Thanks for this interview, part 1, both Rob and Awais.
What I found most disturbing in enduring many psychiatric detentions myself was the lack of even reasonable legal representation. Never did the lawyer assigned meet with me before the hearing, other than minutes before in a brief introduction, and none was prepared to argue in my defense if I needed to challenge previous notes in my records or explain why I could access mental health services better while free in the community.
I don't know that legitimacy of DSM diagnoses or biomarkers for mental illness need or should come into arguments about forced psychiatric care, in the sense that patients fighting detention or conservatorship are often not disagreeing with a diagnosis or need for some kind of treatment, but more about having their own agency in it all and being heard as far as their own insights and intelligence.
What I'd like to see regarding the overload of positive in seeking help, via such mental campaigns as NAMI and other organizations promote, is some balance. For instance, NAMI could do much more toward research in transparency around detentions, maybe also in poor ECT and medicating outcomes, and perhaps offer more help specifically for patients in meds withdrawal or in some kind of harm from treatment. Also, I witness too many mental health professionals shutting down any patients complaints about treatment as discouraging people from searching out "life-saving" treatment, when it isn't always life-saving but may improve life quality, and so the language is too strong, not reflecting either that there's no guarantee treatment will be good. Conversely, some harmed patients are trapped in narratives that all mental health treatment is based on sham diagnoses and introduces mistreatment, coercion, neurotoxic drugs, and brain damage, and that's also too strong of language, not reflecting that indeed many patients are helped, do need treatment in a very legitimate way, and understand the drawbacks of certain treatments.
I think both sides promote polarization when subtleties are overlooked.
And, again, patients deserve proper legal presentation at psychiatric detention hearings, along with less acceptance that past psych notes are completely accurate and that the psychiatrist's recommendation is always the best way to proceed.
Great interview. I’m going to pick up his book. I’m not familiar with the literature, but I imagine even if most deinstitutionalized patients fared alright, a sizable dysfunctional minority could still have a big impact.
I won't be reading Rob Wipond's book or other publications by Mad in America writers. I think it is regrettable that he is offered a forum here. I hope that most of your readers are academic researchers and professionals who are smart enough to see through his faulty assertions. His claim that "70-80% or more of us by adulthood" will be diagnosed with a mental illness conflicts with less than 50% claimed by the National Institutes of Health (NIH) and his statement that it "vastly opens the funnel into detentions for many people will have a psychiatric diagnosis" is nonsense! Such claims illustrate a fundamental problem with mental healthcare policy in the United States: A desire for a simplistic one-size-fits-all policy to meet the needs of a complex patient pool with vastly different needs. Given that a vast majority of persons with diagnosed mental illnesses have highly manageable less-serious conditions, where involuntary commitment is irrelevant and medication is often not even a part of treatment protocol, simplistic policies based on irrational fears about involuntary commitment is killing those with serious mental illness. Many so-called advocates find the sickest of the sick stigmatizing (i.e., shameful) and would rather pretend they do not exist--they might be an obstacle to social acceptance or professional advancement of the less sick. But only about 5% of the U.S. population have a serious mental illness and a minority of them might benefit from involuntary care at some point in their lives. So involuntary care is truly irrelevant to the vast majority with less serious diagnoses, but that does not work for the idealogical anti-psychiatry bias that Wipond and his colleagues at Mad in America wish to promote. What he wants to do is remove a treatment option for persons who are abandoned by those concerned so much about the stigma that it enables ableist thinking about psychiatric illness to the detriment of a minority who are more likely to end up homeless, imprisoned, or dead as a result of the policies they wish to promote. As a parent and caregiver for an adult child with schizophrenia, I have never attempted to involuntarily hospitalize my daughter. But I resent Wipond's wish to interfere with my ability to do so, if there ever comes a time when it is necessary--for example, if she is living on the streets. In Texas, where I live, involuntary commitment is exceedingly difficult to obtain. Even if I had legal guardianship, I would be prohibited by Texas law from involuntarily hospitalizing my daughter. To do so would require a court order which would likely be declined, unless my daughter was subjected to court-ordered competency restoration so that she could be prosecuted for a serious crime that was committed while incompetent. How much sense does that make?
A few points about the meta-analysis he provides to support his assertions that "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." Again, this statement is unsupported if one looks more closely at the data and considers the population that involuntary commitment is meant to serve today. Most of the studies in the source Wipond cites are from countries with incarceration rates that are many times lower than the U.S. incarceration rate. And, even the U.S. states from which small numbers of formerly institutionalized patients are drawn have incarceration rates lower than the world-highest U.S. average. Even using the tiny numbers from the couple of U.S. studies from Indiana and Rhode Island, one can use a little arithmetic to see the incarceration rate for persons who were previously institutionalized is several times higher than the incidence of serious mental illness in the U.S. population. Furthermore, the study does not quantify how many of the deaths associated with those formerly institutionalized are due to homelessness or shootings by police who are the typical first-responders for mental health emergencies in the United States. Those should certainly be considered bad outcomes. The susceptibility of some persons with serious mental illness can be found in other reputable sources: The Bureau of Justice Statistics claims that nearly one-quarter of persons in U.S. prisons and jails show signs of psychotic disorders and the Substance Abuse and Mental Health Services Administration (SAMHSA) claims that a similar percentage of homeless persons have serious mental illnesses. These are the rare individuals, like a person in Austin who spends his time busting up limestone blocks and cutting down trees on public parkland in a delusional battle against Satan, who might need involuntary care. Wipond thinks such care should be unavailable, because he would rather pretend such persons do not exist. Does he also oppose involuntary commitment of persons with dementia and profound intellectual disabilities to longterm care facilities? Would he like the freedom to live homeless or imprisoned like some of the the sickest of the sick who have lost reality contact?
The inpatient unit now is the psychiatric equivalent of the ICU (which is not the case historically). Getting rid of it would leave us scrambling and a bunch of sick people on the streets or locked in the basements of their homes (as such cases are in countries without much psychiatric care)
Exactly this...the same applies in much of the UK. In a city like London an informal (ie voluntary) admission is now the exception, which has left our inpatient units as warehousing for compulsory treatment (which means medicine). No longer the therapeutic community that we learned about when I was starting out...
I am in total agreement with you. You have the kind of informed consumer that Rob Wipond ignores and Awab fails to give adequate attention. As a evidence-based mental health academic professional, I find the misinterpretation appalling of basic epidemiological data and meta analyses, Thanks for calling them out.
Voices like Rob Wipond and their amplification by Awais are the cause of the current crisis in care for the severely mentally ill, not the solution.
We certainly don’t have more psychiatric beds now than, say, the 1950s. Boston Psychiatric Hospital had 5000 beds! Now all of eastern Massachusetts has maybe 350, and the large prisons have the largest psychiatric hospitals. And of course psychiatric legal power can be used for real evil and we have to keep that top of mind, but I was taught that the ethical determination of capacity and the legal determination of competence to make medical decisions you rely on the knowledge of the person, if available, from family and history, what they would want for medical treatment when they are well. So my parents say no ventilator in my future if there is little to no chance of coming off of it I listen to them and respect their wishes. And my patients with recurrent psychosis, when well, prefer being medicated and able to work and not lose their relationships and money to psychotic decision making, but the current mental health law does not honor this ethical stance unless you have a guardianship already in place before they become psychotic or after they become irretrievably chronically psychotic.
The “bed” calculations get tricky cause many aren’t just talking about inpatient beds but also facilities where individuals with intellectual disabilities are living, nursing homes, crisis units, group homes dedicated to SMI, etc. If we look at just inpatient beds strictly, certainly we have way fewer than 50-60s, although the populations are quite different and (if I remember correctly) I think Wipond was arguing that their numbers have increased in recent years too and are comparable to other developed countries.
Excellent interview. Thoughtful presentations of the various dilemmas. From a global health and human rights perspective I think it is important to learn more about the work of the WHO in this area. Where is there controversy, where is there alignment? What are the global implications of the values that we are espousing and enacting?
If you have Kaiser Permanent insurance, in California one of the most common medical insurances, ALL psychiatric hospitalizations are done under the state 5150 law. A patient can walk into the Kaiser Hospital ER, ask for help, and instead of a voluntary stay they are immediately converted to a legally binding 72 hour hold. Every time. It's a company policy.
If that patient is a member of a profession where such a change in legal status can ruin their life, or indeed, just a sick person who thought they were voluntarily seeking help, the results are devastating. The Kaiser system uses the hold to shunt the patient out into a public or private hospital, and takes no further interest in their care, saving the system millions of dollars and exposing the patient to terrible, punitive Care.
No one in California ever seems to mention this. I think it's a big problem. I wish a journalist would look into it.
I am so confused. People here seem to be conflating involuntary commitment and inpatient care. There is a league of difference between a person asking for inpatient care and a person being forcibly committed by the cops.
IMO as long as purely voluntary healthcare is inaccessible such as from long waitlists, financial barriers, stigma, ignorance or other barriers there is just no justification for forcible committal.
If in a different world a person could have found a psychiatrist they chose and a therapist they chose then that is obviously preferable. There is not a justification for involuntary committal when good public mental health care does not exist.
Also there aren't really good options for people in crisis. A person who has a bad reaction to medication and feels suicidal and goes to the ER doesn't really get good purely voluntary help in the first place.
Why are people who believe in Satanic demons on the streets in the first place? First thing they need is a house, a homeless shelter or a tent and necessities like food and water. Involuntary committal is pointless if we can't even guarantee voluntary access to those.
Awais continues his act of giving anti-psychiatry a whitewash and mainstreaming it. I am confident that intelligent patients and mental health professionals will not be reading Rob Wipond and will duly note that Awais has done "it" again. Some of the comments say a lot about the audience Awais caters to.
Thanks for this interview, part 1, both Rob and Awais.
What I found most disturbing in enduring many psychiatric detentions myself was the lack of even reasonable legal representation. Never did the lawyer assigned meet with me before the hearing, other than minutes before in a brief introduction, and none was prepared to argue in my defense if I needed to challenge previous notes in my records or explain why I could access mental health services better while free in the community.
I don't know that legitimacy of DSM diagnoses or biomarkers for mental illness need or should come into arguments about forced psychiatric care, in the sense that patients fighting detention or conservatorship are often not disagreeing with a diagnosis or need for some kind of treatment, but more about having their own agency in it all and being heard as far as their own insights and intelligence.
What I'd like to see regarding the overload of positive in seeking help, via such mental campaigns as NAMI and other organizations promote, is some balance. For instance, NAMI could do much more toward research in transparency around detentions, maybe also in poor ECT and medicating outcomes, and perhaps offer more help specifically for patients in meds withdrawal or in some kind of harm from treatment. Also, I witness too many mental health professionals shutting down any patients complaints about treatment as discouraging people from searching out "life-saving" treatment, when it isn't always life-saving but may improve life quality, and so the language is too strong, not reflecting either that there's no guarantee treatment will be good. Conversely, some harmed patients are trapped in narratives that all mental health treatment is based on sham diagnoses and introduces mistreatment, coercion, neurotoxic drugs, and brain damage, and that's also too strong of language, not reflecting that indeed many patients are helped, do need treatment in a very legitimate way, and understand the drawbacks of certain treatments.
I think both sides promote polarization when subtleties are overlooked.
And, again, patients deserve proper legal presentation at psychiatric detention hearings, along with less acceptance that past psych notes are completely accurate and that the psychiatrist's recommendation is always the best way to proceed.
Thank you Lisa! You’ve highlighted shortcomings of the current state of affairs very well.
Great interview. I’m going to pick up his book. I’m not familiar with the literature, but I imagine even if most deinstitutionalized patients fared alright, a sizable dysfunctional minority could still have a big impact.
I won't be reading Rob Wipond's book or other publications by Mad in America writers. I think it is regrettable that he is offered a forum here. I hope that most of your readers are academic researchers and professionals who are smart enough to see through his faulty assertions. His claim that "70-80% or more of us by adulthood" will be diagnosed with a mental illness conflicts with less than 50% claimed by the National Institutes of Health (NIH) and his statement that it "vastly opens the funnel into detentions for many people will have a psychiatric diagnosis" is nonsense! Such claims illustrate a fundamental problem with mental healthcare policy in the United States: A desire for a simplistic one-size-fits-all policy to meet the needs of a complex patient pool with vastly different needs. Given that a vast majority of persons with diagnosed mental illnesses have highly manageable less-serious conditions, where involuntary commitment is irrelevant and medication is often not even a part of treatment protocol, simplistic policies based on irrational fears about involuntary commitment is killing those with serious mental illness. Many so-called advocates find the sickest of the sick stigmatizing (i.e., shameful) and would rather pretend they do not exist--they might be an obstacle to social acceptance or professional advancement of the less sick. But only about 5% of the U.S. population have a serious mental illness and a minority of them might benefit from involuntary care at some point in their lives. So involuntary care is truly irrelevant to the vast majority with less serious diagnoses, but that does not work for the idealogical anti-psychiatry bias that Wipond and his colleagues at Mad in America wish to promote. What he wants to do is remove a treatment option for persons who are abandoned by those concerned so much about the stigma that it enables ableist thinking about psychiatric illness to the detriment of a minority who are more likely to end up homeless, imprisoned, or dead as a result of the policies they wish to promote. As a parent and caregiver for an adult child with schizophrenia, I have never attempted to involuntarily hospitalize my daughter. But I resent Wipond's wish to interfere with my ability to do so, if there ever comes a time when it is necessary--for example, if she is living on the streets. In Texas, where I live, involuntary commitment is exceedingly difficult to obtain. Even if I had legal guardianship, I would be prohibited by Texas law from involuntarily hospitalizing my daughter. To do so would require a court order which would likely be declined, unless my daughter was subjected to court-ordered competency restoration so that she could be prosecuted for a serious crime that was committed while incompetent. How much sense does that make?
A few points about the meta-analysis he provides to support his assertions that "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." Again, this statement is unsupported if one looks more closely at the data and considers the population that involuntary commitment is meant to serve today. Most of the studies in the source Wipond cites are from countries with incarceration rates that are many times lower than the U.S. incarceration rate. And, even the U.S. states from which small numbers of formerly institutionalized patients are drawn have incarceration rates lower than the world-highest U.S. average. Even using the tiny numbers from the couple of U.S. studies from Indiana and Rhode Island, one can use a little arithmetic to see the incarceration rate for persons who were previously institutionalized is several times higher than the incidence of serious mental illness in the U.S. population. Furthermore, the study does not quantify how many of the deaths associated with those formerly institutionalized are due to homelessness or shootings by police who are the typical first-responders for mental health emergencies in the United States. Those should certainly be considered bad outcomes. The susceptibility of some persons with serious mental illness can be found in other reputable sources: The Bureau of Justice Statistics claims that nearly one-quarter of persons in U.S. prisons and jails show signs of psychotic disorders and the Substance Abuse and Mental Health Services Administration (SAMHSA) claims that a similar percentage of homeless persons have serious mental illnesses. These are the rare individuals, like a person in Austin who spends his time busting up limestone blocks and cutting down trees on public parkland in a delusional battle against Satan, who might need involuntary care. Wipond thinks such care should be unavailable, because he would rather pretend such persons do not exist. Does he also oppose involuntary commitment of persons with dementia and profound intellectual disabilities to longterm care facilities? Would he like the freedom to live homeless or imprisoned like some of the the sickest of the sick who have lost reality contact?
The inpatient unit now is the psychiatric equivalent of the ICU (which is not the case historically). Getting rid of it would leave us scrambling and a bunch of sick people on the streets or locked in the basements of their homes (as such cases are in countries without much psychiatric care)
Totally.
Exactly this...the same applies in much of the UK. In a city like London an informal (ie voluntary) admission is now the exception, which has left our inpatient units as warehousing for compulsory treatment (which means medicine). No longer the therapeutic community that we learned about when I was starting out...
I am in total agreement with you. You have the kind of informed consumer that Rob Wipond ignores and Awab fails to give adequate attention. As a evidence-based mental health academic professional, I find the misinterpretation appalling of basic epidemiological data and meta analyses, Thanks for calling them out.
Voices like Rob Wipond and their amplification by Awais are the cause of the current crisis in care for the severely mentally ill, not the solution.
We certainly don’t have more psychiatric beds now than, say, the 1950s. Boston Psychiatric Hospital had 5000 beds! Now all of eastern Massachusetts has maybe 350, and the large prisons have the largest psychiatric hospitals. And of course psychiatric legal power can be used for real evil and we have to keep that top of mind, but I was taught that the ethical determination of capacity and the legal determination of competence to make medical decisions you rely on the knowledge of the person, if available, from family and history, what they would want for medical treatment when they are well. So my parents say no ventilator in my future if there is little to no chance of coming off of it I listen to them and respect their wishes. And my patients with recurrent psychosis, when well, prefer being medicated and able to work and not lose their relationships and money to psychotic decision making, but the current mental health law does not honor this ethical stance unless you have a guardianship already in place before they become psychotic or after they become irretrievably chronically psychotic.
The “bed” calculations get tricky cause many aren’t just talking about inpatient beds but also facilities where individuals with intellectual disabilities are living, nursing homes, crisis units, group homes dedicated to SMI, etc. If we look at just inpatient beds strictly, certainly we have way fewer than 50-60s, although the populations are quite different and (if I remember correctly) I think Wipond was arguing that their numbers have increased in recent years too and are comparable to other developed countries.
"I think Wipond was arguing..." Please stop defending Wipond's distortion of basic statistics.
Excellent interview. Thoughtful presentations of the various dilemmas. From a global health and human rights perspective I think it is important to learn more about the work of the WHO in this area. Where is there controversy, where is there alignment? What are the global implications of the values that we are espousing and enacting?
There is a bit more about WHO and the global scene in part 2 😊
If you have Kaiser Permanent insurance, in California one of the most common medical insurances, ALL psychiatric hospitalizations are done under the state 5150 law. A patient can walk into the Kaiser Hospital ER, ask for help, and instead of a voluntary stay they are immediately converted to a legally binding 72 hour hold. Every time. It's a company policy.
If that patient is a member of a profession where such a change in legal status can ruin their life, or indeed, just a sick person who thought they were voluntarily seeking help, the results are devastating. The Kaiser system uses the hold to shunt the patient out into a public or private hospital, and takes no further interest in their care, saving the system millions of dollars and exposing the patient to terrible, punitive Care.
No one in California ever seems to mention this. I think it's a big problem. I wish a journalist would look into it.
I am so confused. People here seem to be conflating involuntary commitment and inpatient care. There is a league of difference between a person asking for inpatient care and a person being forcibly committed by the cops.
IMO as long as purely voluntary healthcare is inaccessible such as from long waitlists, financial barriers, stigma, ignorance or other barriers there is just no justification for forcible committal.
If in a different world a person could have found a psychiatrist they chose and a therapist they chose then that is obviously preferable. There is not a justification for involuntary committal when good public mental health care does not exist.
Also there aren't really good options for people in crisis. A person who has a bad reaction to medication and feels suicidal and goes to the ER doesn't really get good purely voluntary help in the first place.
Why are people who believe in Satanic demons on the streets in the first place? First thing they need is a house, a homeless shelter or a tent and necessities like food and water. Involuntary committal is pointless if we can't even guarantee voluntary access to those.
Awais continues his act of giving anti-psychiatry a whitewash and mainstreaming it. I am confident that intelligent patients and mental health professionals will not be reading Rob Wipond and will duly note that Awais has done "it" again. Some of the comments say a lot about the audience Awais caters to.