Asking better questions about involuntary psychiatric care
Acknowledging the necessity of involuntary care allows many to be complacent about the status quo
It is tiresome to see people discuss the same question over and over: is involuntary psychiatric commitment and treatment necessary? People have strong and polarizing opinions on this. My own view is that the answer has to be: yes, under certain circumstances. I cannot see how it can be otherwise. However, simply acknowledging the necessity of involuntary care permits many to be complacent about the status quo, to shrug at the harms and say “it is what it is.” No one should be complacent. I say that as a clinician at the coalface making these difficult decisions. We may be doing the best we can under the circumstances, but this doesn’t absolve us of our collective responsibility to try to change the institutional and social structures for the better. The polarizing attention devoted to whether involuntary psychiatric care should or should not exist distracts us from questions that are more important and of greater practical and ethical relevance. This post is my attempt to highlight some of these questions, and by doing so, disturb the sense of complacency that is commonly encountered.
(When I use the “we” and “our” pronouns in this post, I’m referring to the community of psychiatrists and mental health professionals as well as the society at large, including psychiatric patients, their families, mental health advocates and activists, politicians, and legislators.)
1. It is clear that many patients are helped by involuntary psychiatric hospitalization, and many patients and families see a necessary role for it. It is also clear, however, that some individuals have terrible experiences with involuntary psychiatric care, to the point that these experiences are at times described as the most traumatic of their lives. A place of healing should not leave anyone scarred for life like this. For a substantial proportion, the outcome of involuntary psychiatric treatment is not gratitude, but a long lasting fear and distrust of the mental healthcare system. What should be our response to such testimonies of harm? What is our ethical responsibility to such individuals? What is it about psychiatric hospital that some patients are traumatized in this manner? What can we do to prevent such experiences in the future?
2. Many people say that involuntary care is a “necessary evil.” If that is so, should we not be interested and invested in ensuring that it happens as infrequently as possible? Why is there little interest in, or demands for, the investments in community care and other forms of crisis care that would allow this necessary evil to be necessary less frequently?1
3. Why is it that national and state data pertaining to involuntary psychiatric admissions and treatments are so difficult to obtain? Why is current monitoring of involuntary psychiatric care so poor, the processes so opaque to scrutiny? Why is there little to no interest amongst relevant agencies and officials to track and record even basic information such as rates of involuntary hospitalizations and treatments, let alone patient outcomes? What are the sources of resistance? What needs to happen for this to change? How do geographical variations in rates of involuntary care relate to outcomes such as recovery, engagement in mental health services, suicide, and mortality?
4. When patients are being treated involuntarily, how should patient concerns regarding serious adverse effects of psychiatric medications such as tardive dyskinesia and metabolic disorders, as well as impairment resulting from effects such as sedation and neurolepsis, be taken into account? How can a patient say, “No, I do not want this medication because the adverse effects are not acceptable to me” and be heard? And if patients do develop serious or long-lasting adverse effects from forced use of medications, who is responsible for that?
5. How can we prevent sociopolitical abuses of involuntary psychiatric care? Politicians have not been shy about wanting to use psychiatric hospitalization as a solution for homelessness and criminalization of mental illness. How can we ensure that such abuses do not take place? What means are at our disposal to do so?
6. In the US, for a court to order involuntary psychiatric commitment, there needs to be clear and convincing evidence of the existence of mental illness and associated risk/harm/disability. However, for a person to be involuntarily taken to the emergency room or to be admitted to a psychiatric hospital for observation and evaluation (usually up to 3 days), the bar is much lower, and authorized individuals (such police officers, social workers, etc) with a “reason to believe” may initiate the process. Even if the person is released within days or even if this doesn’t lead to a successful petition for involuntary commitment in the court, this is nonetheless a significant disruption in one’s life, with consequences for one’s relationships, one’s responsibilities, and one’s employment. Given the low bar and the subjective nature of the concerns, the process can be, and at times, is easily misused. Individuals with a history of mental illness are particularly vulnerable to this – their family members, their spouses, their exes, their bosses, anyone can weaponize it against them because their testimony is treated as more credible than that of individuals with mental illness. What is our responsibility here? How can we safeguard against such misuses? What recourse do the victims have?
7. Psychiatric hospitals are currently optimized around considerations of risk and liability (and bureaucratic needs of accrediting institutions). This is reflected in their architecture, furniture, layout, admission processes, nursing monitoring protocols, privileges, etc. What would it mean for psychiatric hospitals to be optimized instead for the therapeutic benefit and psychological well-being of patients? What would it mean for psychiatric hospitals to be optimized to ensure autonomy, comfort, dignity, and social connection for patients? How different would the hospitals look? What would be needed to accomplish that?
8. Is it ethical for suicide hotlines to hide the fact from users of the service, or to not be transparent about it to the users, that there are limits to privacy, and that the police or emergency services may be contacted without their knowledge or permission should the person on the other side of the line feel uncomfortable about their safety? We may very well be justified in calling the police or emergency services, but don’t people have a right to know in advance that this could happen?
9. If a psychiatric patient lacks decision-making capacity, the doctors and the courts get to decide for the patient using a “best interest” standard. This mean that a person with mental illness who, when they were competent, has expressed a clear wish to not be treated with certain psychiatric medications forcibly should they lose decision-making capacity can nonetheless be forcibly treated when they do lose decision-making capacity. What would it mean instead to decide, in situations of incapacity, according to an individual’s will and preferences that were expressed when they were competent (and where unknown, the best interpretation of their will and preferences)? Is lack of decision-making capacity the real justification for involuntary treatment, or is it merely an excuse, and the actual drivers are considerations of risk and control?
10. Why is voluntary inpatient psychiatric care so scarce in countries such as the US? Why is it that in order to be voluntarily treated, individuals have to be subjected to the same restrictions that are imposed on those being treated involuntarily? Why are there no accessible open-door units? Why are discharges against-medical-advice not allowed for psychiatric patients who are there voluntarily?
11. A major reason for involuntary psychiatric hospitalization is to prevent suicide. But does it actually do that? Does it actually prevent suicides? Where is the evidence that it does?
(Marsha Linehan, the developer of Dialectical Behavior Therapy, writes in Building a Life Worth Living: A Memoir: “I often found myself tangling with psychiatrists, who made my life difficult. When I went out of town for the weekend and one of my clients had some kind of suicide crisis, the first response of psychiatrists was to admit them to a hospital. There are no data that show that hospitalization saves lives or is useful in any way with suicidal people. I believed then, and still do, that in the majority of cases, suicidal clients do just fine in outpatient treatment.” (p188))
12. It may very well be the case that if there are more psychiatric beds, more people with mental illness arrested by the police can be diverted to psychiatric hospitals instead of jail. But lack of beds doesn’t explain why these individuals are arrested in the first place. It doesn’t explain why they lack access to food, shelter, and transportation, and why they are living in circumstances that make them vulnerable to worsening mental health and increased policing. Could it have something to do with the fact that countries such as the US have increasingly made food, shelter, and transportation inaccessible to large swathes of the population? If so, what should our sociopolitical response be to this realization?
13. What would it take for us to actually care about the suffering and well-being of individuals with serious mental illness? To care about them, their hopes and their dreams, the traumas they undergo, and their potential as human beings deserving of our compassion and love? What would it take for us to give a shit?
Two books I’ve found quite thought-provoking on this topic are Committed: The Battle over Involuntary Psychiatric Care by Dinah Miller and Annette Hanson and Your Consent Is Not Required by Rob Wipond. A post discussing the two books is in the works.
See also:
I’m not talking merely about psychiatric admissions; the standard response to reducing frequent psychiatric admissions in individual cases often involves more prolonged forms of coercion and control in the community, such as guardianship and outpatient commitment.
These are excellent questions. I was the person who made the call that resulted in an involuntary commitment for my best friend; I don't doubt that was what was needed at the moment. But the problem is that call resulted in a years-long odyssey through an institutional system that refused to listen to him, that devalued his own opinions about what he needed and why. He was compelled to take medication against his will, when he was lucid and knew exactly what was being done to him. The delusional episode lasted a short time, but the removal of his autonomy lasted for years and years. The problem is that it is impossible to achieve psychiatric recovery without wanting to recover, and if you're spending all of your time embittered about being involuntarily committed, you're unable to take charge of your own care and advocate for what you need for your own recovery -- you're stuck in a stew of resentment that is therapeutically counterproductive.
This was a great read.
I think that people who have never themselves been on psych meds, or if they have, never had any particularly adverse side effects, tend to SERIOUSLY underestimate how bad it can be.
I was on Haldol for many years and did fine. Eventually, though, the pills began losing their desired effect while I got more and more adverse side effects. I would get slurred speech because I couldn't quite control my tongue movements, like my tongue felt thick and sluggish, and I got more and more facial ticks. I tried Abilify instead but it just knocked me out, I just slept and slept (even on a pretty low dosage) (I know this isn't a very common Abilify side effect, but it's still a known one that some people get), and decided that Haldol was less bad all things considered. Stil very bad though - as we say in Sweden, like choosing between cholera and the plague.
Eventually, as I've written about in numerous publications now, I learnt to manage medication-free (though that would certainly not have been possible unless my entire life situation had become very stable and idyllic).
As antipsychotic side effects go, mine were still on the mild side. Yet, if I imagine someone FORCING me to continue taking either Haldol or Abilify, that scenario is HORRIBLE. Absolutely HORRIBLE.
I think most sane people realize that it would be horrible FOR THEM if someone forcibly drugged them, day after day, and they suffered badly from the drug but it was still forced upon them. But they somehow can't transfer that insight to the mad, who are seen as a different class of people, and therefore what's forced upon us can't possibly be as bad as if someone did the same to a sane person.
Kantian philosopher Christine Korsgaard wrote about the following phenomenon in her book Fellow Creatures: We all have a vicious tendency to implicitly assume - even if we'd never explicitly SAY as much, or even explicitly THINK this to ourselves - that when people (or animals) who are unlike us are mistreated and made to suffer, it's bad, sure, but it can't possibly be AS bad as if the same thing happened to US. I think she's absolutely right in this, and it's a huge problem.
I've talked to this person who's suffered so, so horribly from medication side effects, and who said that she really wished there were a kind of inpatient treatment where you could check yourself in when you realize a psychotic episode is on the way, but you wouldn't have to go on meds. You could just stay at the ward with nice and calm nurses watching over you until you calmed down again and was fit to re-enter society. But unfortunately, there is no such service, and for that reason she has seriously contemplated suicide. (Now she's trying other strategies and solutions, I hope for the best, but - WHY is there no such option? WHY?)