of note, an AOT order could stipulate that someone take a certain medication but not, say, that they go on a grueling stadium tour or perform a certain dance move. Britney has stated she takes her medications as prescribed but for some individuals where conservatorships are being considered, this can be a major issue.
Establish Meaningful Community Integration and Support with A Trusted Team: The work we do at our practice, Brooklyn Minds, and the work of community integration programs like Ellenhorn, where I was the first NYC Medical Director, focuses on individuals for whom traditional mental health help has not been helpful. Indeed, traditional psychiatric care often has been harmful for them. Programs like ours use team-based approaches that prioritize autonomy, collaboration and trust over a false sense of safety sometimes afforded by involuntary hospitalizations and other coercive measures. One of our panelists, Rachele Vogel, PsyD., for example, runs a program in our practice called the Winnicott Program where we utilize peer coaches and companions to help people stay out of the hospital and on track with whatever goals they set out. We involve families as appropriate and also help people make and maintain healthy boundaries when relationships call for them. To me, this is simply good and humane mental health care. Sadly, much of our mental health and healthcare system is fragmented, myopic and runs on concerns around medicolegal liability so our approach is not the norm. We are biased but we think it should be and thankfully programs like ours and those who are part of the Association for Community Integration Programs are doing the hard work necessary to help people with complex mental health vulnerabilities and with amazing strengths and passions live lives full of meaning and connection.
If You See Something, Say Something. When legions of Britney Spears fans like our panelists Leanne Simmons from FreeBritney LA and Val Isabella who leads weekly rooms on Clubhouse took up the #FreeBritney cause, they did just that and continue to do so to the point outlets like the NY Times and the New Yorker and even bi-partisan politicians and the ACLU have taken notice. Fans, you have my attention now too and like Britney, I’m mad as hell about this and not going to take it anymore! Let’s continue to put our hearts, minds and voices to good use to help those around us who so desperately need to live their lives without undue interference from systems and forces who do more harm than good.
What are your thoughts on Britney’s plight? Let us know in the Comments and be sure to join us on Friday July 23rd at 1pm EDT on Clubhouse for part 2 of our #FreeBritney programming: “Toxic Celebrity Culture” featuring the author of Fragile Power and Healthcare Pros to The Stars exploring how we as a society co-create nightmarish situations for celebrities like Britney and the impact that has on our culture. The show link above contains invites to Clubhouse if you are not already on it. And with that, as they say on Clubhouse, I’m complete.
Thank you for leading the way with your team in creating systems that will actually take care of people!