Reconsidering Involuntary Psychiatric Care: A Conversation with Rob Wipond (Part One)
This post is part of a series featuring in-depth interviews and discussions intended to foster a re-examination of philosophical and scientific debates in the psy-sciences. See prior discussions with Diane O’Leary, Richard Gipps, David Mordecai, Emily Deans, and Nicole Rust.
Rob Wipond is a freelance investigative journalist who became interested in mental health laws when his own father was forcibly treated. He writes frequently about the interfaces between psychiatry, civil rights, community issues, policing, surveillance and privacy, and social change. His articles have been nominated for seventeen magazine and journalism awards in science, law, business, and community issues, and he’s the author of the book Your Consent is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships (2023). He also volunteers and works with nonprofit groups that help strengthen social connections and mutual aid between neighbors in urban areas and multi-unit buildings.
Awais Aftab is a psychiatrist and clinical assistant professor of psychiatry at Case Western Reserve University. He is interested in conceptual and philosophical issues in psychiatry and is the author of this Substack newsletter.
Aftab: Let me start by sharing a personal mini-review of your book Your Consent Is Not Required. I found the book instructive, challenging, and eye-opening. It is well researched and offers a scathing critique of involuntary psychiatric commitment and treatment as it happens in North America. The book does a good job of challenging popular political narratives around the relationship between psychiatric hospitalization and incarceration and homelessness; it explores the expanding scope and utilization of involuntary commitment laws, the lack of transparency with regards to the implementation and outcomes, the lack of rigorous checks and balances, and, in what was personally most alarming for me, the ways in which psychiatric commitment laws are being abused and misused. One of the strengths of your book is that you are also interested in abuses of psychiatric powers beyond hospitalization, and the discussions around guardianship, schools, long-term facilities, and the weaponization of psychiatric commitment in the workplace and against protestors, whistleblowers, etc. are all quite important. In a democratic society, we need such critiques and investigative reporting, so I see your work as essential, and I’m glad that you and others are engaged in it. That said, I do have complaints. Your frank disapproval of psychiatric diagnosis and treatment in general and involuntary psychiatric care in particular makes for a rather polarizing narrative. The rhetorical style, while popular with psychiatric critics and psychiatric survivors, is likely to alienate a lot of people, including psychiatrists, mental health clinicians, and patients and families whose experiences with mental healthcare have been different. The book offers little to no discussion of the complexities of psychopathology and mental healthcare, and the factors that make involuntary psychiatric care a necessity for so many, and chooses to portray as negative a picture of psychiatric care as possible. If someone were looking to understand the clinical and ethical complexities of involuntary psychiatric care, this isn’t a book I’d recommend to them, but if someone were interested in understanding all the ways in which involuntary psychiatric care can and does go wrong, and the ways in which it causes harm, and the ways in which current systems are resistant to scrutiny, this is a book I’d recommend to them. While we have fundamental disagreements when it comes to psychiatric diagnosis and treatment and the place of involuntary psychiatric care, there is common ground when it comes to the need for checks and balances, for transparency, for scientific study of outcomes and alternatives, and the need to address abuses and harms.
So with that, let’s hear from you about your book, what you intended for it to accomplish, what you’d like the readers of this newsletter to know, and what are important takeaways for the psychiatric community.
Wipond: I’m encouraged to hear that you found value in the book, and that you really ‘got’ many of the issues and concerns I was trying to convey. My main goal was to draw attention to and help spur more public dialogue about psychiatric legal powers, and so I also appreciate you opening up discussion about the book with me.
I didn’t want to be “polarizing” or to “alienate” anyone, but I’ve accepted that these issues are immensely polarized, and it’s impossible to publicly discuss them without touching those cultural nerves. There’s not much that’s more inherently polarizing than the reality of some people detaining and forcibly drugging other people against their will. Consequently, these are the constraints we are in — as I imagine you know; for example, you can try to speak like the most diplomatic psychiatrist imaginable about why you think forced treatment is sometimes necessary, and some people will understandably still find that triggering, infuriating, or polarizing, right? But incidentally, I did not draw “as negative a picture of psychiatric care as possible.” If I’d wanted to do that, I would’ve chosen the most extreme examples and egregious abuses of mental health law powers I found; instead, with only some exceptions, I selected examples and stories where I could also verify that they reflected fairly common practices.
Another goal I had was to lift the voices and perspectives of the many, many people who’ve felt deeply harmed, and have objectively been seriously damaged by involuntary psychiatric treatment. These people are too often dismissed as collateral damage, silenced and ignored; and consequently, the general public has little understanding of the true scope and risks of mental health law powers. My book is an attempt to, in some small way, counter-balance the enormous deluge of positive promotional messaging about voluntary help-seeking and involuntary treatment that we’ve been hearing in media and elsewhere for decades.
Wipond: My book is an attempt to, in some small way, counter-balance the enormous deluge of positive promotional messaging about voluntary help-seeking and involuntary treatment that we’ve been hearing in media and elsewhere for decades.
I will say I’m not surprised that you found the book thin when it comes to addressing “the complexities of psychopathology and mental healthcare.” When I was pitching this book to agents and publishers, I explained, “This is not a book about ‘mental illness’ or ‘mentally ill people.’ This is a book about the expanding uses and abuses of psychiatric detention and forced treatment powers against a widening array of people across society.” The book focuses mainly on showing, contrary to the dominant public narratives circulating out there, that the legal criteria for detaining people in psychiatric institutions have broadened a lot, rates of psychiatric detentions across the United States and Canada have been rising for decades, and a shockingly wide and ever-widening spectrum of people are getting directly, personally affected—often self-reported as terribly negatively. So, if some pro-force advocates read and digest the book as simply an eye-opening collection of cautionary examples of the serious harms that not-uncommonly result from our current mental health laws—and how and why these can happen—then I’d see that as a positive impact.
And as I examine in the book, at this time we don’t truly know whether such harms befall a significant minority or rather a substantial majority of involuntary patients, because our large-scale monitoring of these practices is so poor—I think that’s important to publicly discuss, too, and it’s dismaying to me when pro-force advocates don’t share that concern.
Aftab: Treatment Advocacy Center has been working hard to promote a certain narrative around the availability of psychiatric beds and the high rates of individuals with mental illness who are in jails/prisons or homeless. What’s your assessment of this narrative? What does it overlook? What does it get wrong?
Wipond: Talk about overly rhetorical claims! Treatment Advocacy Center and the National Alliance on Mental Illness and countless journalists, mental health leaders, and politicians have been trafficking for decades in claims that state hospital psychiatric beds have decreased by 96% since the 1950s. They’ve used this to blame mass imprisonment and mass homelessness on “untreated mental illness,” and to push to expand mental health laws even more and increase funding and long-term forced psychiatric interventions. It’s disinformation, yet it’s driving social policy across the country right now.
First, every study that actually followed deinstitutionalized patients found that very few ended up homeless or in prisons, and most prison and homeless populations today don’t generally have higher-than-statistically-expected lifetime prevalence rates of mental disorders. Rising homelessness is mainly a result of economic policies. And mass imprisonment is in part the result of aggressive policing, including of people who are unhoused and struggle to simply sleep, find shelter, defecate, become emotionally distressed, or survive without breaking nuisance bylaws and prompting 911 calls.
Second, as I discuss in the book, and recently expanded on with new data in a more methodical analysis, we can’t understand and meaningfully discuss what happened with deinstitutionalization unless we include the psychiatric beds that were explicitly created to replace those 1950s asylums. When we add up the increases in psychiatric beds in private hospitals, general hospitals, assisted living facilities, supportive housing, group homes, etc. etc., then the actual per-capita number of psychiatric beds in America appears to be several times as many as existed in the 1950s. And that’s not surprising since, even adjusted for inflation, the nation is spending nearly sixty times as much on mental health care today.
This gives us a completely different view of what’s happening in mental health care: There has never been more funding, more beds, and more people getting either voluntary or involuntary mental health services—and yet the system is by all accounts still “in crisis.”
Wipond: There has never been more funding, more beds, and more people getting either voluntary or involuntary mental health services—and yet the system is by all accounts still “in crisis.”
Aftab: One factor to consider in the discussion around psychiatric beds is that unlike the 20th century, most inpatient psychiatric admissions these days in the US are of short duration, typically a few days, perhaps a few weeks, even for individuals who would like to stay longer (forensic settings are a very different story). For some individuals with more protracted needs that cannot be adequately managed in the community, this creates a revolving door of emergency visits and psychiatric admissions. So, I think you are right that we have more psychiatric beds now than we probably ever did; at the same time, our ability to provide for long-term needs for individuals with serious and persistent mental illness may be lower. I’m not trying to advocate that we should bring back the asylums! I think we need solutions grounded in community care. I’m just pointing out that discussions around the number of beds often don’t take into account the ability to care for patients with long-term needs.
Wipond: The shortening of the average duration of hospital inpatient stays is certainly true and relevant. But a lot of the other kinds of community beds today are long-term beds – such as nursing homes, group homes, supportive housing, and so on, where psychiatric treatments are provided and sometimes enforced. So my own suspicion, based on some evidence that I discuss in the book, is that the so-called “revolving door” syndrome you’re describing is largely caused by a variety of other factors. For instance, as I just described, there’s less affordable housing, combined with ever-more-aggressive policing of unhoused populations going on through urban-control bylaws, and these people are frequently being taken to both jails and psychiatric institutions based on quick, ad hoc judgment calls by police or others in the field. In addition, staff at many of these group homes, supportive housing facilities, and so on, both legally and quasi-illegally enforce treatment compliance and actively use calling police and sending people to psychiatric hospitals as a punishment/control tool for behaviors they find disruptive. This is likely why many detentions seem to last only a matter of hours or a day or so—because inpatient psychiatrists are disagreeing with police, group-home staff, community therapists, or others that these people even meet detention criteria. Now, that said, you and I both are unfortunately stuck with the fact that there’s been a widespread knee-jerk reaction to blame all of this on the patients themselves and the alleged severity of their illnesses and under-treatment, while there’ve been virtually no efforts to seriously study exactly what’s truly causing the “revolving door.”
Aftab: What are some policy implications of your work?
Wipond: The World Health Organization has started calling for the abolition of psychiatry-by-force, and I think the arguments for it are strong. But our society appears to be going in the opposite direction right now, so I would also point to other possible reforms that might get more public traction. If there’s one thing I advocate for most strongly, it is greater transparency. This is another place where I think you and I agree—and I honestly don’t understand why any thoughtful, caring psychiatrist would not agree. There are many ways that this idea can become embodied in policies: Better data collection, regular gathering of feedback from patients about their experiences, studying real-world outcomes of involuntary treatment, and sharing all this with researchers from different backgrounds and disciplines to review and comment upon, and publicly releasing reports on it all. Along with that, we clearly need more robust and independent accountability frameworks across the board—it’s simply too insurmountable most of the time to successfully get concerns about poor, unhelpful, or abusive involuntary psychiatric care addressed. This is especially important because involuntary psychiatric patients are often a very vulnerable population to start with, and even when not, the mental health laws put them in a very vulnerable position anyway. The risks of oppression and abuse in these situations are extreme. I would encourage all psychiatrists to stop reassuring themselves that this isn’t an alarming, pressing concern because they themselves are good, nice psychiatrists. Even if that’s true, if you can’t see the extreme dangers of these laws in the hands of largely self-regulating professions, especially without strong, clear accountability frameworks, then you are not looking. I’d also like to see the laws changed so that physicians and psychiatrists do not hold the ultimate decision-making power over all other types of practitioners and caseworkers. I’ve heard countless psychologists, counselors, social workers, and others complain that they believed they had a better understanding of a particular patient and what sort of help would work, and they were simply over-ruled by a psychiatrist—what about non-hierarchical interdisciplinary teams overseeing involuntary patient cases?
Wipond: If there’s one thing I advocate for most strongly, it is greater transparency. This is another place where I think you and I agree—and I honestly don’t understand why any thoughtful, caring psychiatrist would not agree.
Aftab: One of the topics we’ve had some public disagreement about is the role of psychiatric classification and diagnosis in involuntary commitment. From my perspective, your critiques of the DSM and lack of biomarkers etc. in the book misunderstand the relationship between diagnosis and involuntary care. You seem to think that anyone with a mental illness is potentially subject to “getting locked up in a psychiatric hospital” (because the mental health laws also reference mental disorders) and that changes in the DSM have enabled individuals to be psychiatrically committed who would not otherwise have been committed. From my perspective, it’s a bit like saying that anyone with a medical condition can potentially be found to lack decision-making capacity (sure, but that’s not how it works). Although laws usually mention mental illness as one of the prerequisites, in practice, it is not the presence of “mental illness” — the judgment that this person has a mental disorder — that makes someone a potential candidate for psychiatric commitment, but rather it is the presence of one or more features related to harm to self/others, grave disability, or clinical decompensation (depending on the jurisdiction and their laws). Instances of psychiatric commitment where these features of risk/disability are present but individuals are not mentally ill (in the legal sense) are the exception rather than the rule. We should also be careful to distinguish between the judgment of mental illness (the judgment that psychopathology is present, whether a specific diagnosis is offered or not), the descriptive features of psychopathology (delusions, hallucinations, suicidality, mood disturbance), and the formal DSM or ICD diagnosis. We should also distinguish between a correct legal understanding of “mental disorder” (how the law understands it) and clinical use of diagnosis, and we should also distinguish between the correct clinical use of a diagnostic label vs the power that label may have to bias the judge or jury, etc. This is an area where conceptual rigor is very important for a robust discussion, but I found very little of it in your book — other than usual laments about the lack of biomarkers, which the law neither mentions nor concerns itself with. How do you respond?
Aftab: Although laws usually mention mental illness as one of the prerequisites, in practice, it is not the presence of “mental illness” — the judgment that this person has a mental disorder — that makes someone a potential candidate for psychiatric commitment, but rather it is the presence of one or more features related to harm to self/others, grave disability, or clinical decompensation (depending on the jurisdiction and their laws).
Wipond: I think you and others raised a valid point — it’s important to distinguish, for the sake of clear discussion, between the definition of mental disorders in the Diagnostic and Statistical Manual of Mental Disorders on the one hand, and on the other hand how mental health laws typically refer to a “mental disorder” or “substantial disorder of the mind” without referencing the DSM. I wish I had addressed this in the book more clearly. That said, I’d just be clarifying, not changing, what I was trying to point out in the book. Basically, my point is, the fact that some 50% of children have allegedly had a DSM-defined clinical mental disorder already before the age of eighteen, and 70-80% or more of us by adulthood, vastly opens the funnel into detentions for many people. The widespread labeling and associated prejudices about mental disabilities together function as a social funnel pointing towards and into psychiatric services and institutions. (You’ve correctly pointed this out in your own writing, that people labeled with mental disorders are more likely to be forced into institutions for psychiatric evaluations and detentions and suffer mental health laws being “weaponized” against them.)
You counter-argue that “Although laws usually mention mental illness as one of the prerequisites, in practice, it is not the presence of ‘mental illness’ – the judgement that this person has a mental disorder – that makes someone a potential candidate for psychiatric commitment, but rather it is the presence of one or more features related to harm to self/others, grave disability, or clinical decompensation.”
But you are describing here step two in the clinical and legal evaluation for commitment, not step one. Step one is, the person is suspected of having, or is labeled as having, a mental disorder or substantial disorder of the mind—as you state, this mental disorder is a “prerequisite.” Then, step two in law is, the danger to self or others or degeneration is said to be occurring as a result of, or caused by, that mental disorder. Granted, in the fine print of the law, the legal definition of mental disorder is not literally, not exactly the same as being labeled with a DSM mental disorder. But in actual practice, the two are almost always conflated—so much so that certain DSM labels, such as schizophrenia or bipolar disorder, are often at commitment hearings simply assumed by psychiatrists and judges to be linked to increases in the likelihood of future degeneration, violence, non-compliance, and so forth. By way of illustration, there’s a case in my book where an attorney has to pressure a psychiatrist to put aside his own generalizing prejudices about “bipolar disorder,” and determine whether he has evidence that the woman actually in front of him is actually herself at serious risk. And we have the current example where California has now explicitly made the DSM diagnostic class of “schizophrenia and other psychotic disorders” the key step-one legal criterion in compelling people into their new coercive Care Court system. DSM diagnostic labels are legally powerful—even though, as we’re both saying, they actually should not be.
Conversely, any ordinary person can be a danger to themselves, but not become subject to mental health laws. We expect that nobody can lock us up and forcibly sedate us for simply engaging in risky activities—even if the particular activities might likely lead to loss of jobs, ruptured relationships, illness or death. But once I’m labeled as having a mental disorder, those same risky activities become a key issue in step two of the commitment process. A prime example is “poor self-care”—we can’t lock someone up simply for not cleaning, eating well, or dressing appropriately for the weather. But once the person is labeled with a mental disorder, disregard for such self-care is written right into some mental health laws as a criterion for forced treatment. This is why legal experts call mental health laws discriminatory—these laws have created a second set of rules and diminished citizenship and lesser rights for people labeled with mental disorders or mental disabilities.
And please don’t dismiss the relevance of the lack of biomarkers here—if we had laws that compelled people into invasive neurological treatments but didn’t require as a prerequisite clear biomarkers for neurological diseases and instead merely indications of serious illness or distress that seemed somewhat like symptoms of certain neurological diseases, responsible doctors would be the first ones to protest those laws, wouldn’t they?
Aftab: Any law that doesn’t recognize the reality of mental illness, psychopathology, poor mental health, whatever you want to call it, is discriminatory in its own way because it fails to recognize the existence of impaired individuals who require our collective help.
Aftab: It is important to be aware of the biases involved in and resulting from a diagnostic label, and I don’t disagree that some risky behaviors that we otherwise tolerate become a basis for involuntary care in the context of mental illness. I worry, however, that those who see mental disorders as mere labels fail to see the psychopathology and the impairment that the labels are trying to capture. At a certain point, poor self-care, e.g., becomes so profound that it isn’t necessary to impose any kind of label on it; any reasonable observer is able to recognize that the person is not well. Any law that doesn’t recognize the reality of mental illness, psychopathology, poor mental health, whatever you want to call it, is discriminatory in its own way because it fails to recognize the existence of impaired individuals who require our collective help. With regards to diagnostic biomarkers, it’ll be great if we had them in psychiatry, but the state of science is what it is, and medical decision-making and associated laws have to be based on our current best clinical and scientific understanding of things. I’ll also point out that widely accepted ethical and legal standards of decision-making capacity across medicine do not require the existence of biomarkers, and objections to involuntary psychiatric treatment based on a lack of biomarkers have no grounding in medical ethics.
Wipond: I agree with a lot of what you’re saying here, but I would word it differently…
[To be continued]
This conversation is concluded in Part 2.
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