Reconsidering Involuntary Psychiatric Care: A Conversation with Rob Wipond (Part Two)
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.
Read Part One of this discussion here:
Wipond: I agree with a lot of what you’re saying here, but I would word it differently: The mental illness diagnostic labels are the problem, because they are hiding something under a false sense of knowing. And that false knowing leads to a plethora of other problems, such as claiming we then know how to solve or cure it, and then passing laws that authorize imposing this alleged cure on a person and blaming the person as being “treatment-resistant” or “severely” mentally ill when the treatments don’t help much if at all, and so on. So, let’s put aside psychiatric labels and describe what we actually see. In this case, you’re describing a person who appears to be physically unwell and is making choices or not making choices that make him more physically unwell. Okay; if we truly want to help this person, how do we help? Well, it seems to me that labeling him as schizophrenic, or depressed, or OCD, or as having a substantial disorder of the mind, or whatever, isn’t advancing anything, except sending him and us down a particular track without good evidence. Let’s back up, and do our best to collaboratively figure out with this person what food he might like, what kind of shelter might work for him, what sort of decisions and practical activities he might appreciate having help with, and so on. Maybe that involves offering psychotropics, too. Let’s figure out how to reduce the suffering the person may be experiencing. It's called supportive decision-making, and that’s what most disability advocates think should happen in all questions of competency, rather than draconion on-off switches for all of a person’s basic rights.
In that context, I would challenge your assertion that “involuntary psychiatric care” is “a necessity for so many.” While I can readily imagine arguments for temporarily stopping people from certain actions under certain circumstances, that’s a simple policing action. But in my research I’ve not found any good studies showing involuntary psychiatric interventions help more than they harm, and I’ve not seen anyone personally for whom ongoing administration of psychiatric interventions against their will, such as powerful antipsychotic tranquilizers with their potentially terrible adverse effects, was “a necessity.” I’m not even sure what you mean by “a necessity.”
Aftab: By necessity I’m referring to something quite practical. In our societies as they are currently organized with the sorts of resources we have available right now (and not in some future, hypothetical utopian society), there are situations where someone’s behavior in a state of mania or psychosis is so altered and their judgment is so impaired that it exceeds the ability of their family and friends to care for them and it either puts them in harm’s way or leads to public disruption. In the foreword to Miller and Hanson’s book Committed, Pete Earley talks about his son who became psychotic, and started roaming the streets for days without sleep, believing that God had ordered him to undertake a divine mission, and disregarding his family’s entreaties. He eventually broke into a stranger’s house and was arrested by the police, leading to his psychiatric hospitalization. In this newsletter, in comments on various posts, Joseph Meyer has shared the story of his child’s psychosis and the necessity of involuntary care. Families and many patients are quite aware of this and will tell you if you ask them. To share snippets of the sorts of situations clinicians see: someone with persecutory delusions who is tearing down their house searching for the devices that are releasing poison into the house; someone has barricaded themselves into their room because they believe that they are being targeted by a Martian satellite; someone who is repeatedly threatening the neighbors because they believe the neighbor is spying on them with cameras; someone who runs away from the house because they believe that their family members have been replaced by imposters; someone who tried to hang themselves unsuccessfully and are now in the emergency room, and remain profoundly depressed and suicidal, etc. It is also the case that when someone is acutely impaired due to mania or psychosis, and they do not recognize that they are in such a state, psychiatric medications are one of the few things you can use to ameliorate that state, somewhat reliably, in a matter of days and weeks. There is no question that over the short-term benefits outweigh harms for most people, and the vast majority of involuntary use is short-term. (It gets more complicated with long-term use, but for many people on-going use of psychiatric medications offers the best chance of controlling their symptoms or reducing their risk of relapse, and in those instances, the risks and benefits have to be weighed on an individual basis, which often doesn’t happen in practice unfortunately. My own view is that involuntary long-term use, such as in outpatient commitment, should be very rare.) I think when activists and journalists such as yourself adopt the view that involuntary treatment is (almost) never necessary, you are so disconnected from the experience of patients, families, and clinicians that they write you off as idealistic or misguided, and then they have little reason to pay attention to the important things you have to say on the topic. At the same time, we have the other problem that there are many clinicians (and families and activists) who are so complacent about the traumatic nature of involuntary care or the ways it is abused that they too become disconnected from the experience of patients and families. Which is why I acknowledge the necessity of involuntary psychiatric care in some circumstances while advocating that we should work to reduce it as much as possible by expanding voluntary care and developing community alternatives (à la Trieste) and that we should work to make the inpatient experience as humane and therapeutic as possible.
Aftab: I think when activists and journalists such as yourself adopt the view that involuntary treatment is (almost) never necessary, you are so disconnected from the experience of patients, families, and clinicians that they write you off as idealistic or misguided, and then they have little reason to pay attention to the important things you have to say on the topic. At the same time, we have the other problem that there are many clinicians (and families and activists) who are so complacent about the traumatic nature of involuntary care or the ways it is abused that they too become disconnected from the experience of patients and families.
Wipond: The challenge is, I don’t know any psychiatrist or indeed anyone else who argues against reducing involuntary care “as much as possible” to only cases where it’s a “necessity,” while making it more “humane.” Everyone says what you’re saying—except those who want forced psychiatry abolished completely. Nevertheless, the opposite is happening. As I show in the book, for decades rates of force have been rising, and force is being used on ever more diverse people in an ever wider array of situations. And it’s usually not as inhumane as in the 1950s, but it’s often not a whole lot better, either. So what’s going on?
Well, I believe that part of what’s going on is the rest of what you’re outlining in the above response: You’re defending very limited uses of involuntary treatment, but because you’re using a lot of conversational shorthand at key points, it ultimately has the effect of broadly promoting forced treatment—in spite of your stated intention. And while we all naturally, inevitably use conversational shorthand at times—I do, too—it’s far too common and especially pernicious when being used to rationalize taking away others’ most basic freedoms and bodily autonomy.
Wipond: You’re defending very limited uses of involuntary treatment, but because you’re using a lot of conversational shorthand at key points, it ultimately has the effect of broadly promoting forced treatment—in spite of your stated intention.
For example, most people think of “necessity” as a need—like humans need food and water for survival. So, when you said involuntary treatment with psychotropics was often a “necessity,” without any clarifications or qualifications, I asked you what you meant; to me, it’s nonsensical to compare physically toxic chemicals to food and water. You clarified that what you meant was something that could be more accurately summarized as ‘in certain cases of extreme individual suffering amid problematic, oppressive social contexts, a psychotropic drug may sometimes be somewhat effective in the short term for helping someone feel a little better or more functionally capable or become easier to care for by their family.’ I agree with that! I discuss that perspective in my book. And to be a little more balanced and accurate, we should add the further clarification that, even for this person, even in the short-term, the experience of force and the numbing sedation and adverse effects of these drugs may still be extremely distressing and damaging. And it’s very likely that the small, drug-related ‘good’ could have been achieved voluntarily and without security guards and restraints with a little more patience and relationship-building between the prescriber and patient—especially if that patient didn’t already have a history of being brutalized in psychiatric care.
But many pro-force advocates don’t say any of this in the public sphere, they say things like, “Involuntary treatment is sometimes needed and psychotropics are safe and effective.” By that point, it’s so far from factual that it’s like a manipulative, sensationalist news headline. And it’s polarizing in its own right. Knowledgeable critics hear that kind of shorthand from psychiatrists or others and they can’t help but wonder if they are being deliberately deceptive or if they are ignorant of the treatment studies and the experiences of those who have been forcibly treated. So, collectively, we need to speak a lot more honestly and accurately about what forced treatment actually involves, and what the impacts are—and what’s mainly been missing in public discussions are the limited effectiveness of treatments, the serious adverse effects, the suffering, the damages, the backlashes, and the lifelong trauma that can result.
You also sketch pictures of people barricading their homes against Martian invasions and such, and say that these people lack insight into their “state,” that psychotropics can restore insight, that psychotropics are the only reliable tool for helping and clearly do help, and so on. Well, all of this is also shorthand, right?
These are your opinions, based I presume on your clinical experiences and conversations with others and studies of voluntary patients—but it’s again important to be clear that there are actually no good, reliable scientific studies showing that forced treatment does any of those things. There are barely any studies of involuntary treatment at all, and there’s also no organized, real-world outcome tracking and reporting going on in mental health systems. There’s no clear, consensus scientific definition of ‘lack of insight’; it’s just loosely characterized in the literature as strong-minded people who disagree with their psychiatrists’ diagnoses and treatment recommendations—and that’s how it’s generally understood in clinical settings and at hearings, too. And that’s why most patients quickly learn they’re far more likely to win their freedom back sooner if they simply behave as they’re told for a while and manage to convince the psychiatrists and judges that they now agree that they have mental disorder X or Y and that the drugs are helping them.
Meanwhile, if we expand on any of these shorthand anecdotes about cases—these kinds of anecdotes which are often pulled out in public debates and to me sound too much like dehumanizing caricatures—what might we find? I’ve interacted with many people like those you’re describing and I always—not sometimes, not most times, always—find that there’s much more to it than the wacky-seeming ‘symptom.’ For example, most modern homes are so fully constructed and decorated with hazardous materials that they’re literally rotting into toxic dumpsites and off-gassing poisonous fumes by the day as we’re living in them—some of which can cause serious psychiatric symptoms, incidentally. Did anyone offer to help more methodically investigate the types and amounts of the poisons in that man’s home, or did they just pathologize his frantic reactions? And it turns out the barricaded man is an immigrant war refugee whose entire family was killed, and last week there was a gang shooting on his street and there are now low-flying police helicopters surveilling the neighborhood disturbing his normal sleep hours while he’s been battling a chronic illness with no health insurance, and he wasn’t anyhow bothering anyone with his temporary barricade except the neighbors who are somewhat racist and called 911 instead of warmly encouraging him to join them for dinner. And then the sight of armed, uniformed police triggered horrifying flashbacks, and so by the time the man got to hospital, he seemed completely gone, and as the days dragged on the barred hospital windows and uniformed staff became for him a source of unspoken, unremitting terror… Okay, now we understand this man’s situation a lot better, and the opportunities for connecting, for helping, for calming, for change, seem much more varied. He’s not permanently and completely out of touch with reality; he’s simply been pushed to an extreme state. What are some of the pathways to help him find his way back?
Wipond: This is probably partly why you felt my book did not deal well with the “ethical complexities of involuntary psychiatric care”—because I don’t think involuntary psychiatric care is ethically complex, I think it’s bad.
This is probably partly why you felt my book did not deal well with the “ethical complexities of involuntary psychiatric care”—because I don’t think involuntary psychiatric care is ethically complex, I think it’s bad. I see forced psychotropic drugging and forced electroconvulsive therapy as blunt hammers smashing down on complicated circumstances and complex brains. And it’s hardly only me pointing this out. The World Health Organization has studied non-coercive approaches to helping in even these kinds of extreme cases, and issued guides based on working models from around the world for every stage of the involuntary intervention process from crisis to long-term care. Institutions that are actually friendly, inviting, and non-threatening to stay at, peer-run respites and retreats, Open Dialogue, arts engagement, outdoor activities, nurturing communities, availability of non-drug therapeutic options, non-hierarchical supportive group housing, to name just a few. And that doesn’t even get to the wide array of powerful, non-drug approaches to psychoactivation and inner transformation that many people in extreme states are much more willing to try, if offered, than psychotropics. Tell them they’re going through a powerful transition period of their lives and you want to support their process to be as safe as possible, not that they’re mentally ill and that what’s happening must be suppressed at all costs, and watch how much easier it often is to establish a working relationship. Sure, none of these work for everyone all of the time, but they’re reasonably effective, and without any of the trauma and damages of forced psychiatric treatment. And these approaches are hardly utopian—they’re often cheaper than our current approaches.
Aftab: Your response highlights how fundamental disagreements about the existence and nature of psychopathology intersect with debates about involuntary treatment. I can see how someone with your views on the nature of psychosis (and associated phenomena such as lack of insight) would see involuntary psychiatric care as plainly and unequivocally bad because it is unnecessary to begin with – were it not for the pathologization and the control of behavior, there would be no need for it. For me – and I imagine for most mental health professionals and many patients and families – the reality of psychopathology transcends the labels we use to describe it and the necessity of care is blindingly obvious. The dilemmas arise because we have to ethically balance autonomy and beneficence in situations where a person’s judgment is extremely impaired and the tools we have at our disposal are imperfect and capable of harm, and the optimal strategy would be different in different social arrangements. That is why I see improving social arrangements to be the key to reducing coercion in mental healthcare. There are individuals who are profoundly unaware of the drastic alterations in their own behavior or of how divorced their perceptions and thought have become from the perception and thoughts of the people around them. Any paradigm of care has to take that into account. Insight isn’t really about disagreeing with a diagnostic label and proposed treatment, although it may superficially seem that way. If you say that lack of insight is a clinical judgment, so there is an inherent subjectivity to it, it is vulnerable to bias, and it can be corrupted by power dynamics, I’ll agree with you. But if you were to say that there is no reality to lack of insight other than the fact that clinicians use it as a label for people who disagree with the diagnosis and the treatment recommendation, I’ll object (I’m mindful that you haven’t explicitly made such an assertion). I don’t think that psychosis is purely a state of deficit, a brute physical symptom without meaning or significance that should always be suppressed. On the contrary, I think psychotic symptoms are rich with meaning and connections to one’s life and psychological development in complex ways that can be productively analyzed, and I’m quite sympathetic to movements such as the Hearing Voices network. But all that coexists with the fact that a state of delusion is a state of deep disconnect from our shared reality.
Aftab: The dilemmas arise because we have to ethically balance autonomy and beneficence in situations where a person’s judgment is extremely impaired and the tools we have at our disposal are imperfect and capable of harm, and the optimal strategy would be different in different social arrangements.
It is interesting to me, for example, that the anthropologist Tanya Luhrmann has to go out of her way in her book Of Two Minds to insist on the reality of mental illness, while acknowledging that “how” we look at mental illness cannot be clearly separated from the “what” of the illness. She writes: “Madness is real… Most people who end up in a psychiatric hospital are deeply unhappy and seriously disturbed, and many of them lead lives of humiliation and great pain. To try to protect the chronic mentally ill by saying they are not ill, just different, is a misplaced liberalism of appalling insensitivity… It is hard to describe, to someone who has never seen it, how terrible and intractable madness often is.” Delusions are not reasonable concerns, say about environmental toxins, expressed in an idiosyncratic way. As the philosopher and psychologist Richard Gipps puts it, psychotic thought is “not simply puzzling but deeply disturbed – and deeply disturbing.”
I doubt that any movement to end involuntary psychiatric care that doesn’t appreciate the impairment of insight and judgment that often accompanies severe mental illness will be successful. On the other hand, I respect and admire those who recognize the reality of psychopathology, and the necessity of care for those in an impaired state, and the hard work that is needed to creatively work with people in such states in a non-coercive manner. Consider the mental healthcare system in Trieste, which is also recognized and lauded by the WHO; here’s a description of how they handle acute psychosis from a 2019 online piece:
“When someone has a psychotic episode in Trieste and there’s a call for help, it’s usually a mental health team that responds, not police, and the team often has already built a relationship with the client. At one mental health center we visited, a nurse described a recent event in which she responded to a distress call and spent seven hours with a patient who eventually agreed to come in for help.
The doors of community mental health facilities are not locked in Trieste, and we were told that if patients choose to leave, staff members follow them to make sure they remain connected to help.
Psychiatrists at one mental health center said they had only five cases of involuntary commitments last year. It happens rarely because when people have easy access to regular help and begin to know and trust care providers, they’re easier to treat, and not as inclined to have their conditions deteriorate, or to resist therapy or medication that might help.”
Do you think Trieste has diagnoses validated by biomarkers, or has antipsychotic medications that are safer and more effective than we have in the US, or that psychiatrists in Trieste don’t talk about people lacking insight? They have the same diagnoses, psychiatric terminology, and medications as we have. Apparently, compliance with antipsychotic medications is reported to be high in Trieste due to the quality of therapeutic relationship and social network enhancement. Possibly Trieste is as good as it gets with the current state of science – but in order to spend hours convincing a patient to come in for help and to follow them around to ensure safety if they leave the facility in an acute crisis, you have to begin with the fundamental recognition that the person is unwell. You can’t do that if you think that delusions are merely misunderstood quirky beliefs, that to consider people mentally ill is to pathologize them, that diagnoses are spurious, that treatments are ineffective and harmful, and terms such as insight have no reality other than as instruments of clinical power. You can’t have Trieste – and the massive investments in community care and crisis care that it requires – while believing all those things.
You are an excellent advocate for harmed patients. If I were someone harmed by involuntary psychiatric care – and if your book does one thing, it conveys the visceral appreciation that it could be any one of us on an unlucky day – I’d look up to you as a champion of my rights as well. I’m glad that you do the work you do. At the same time, I think you have a particularly negative assessment of psychiatry that colors everything you say about involuntary psychiatric care. I don’t expect to persuade you – we don’t change our minds so easily! I also don’t want to pretend that I have offered any knock-down arguments against you; I haven’t. These are complex matters and I’m glad that we are having this exchange. My hope in saying all this has been to clarify why people like me are not fully persuaded by what you have to say. We are trying to communicate across a gulf, a gulf created by the anger and distrust that coercion leaves behind in its wake, but also a gulf that separates two very different conceptions of the reality of mental illness.
I do agree with you that simply talking about the necessity of involuntary treatment and remaining silent about all the ways in which involuntary treatment falls short and harms – as many of my psychiatrist colleagues do – only leads to an expansion of involuntary care. That is not the outcome I desire. I want us all to recognize these harms and I want us all to do better. More fundamentally, I want us all to care deeply about the lives of individuals with mental illness and create a society in which they can flourish.
Wipond: I readily acknowledge that intense, profound, and/or unusual mental and emotional suffering happens, and that truly helping someone who’s in a deeply distressed or disconnected mental state can at times be very challenging and demanding. I’m simply saying that it’s a big, unproven leap to go from there to something like, “This problem is caused by mental illness and requires psychiatric interventions whether the person likes them or not.” More accurately, as you write, “the tools we have at our disposal are imperfect and capable of harm” and “the optimal strategy would be different in different social arrangements” and improving social arrangements is “key to reducing coercion” — I agree with all of that. I’ve also seen that certain aspects of people’s thinking or behaviors can become distorted or impaired such that even they, on a different day, will say, “What on earth was I thinking?” But this kind of temporary or ongoing impaired insight potentially leading to actions that are dangerous to self or others is essentially a universal feature of human minds and ordinary living—disastrous investments, ruinous or ruined marriages, violent acts, stupid accidents, poor forethought with vast consequences, not following reasonable health advice, and so on. Humanity has this problem! Conversely—and I’m not saying you’re necessarily using the phrase this way—the way “lack of insight” is embedded into mental health laws and often used in clinical settings and public dialogue implies that people labeled with major depression, anxiety disorders, or schizophrenia are globally impaired like people with advanced Alzheimer’s who no longer know who they are, where they are, or how to do basic daily functions. That’s a gross exaggeration of the degree of impairment of most people being detained in average psychiatric hospitals, and it’s dehumanizing.
Wipond: As you write, “the tools we have at our disposal are imperfect and capable of harm” and “the optimal strategy would be different in different social arrangements” and improving social arrangements is “key to reducing coercion” — I agree with all of that.
And I absolutely agree with you that the way a person views the nature of madness strongly influences their views on insight and how to intervene and on forced psychiatric treatment. As a consequence, I do think non-coercive practitioners often think very differently than coercive ones. All too often, a coercive practitioner’s or pro-force advocate’s beliefs in psychopathological psychiatric labels, psychiatric treatments, and “lack of insight” hide a reality—they throw a heavy, distorting veil over a reality which to the rest of us, to use your words, is blindingly obvious.
I’ll share a brief story from a recent conversation I had that, in some ways, also aptly summarizes what my whole book is about. A young street counselor found a homeless person in a severely troubled and disoriented state and seriously physically endangered. The counselor was warm, caring, spent time sitting there with this man listening, talking, sharing, and gradually built up a rapport and persuaded the man to go voluntarily to hospital to get help with his physical problems. Notably, the man, probably based on experience, insisted, “As long as you come with me.” Well, the presence of the counselor didn’t help. The paramedics treated him like a dangerous madman, an animal, and this man’s journey quickly degenerated into traumatizing experiences of psychiatric force. By the end of it, the counselor walked out of the hospital back into the street and was so shaken he started questioning his life, his work, everything he was doing, and was he really helping more than harming. The counselor was visibly sobbing about all this while walking around the streets confused and unable to explain even to himself let alone to others why he was having such a powerful reaction not unlike a panic attack—and ultimately, police took the counselor against his will to a psychiatric hospital! This young man told me he has been forever changed by this experience. For him, the veil has been lifted. The veil that prevents us from seeing the thin line between sanity and madness, the sane and the mad, alleged insight and alleged lack of insight, how our oppressive society can drive some reasonable people into delusions while other people’s delusional inner worlds get cushioned by good social fortune, power, and privilege, the nice-sounding promotions about involuntary psychiatric care and the actual intimidation, threats, terror and brutality of it for so many. And this is the veil that needs to be lifted for all of us: see forced psychiatric interventions for what they are, and not filtered through a lens of dehumanizing attitudes and beliefs about certain types of people. If nothing else, at least then the public dialogue about involuntary psychiatry will become more honest.
Wipond: I don’t hear anywhere nearly enough psychiatrists speaking out and showing genuine understanding and concern about how harmful and unhelpful involuntary treatment can understandably be for many people. That ongoing lack of collectively expressed public acknowledgement and concern does at times make me question the foundations of the core psychiatric enterprise.
You’re probably right that I have a relatively negative view of psychiatry, and that’s partly because nearly all of my exposure to it over two decades has been witnessing coercive psychiatry and its impacts. But it’s also because I don’t hear anywhere nearly enough psychiatrists speaking out and showing genuine understanding and concern about how harmful and unhelpful involuntary treatment can understandably be for many people. That ongoing lack of collectively expressed public acknowledgement and concern does at times make me question the foundations of the core psychiatric enterprise. So I thank you for the conversation, for being open and willing to visit these issues together deeply and in respectful ways, and for the opportunity to share this discussion with your readers and others.
Aftab: Thank you!
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