The Need To Rethink Psychiatric Judicial Advocacy

In my brief time in residency, I’ve seen the impact of judicial cases extend from the courtroom to the hospital. I’ve cared for transgender adolescents in our emergency department citing lack of access to gender-affirming care as a condition of suicidal thought. I’ve met visiting fourth-year medical students using a state’s access to full-spectrum reproductive care as a major criterion of where to apply to residency following Dobbs v. Jackson Women’s Health Organization. Amid these deeply concerning effects, I have also seen how organized psychiatry, the professional groups that represent the collective interests of psychiatrists, play a crucial role in advocating for our patients and profession. In the courts, this advocacy takes the form of amici curiae (“amicus”) briefs, “friend-of-the-court” documents that psychiatric organizations use to provide additional expertise on the mental health consequences of court decisions.

As more judicial cases potentially affect patients’ mental health and the practice of psychiatry, APA and other psychiatric organizations have intensified their judicial actions. APA participated in 15 amicus briefs in 2022, compared with just five in 2012. Despite the increased efforts, this current approach to judicial advocacy faces notable challenges. The judicial advocacy process is less predictable than legislative efforts, which has led to struggles in setting clear goals, deciding which cases to support, and gauging strategy effectiveness. Additionally, surveying potential court cases is a daunting task, with federal district courts alone handling over 300,000 cases annually. Psychiatric associations lack formal judicial surveillance tools, and instead they rely on shared information from various sources.

Psychiatric organizations often collaborate with other advocacy groups for judicial advocacy. For example, after receiving a support request, APA recently participated in an amicus brief filed by the American Academy of Pediatrics on the need for evidence-based, gender-affirming care for adolescents. However, relying on cooperative efforts alone leads to missed opportunities, especially in lower-profile cases with potentially misaligned goals from other organizations. An example is the 2022 North Carolina Supreme Court’s decisions regarding involuntary commitment hearings. Here, an amicus brief was filed by various advocacy groups, including the National Association of Social Workers, without invited input from the North Carolina Psychiatric Association. While cooperation should continue, clarifying the process and roles of those involved in judicial advocacy may empower psychiatric organizations to participate in, or even spearhead, judicial advocacy efforts.

A successful judicial advocacy operation should engage psychiatric activists at every level, from national committees to practicing psychiatrists. Increased judicial surveillance by state/regional psychiatric associations in their jurisdictions, like the process for state legislation, could prevent missed cases. This process would also ensure initial vetting before being brought to their national organization. Whether through surveillance or support requests, national organizations’ judicial action committees must triage the level of advocacy required for each case based on their current resources and the advocacy’s organizational alignment. Some cases consider established policy positions, making the decision to support an amicus brief an easy one. However, more challenging decisions arise in cases without thoroughly established policy positions, such as those regarding involuntary commitment. It is the role of individual psychiatrists to help address which cases should be given support via amicus briefs. Psychiatrists can fulfill this role by engaging with the advocacy arms of their psychiatric organizations and sharing stories of how current policies or court decisions impact patients and practice.

In conclusion, overcoming challenges in judicial advocacy requires increased awareness and engagement from practicing psychiatrists and clearer expectations from psychiatric organizations. By doing so, organizations such as APA can more effectively navigate evolving advocacy demands and fulfill their obligation to advocate for psychiatrists and their patients. ■

Brody Montoya, D.O., is a second-year psychiatry resident at Cape Fear Valley Hospital in Fayetteville, N.C.