The Double Standard of Forced TreatmentForced treatment for people with mental illness has had a long and abusive history, both here in the United States and throughout the world. No other medical specialty has the rights psychiatry and psychology do to take away a person’s freedom in order to help “treat” that person.

Historically, the profession has suffered from abusing this right — so much so that reform laws in the 1970s and 1980s took the profession’s right away from them to confine people against their will. Such forced treatment now requires a judge’s signature.

But over time, that judicial oversight — which is supposed to be the check in our checks-and-balance system — has largely become a rubber stamp to whatever the doctor thinks is best. The patient’s voice once again threatens to become silenced, now under the guise of “assisted outpatient treatment” (just a modern, different term for forced treatment).

This double standard needs to end. If we don’t require forced treatment for cancer patients who could be cured by chemotherapy, there’s little justification for keeping it around for mental illness.

50 Comments to
The Double Standard of Forced Treatment

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  1. I would like to hear more about this, and how you WOULD prefer that certain situations be handled. What would the laws and mental health practice look like if forced treatment was eliminated? What would you do in the case of a client refusing treatment for depression, schizophrenia, bipolar disorder, etc? Also, would you still allow for involuntary committment of suicidal individuals?

    • As a society, we need to agree to get rid of the double-standard. Either we force cancer patients to undergo chemotherapy for cancer treatment when it’s “likely” it will help them, or we stop forcing people who have a mental illness to undergo treatment.

      I prefer that human beings be given the choice. And if not an imminent threat (e.g., if you let them go, they will try to kill someone) to others, to be left alone to their own devices. (If they are a threat to others, I believe that they can then undergo strictly time-limited treatment that is overseen by a better, more objective system than we currently have in place.)

      • I’m glad tht you added this comment regarding imminent threat. I worked as a community social worker for a number of years in a ACT program directed at individuals who have legal records. Many of these individuals had involuntary commitments, often in response to a history of violent behavior when they were psychiatrically acute. I agree that if a person makes a decision that will not cause direct harm to others in any way, they have every right to make that decision. I also understand that unlike cancer, some psychiatric illness by definition impact a person’s judgement. This is not a flaw in the person, but it is a very real concern that requires some method of public safety. It is not an easy discussion, and there is a lot of room for improvement in our system. Thanks for adding your voice to this conversation.

      • I also understand that unlike cancer, some psychiatric illness by definition impact a person’s judgement.

        I’d find it hard to believe that if you weren’t just told that you may only have a few weeks or months to live, and that a treatment may or may not be effective for you, that that wouldn’t effect both your emotional state and judgment.

        Except in the case of disorders with delusions as a hallmark symptom (e.g., schizophrenia), impaired judgment is not a recognized psychiatric symptom of that vast majority of mental disorders.

        Most of us live a life full of impaired judgments and times of questionable decision-making. Unless we’re an imminent threat to harming others, what should it matter? It certainly shouldn’t be used as a criteria for determining taking someone’s fundamental right of freedom away from them.

      • Where to start?

        Regarding the discussion of the criterion of harm to self/or others in involuntary commitment or forced “treatment”, one has to be mindful of the obvious potentiality for abuse contained within this justification. Just because someone claims you’re a threat or perceives this to be the case, does not mean you are, and doesn’t mean that the psychiatrist isn’t telling porkies.

        Embedded in this line of reasoning is the assumption that psychiatrists can be trusted to tell the truth about their patients, as well as the assumption that the psychiatrist has broken free from the stultifying constraints of human nature and perception. This is symptomatic of the prevailing prejudgment in discussions of psychiatric procedure of the psychiatrist as some sort of inerrant investigator of the mind and human behaviour, of the psychiatrist as the omniscient, objective narrator of their patient’s lives!

        The truth is that psychiatrist’s aren’t educated atop Mount Olympus where their education imparts to them a wisdom inaccessible to the rest of us and vaccinates them against the lunacy, unreason and other limitations intrinsic to the species (contrary to what the Mental Health supremacists would have us believe, of which I can see there are some here!).

        Under no circumstances must psychiatrists be extended powers and privileges that the rest of us do not expect. If someone is a very real threat to someone else, that is a job for the police, who are not enfranchised to go around poisoning, abusing and symbolically and often literally killing people under medical auspices, the reality of which we try to articulate out of existence, euphemising these medically-disguised predations and abuses as “assisted treatment” etc.

        As for potential suicides, I have long disabused myself of the notion that psychiatrists are some sort of breed of existential alchemysts, taking the base materials of existence and turning them into gold with their wonder treatments. Life sucks, and I hardly think it should be left to those who have contributed so bounteously to this ugly reality to go around “treating” those who have had their fill of existence. Psychiatry, to my mind, promotes suicide more than it cures it.

        The fact that lots of people commit suicide on psychiatric wards doesn’t bother people, nor that lots more would if it wasn’t so difficult, and how many people commit suicide on psychiatric drugs?

        Anyway, forced treatment is a contradiction in terms. Just as something ceases to be sex, and becomes rape, when it is imposed by one on another, something ceases to be treatment, and becomes a kind of metaphorical, medicalized rape, when it is imposed upon another person.

        One commenter implies that the needs of the many outweigh those of the few, which constitutes what has been described as the tyranny of the majority. If society wants to consider itself just, as it seems to be able to do with great facility, it must not advance its own cause with evil weapons. Such utterances bear the stamp of an incurably collectivist mentality. The kind of logic at work there can be used to render justifiable just about any depravity, iniquity or barbarity.

        Perhaps that commenter believes that forced drugging or ECT, if not entirely justifiable on moral grounds, is justifable on the grounds of expediency and neccessity. Yet the police are there to deal with people who pose a real threat, so there is no need to drug people against their will.

        One commenter, in his/her desperation to justify the continued existence of forced psychiatry, says we should try to implement forced treatment in a more humane manner, which, as Szasz
        once said, is like trying to prettify the plantations. Yes, let’s try and poison and traumatise people in a more humane way, let’s coerce and abuse people with velvet gloves on!

        As John Mill once said, “..it is contrary to reason and experience to suppose that there can be any real real check to brutality, consistent with leaving the victim still in the power of the executioner.”

      • Absent from the discussion about forced treatment and/or treatment without consent is the U.S. Constitution, and/or laws of the state. Taking freedom without Due Process violates the Constitution. American jurisprudence includes the notion of mens rea and actus reus, for a finding guilt of a crime. If a person is a suspect of a crime, police have the option of probable cause for arrest, and/or obtaining a warrant for surveillance. All too often psychiatrists believe they have superior knowledge and morality, that they do not need to obey laws that regulate their behavior. They believe they are above the law. One more problem is that lawyers, judges, psychiatrists, journalists believe that an accusation of mental illness is a finding of guilt of a criminal act. One more concern is how mental illnesses are created, i.e., by consensus. See, e.g., Boston University Psychologist Margaret Hagan’s book, Whores of the Court.

  2. As is the beauty and aggravation of mental health, life is gray and so are the treatment options that patients can access. However, I didn’t read you mention there are times that somatic interventions can be “forced” if someone is deemed incompetent and is refusing a life saving procedure that just doesn’t make sense to refuse. The big question is this: if someone is saying ‘NO’ to a treatment intervention and may die, or worse put others at risk should the status quo be maintained, when is it ok to accept this position? Would you at least agree the needs of the many outweigh the needs of the few?

    I have been on the fence about forced treatment, because at the very least, when a patient interprets care as punitive, the alliance is lost and efforts to regain trust and motivation for change are surely minimized. But, that said, and this is the legit question of the day in this culture these times, WHO is responsible for a negative outcome should a patient be allowed to refuse care and there are consequences for later choices/actions by said patient?

    We are a culture of accountability and liability. And while you and I know the risk for violence by mental health patients is no higher at the very least than that of the general public, all it takes is one example, like Mr Loughner in Arizona for instance, and then the public will clamor for immediate change.

    Or better yet, we are a culture of NIMBY, and boy, there is a lot of space with all those back yards to have to avoid, eh?

    • I think we overestimate the potential for harm to others in most cases like this, and underestimate the real likelihood of harm of the patient when we take away a very basic human right — liberty.

      It seems incompatible with a country that was founded on such a basic, fundamental principle.

      Policymakers and many professionals believe they are doing the right thing and a good thing by saving these people from themselves. I genuinely believe that nowadays, most of these professionals’ hearts are in the right place. However, the road to hell is paved with good intentions and we have enough data to show that taking away a person’s freedom isn’t really a good way to encourage and help in that person’s recovery.

      • Yeah, I totally agree with the adage “the road to hell is paved with good intentions”, in fact that should be above every clinician’s doorway, but, I have met people who have no interest in accepting treatment needs, and the status quo is MUCH disruption and discord for family, employees, and the community at large. It doesn’t happen often, but, I have worked with some patients who have shown some insight and judgment once willing to work with the treating staff and see that refusing care has at least more hassles than benefits.

        Every case is an individual case, that I totally believe and advocate for, but to take an extremist point of view and eradicate the process entirely, well, what good is that against involuntary commitment for all until proven otherwise?

      • Because the profession has shown it can’t be entrusted with the current process.

        I thought abusive behaviors were over in the 1970s. Yet today, I still hear patient stories that are unimaginable — uncaring judges and mental health professionals who ignore the choices of the patient and the patient’s family. And I’d say if I only heard one a year, that might be okay on some level. But I hear of *dozens* a year, in all different geographic regions throughout this country.

        It’s time to scrap the whole thing and start over with “No forced anything” as the foundation (not an after-thought as it is today).

    • It would seem that you favor forcing people to fit your personal parameters. 100 years ago it was perfectly correct for a woman to be given in marriage to a man who was well within social bounds to beat and rape her on a daily basis. I almost wonder if you’re one of the people who are willing to continue that little social gem today?

  3. So what are your views on using feeding tubes (forced nutrition) for eating disorder patients?

    • If it’s against the patient’s will and involuntary, I’m against it.

      If a person wants to starve themselves to death, it should be allowed. As horrible as that sounds, the rest of medicine allows this (e.g., just look at our recent assisted suicide discussion, where some docs think it’s perfectly okay to let a person starve themselves as a “compassionate” way to die). The rest of medicine allows someone who has cancer to refuse all treatment — which in many cases is equivalent to a death sentence.

      Why would we make special exceptions for mental disorders and take away a person’s fundamental freedoms? I’m not sure where in the Constitution there’s a right there for the government to force treatment upon you.

  4. my mom suffers from paranoid schizophrenia and i am very thankful that she has been forcibly treated! in her mind, nothing is wrong with her, so she would never agree to treatment or medications. where would she be now without being stabilized?? homeless? dead? she most certainly would not be living with my dad who can oversee her care. just because this system isn’t perfect doesn’t mean it should be ended! talk to any family member of a person suffering from mental illness-you will see a very different picture!

    • I’ve talked to hundreds in the past decade, and there are two sides. For the community and family, they love forced treatment in most cases. It means it takes the problem patient off of their hands, and “gets them the help they need.”

      But in the majority of people I’ve talked to who’ve undergone forced treatment and are in recovery, they found it one of the most degrading and dehumanizing experiences a person could ever feel.

      Until any of us have had all of our choices and freedoms taken away from us against our will, I’m not sure we really understand that point of view. So we “do what’s best for them,” and while our hearts are in the right place, we’re doing many of them a great harm in the process.

      • Just a thought….since there are 2 sides…..& it sounds like the negative side is in THE WAY the treatment is provided without dignity…..then maybe what needs to be looked at is more control on the way that forced treatment is implemented rather than getting rid of it all together since there are very good outcomes that come from it when those people received that forced treatment in a respectful humane approach. I agree that much of the forced treatment has never evolved from the ancient practices……but to me, I would rather put controls on the way forced treatment in implemented than to take away the good that forced treatment done with human respect can achieve……throwing out the baby with the bathwater isn’t the answer either.

      • Hear, Hear! As someone who has been strapped down, forcibly medicated and the told that I need to express gratitude for the experience, I would LOVE to see some of them on the other end of the straps!

  5. I think the issue is that if someone has cancer and refuses treatment…it is a bit different from someone who suffers from delusions, becomes homucidal, yet refuses treatment. In addition, there are people who initially refuse treatment, psychotic and suicidal, who have a very rough road…but get better with treatment and survive their pain, further contributing to society. this is a very gray area which deserves further exploration…but it could result in so many tragedies.

  6. I am both shocked and pleased with your article, Dr. Grohol. I never in my life expected to hear a psychiatrist or psychologist espouse such views. *My* views. When you have a mental illness, people judge you without knowing any other thing about you. I find it horrific that a person can be forced to take medication, especially since there is no way to know what harm it may cause later in life. Nobody has to agree with me as to whether it’s safe or a good choice; it should be mine to make. *My* body, *my* choice.

    As for family members who have to “deal” with us, I absolutely believe if a person is so disruptive to a family, maybe that person should be placed elsewhere, but there needs to be a long discussion, and it still doesn’t mean a person should be forced to take medication, even if it makes the person easier to handle. I have a lot of relatives I can’t stand to be around, most not diagnosed with a mental illness, yet I couldn’t send them from their homes if I still lived there.

    When I was a young adult, I didn’t have the means to move out on my own. My mom allowed some family members come stay in our home “for a few days,” which turned into two and a half years. They were very abusive and controlling, and my mom let them get away with anything they did. They made my life hell and worsened my OCD and panic disorder. If I could be sent away, why couldn’t they? It’s because they weren’t considered mental cases, except for my (adult) cousin who is mentally a baby and can’t walk or talk. Never mind that they brought roaches into our house (I saw them crawling out of the TV they moved in from their old place), allowed me to use the bathroom once a day, made fun of me and all the other crap they pulled. But enough of that. I’m not here to recount my story of those years.

    I’m not violent. Unless I’m a threat to someone else, no one should be able to tell me what to do. I know people do things to themselves because they suffer depression and other problems, but I believe a person should have control over their own body, because we’re in a county (USA) of freedom. Freedom should never be taken away except in dire circumstances, and that means freedom to control my body should be mine, and mine alone.

    Thank you, Dr. Grohol.

    • Thank you for your first-hand experience; it reflects what I hear time and time again from patients who’ve undergone some form of this.

      I do believe we can do a better job with treatment and support options within the community. I don’t believe it should fall solely upon the family to try and cope with these situations on their own.

      But it should be done in the least-restrictive manner possible — and it’s not being done that way today. And it should be done as much as possible with the patient being a willing and active participant in their own care. Yes, even people experiencing active delusions can still make decisions for themselves.

      The problem in the profession is that we’ve lowered the bar too far. We can probably find a way to reform the current system, but it would take a lot of work and a willingness of the system to do so.

  7. The issue forced treatment for people with mental illness is very wide, for it involves the relationships between body, brain, mind, soul and spirit.
    If you move from the assumption that only body and brain exist while mind, soul and spirit belong just to the philosophical and religious speculation, the problem is soon resolved in these terms: “As human being is just flesh the psychiatrist has the right to treat his patient by whatever means at his disposal included pharmacotherapy and electroconvulsive therapy.” But, if human being is also mind, soul and spirit, can the psychiatrist treat these latter elements by drugs?
    A fact is that so far the scientists do not know how human brain works. They even do not know how a cell reproduces. The treatment for the madman is based upon symptomatology. It is possible to treat the symptoms but not the underlying cause. It is like if when there is a fire in a room and you strive to prevent the propagation of the fire by cooling the walls. The fire is kept under control but it still remains inside the room.
    If we move from the assumption that human beings are made from body, brain, mind, soul and spirit, the psychiatrists cannot treat by drugs or ECT (electro convulsive therapy), something they do not know, that is soul, spirit, mind and the processes of thought.
    The bottom line is that man is not only flesh, therefore whatever treatment for people with mental diseases has to move from the cure of his soul and mind first, while the therapy by medicines or electro convulsions should be regarded as the last chance.
    Ettore Grillo author of The Vibrations of Words

    http://www.amazon.com/author/ettoregrillo

    http://www.youtube.com/watch?v=sAotfnxdE10

  8. We could have a thread of hundreds of comments that show the pro and con of involuntary commitment. In the end, as I said above, what happens when a person refuses care and then either harms him/herself and/or others linked directly to mental health problems? This culture will demand accountability and liability, so that can’t be ignored nor dismissed.

    All this article seems to be advising as the thread is progressing, is basically removing involuntary commitment leaves us to care by prisons or graveyards. Not much of a substitute, hmm?

    • As example A of this concern, while not the most applicable as the shooter was not actively in consideration of commitment, now the movie theater where the shooting occurred in July is accountable for his actions? Read and discuss amongst yourselves.

      http://news.yahoo.com/judge-merges-lawsuits-against-cinema-chain-colorado-shootings-021719465.html

    • If people break the law, no matter the reason, they should face the consequences of their actions. If that means jail, well, that’s exactly what we’ve done with substance abusers over the past two decades. I wouldn’t call it successful, but at the same time, we seem perfectly okay as a society of turning a blind eye to these people’s mental health needs. But not that of a person with schizophrenia.

      We have an illogical and inconsistent policy here, which is wildly out of whack with actual risk (versus perceived risk and fear of liability).

      We live in a random world where not every harm can be prevented. While we can take reasonable methods to help prevent many harms, I know of no research that backs up the supposition that forced treatment is somehow benefiting society (and it’s of questionable benefit to the people who it’s forced upon).

      I can’t address all the practical implications of a moral position. But morally, forced treatment is wrong. It is inconsistent with the fundamental human right of freedom, and is wildly inconsistent with medical treatment for other health concerns.

      • I have NO issue with psychiatry distancing itself from Antisocial Personality Disorder, and equally feel primary Substance Abuse/Dependence is NOT solely a mental health domain for care. That said, what do you do with a person who premorbidly had no antisocial traits nor definable substance struggles, but after the onset of a mood/thought disorder then presents with such features? Come on, I have done some correctional work, we agree that mental health gets no real care in those settings!

        This next comment gets howls of outrage from the very colleagues I am critical of, but, forensic psychiatry and addiction psychiatry have not helped the cause of primary mental health domains. Sorry, I have not signed on to treat disorders not seen as impacted significantly in my training, nor amenable to the basic tenet of what care is about: change and at least some insight for receiving care.

        I’m sure there will be strong rebuttal to the above! But, we talk above about risk to the patients in involuntary commitment, what about the risks to providers forced to treat people either not amenable to intervention, but in fact can prey on those offering empathy and support? Hmm?

    • I would have preferred an honest prison, and I was trying for an honest graveyard. To this day I believe that I would have been better off in a grave…but that is me making choices for me, obviously something you CANNOT allow.

  9. So I am one of those mental poatients who has been forced into treatment many times. Having this happen, having my freedom removed from me when I did nothing wrong has been incredibly damaging. After the first forced treatment, I got so scared that when I was released I ran from any and all psychiatric treatment. Which led to many more years of suffering that I did not need to experience. Had the experience been voluntary, I would have not been so afraid of meds and therapists and would have gotten treatment much sooner. By the way, that forced treatment was a joke. I was told to sit on a couch and not move for 3 days. I was only 17 and put in an adult institution. The staff had to protect me from the adult men there who might assault me sexually. So there I sat for 3 days, taking whatever meds they gave me, eating, and lying through my teeth that I was much better now and I realized the error of my ways. Unless you have been through this, you cannot imagine how dehumanizing and humiliating this is. Many years later, when put back into that same institution against my will, I was raped by a staff member while I was in restraints because I wanted to hurt myself. Lets just say I left there broken in a way that has never been healed. So please tell me, which is better? Is it right, morally right, to force someone into treatment and then have that person be so mistreated as so many patients are? This was a hospital run by the county for the indigent. Which meant that there were mostly schizophrenics there although I have bipolar. Those who are weakest and sickest get the worst treatment and are forced to do so by the law. Because we are supposedly a “humane” society. How about all of you who want to take away my rights have to first live a day in my life. How about the day I was raped, in restraints, and in a hospital? Maybe then you would have a different idea of what is humane.

    • I was removed from my own home by the police at the request of my husband and at the recommendation of my psychiatrist. I was brought to a mental hostpital with a 72 hour hold. The place was a disgrace by any standard and the phsycial and mental abuse there were criminal. To think that my husband and psychiatrist allowed me to be held there, when neither of them had ever been there, knew anything about the facility, and thought it proper to send me there when I was my sickest did more permanent damage than they will ever know. I love my husband deeply but it will never be the same. I also still care for and trust my doctor. BUT, if and when, I ever have the slightest inclination that my bipolar cycle is rearing its head, I will be so far away no one will find me. I liken that experience to a sick animal being put out in the rain and cold when they needed help most. I would rather ride out my illness in the back of my car at a rest-stop than allow myself to be so mistreated and frightened. So if you love someone with a mental illness or are a doctor in a trusted position by your patient and are reading this post, please do not EVER knowingly inflict such psychological damage. All you can be sure of is that you have broken your loved one’s or patient’s trust and core sensibilites.

  10. Dr. Hassman:

    You keep implying that someone with a mental illness is likely to become violent or a criminal, when that isn’t statistically true. Until a person commits such an act or at least makes a threat (because we are a country where we’re supposed to be “innocent until proven guilty”), no one should be able to force someone into treatment, jail, or whatever other way they want to control the person. It’s easy to judge as you do and say, “Let’s control this group of people!” when you’re not considered one of the group, and especially when you’re one of the ones who desires the power to decide others’ fates.

    Only when someone has made threats or has shown him- or herself to be harmful, should we be discussing taking that person’s freedom away.

    • What I am saying is the current system is not perfect, but advocating to eliminate any involuntary process is not a solution. And, as I said earlier in this thread, the risk for violence for mental health patients is not higher than the average population, but, if we ignore somewhat adequate predictors for violence, like having a past history, repeated verbal threats to harm, use of substances, and there are some diagnoses that do tend to greater risk, all of this can’t be swept aside for Dr Grohol’s opinion.

      And I do not read a rebuttal about my concerns of accountability and liability. People who are survivors of suicide patients, there are not vignettes of wishing more was tried to avoid the death when the patient refused care? It’s not just about violence or homicidality I am concerned with here.

      • As a person who has been diagnosed as Bipolar and whose husband was diagnosed with paranoid schizophrenia, I would like to comment on the issue of accountability and responsibility. First, I always ask myself WHY some family members seem hellbent on “taking care of” their family member with a mental illness diagnosis. I have heard countless stories about the abuses, indignities and hurt they have suffered at the hands of their “crazy” relative. So, I ask myself, WHY do you
        continue to allow this kind of behavior in your home? Do you have a martyr complex? Are you riddled with guilt and feel like you deserve to be treated this way?

        When my (now-deceased) husband began to display dangerous and scary behaviors, I simply would not tolerate it. Just because he was “crazy” did not give him permission to endanger my son and I. On a lesser scale, it did not give him permission to scare the hell out of us! If possible, I secured alternate housing for him. If not, I called the police and let them handle it.

        When you set boundaries and stick to them, you at least preserve your own dignity (and your son’s) and your right to live in a somewhat safe environment. You also let your relative know what you will and will not tolerate. Trust me, even in his “delusional” state, my husband knew what this meant.

        As long as your relative/friend has not been legally deemed incompetent, the responsibility lies with him/her. Perhaps this sounds cold and crass. It is anything but! Although I have not attempted to commit suicide in a VERY long time, my family members are hyper-vigilant about the possibility that it could happen ANY day now – for NO apparent reason! Although I gave my family “permission” to NOT accept responsibility for me (if I EVER did decide to commit suicide) – in fact, I BEGGED them to NOT accept this responsibility – some of them refuse to let it go! I wanted to tell them (but didn’t, for fear of scaring them or giving them unfounded ideas) that if I truly wanted to “off” myself, there was nothing any of them could do to stop me. Still, they will NOT let it go. Sigh, I am NOT responsible for them and their refusal to let go of this!

        My husband truly benefited from certain psychotropic medications. Unfortunately, he was loathe to take them – even though he knew the slightest stressor would send him into deep psychotic symptoms and behavior. I tried to work with him, gently, to help him avoid the inevitability of this. Sometimes it worked; sometimes it didn’t. In the end, he was responsible for his own demise – in spite of the efforts of MANY so-called professionals and his family.

        Initially, my son and I felt guilty and responsible for his death. After thinking it through and talking with others, however, we let that go. Ultimately, my husband made the choices that resulted in his death. I often wonder if he refused medication because a part of him preferred to be in this altered (so-called psychotic) state. He did not appear to be in pain (mental, emotional or physical) when he was “psychotic”. In fact, he seemed to enjoy being more domineering and “in-control” of those around him. Only he would ever know for sure.

        For you righteous, do-gooders with good intentions, I want you to know that it is okay to let go and to not be responsible for your “crazy” patient/friend/relative. In the end, you really don’t have the power to control their outcome. And I would ask you to ask yourself this question? WHY are you SO vested in “saving” other people? WHY do you think it is your responsibility to do so? Even if you are a mental health professional, you do not have ultimate control over the situation (unless you were aware of “imminent” danger and willingly did nothing about it). If you are that frightened of the possibility of one of your patients offing him/herself, perhaps you are in the wrong field. Also, what is it about you that makes you believe YOU must “save”someone from themselves? Do your attitudes and beliefs belie an underlying insecurity about your inability to save yourself? Just asking . . . .

  11. I don’t know why but this has me remembering a story about a woman in the news about a year ago. She had schizophrenia was a devoted mother and did everything she could to deal with her illness. Like so many places there were budget cuts and she lost her access to the medicines she needed, but she kept trying. When she started getting delusional she begged for help,she asked her mother to take her children, she called 911, she drove to a state hospital, she was denied help, there were no beds, no money, no medicine, she killed. Then the media and most people on the internet condemned her.

    Until we as a socitiy have in place a system that helps everyone who asks for help I don’t believe we are in a position to judge whether or not someone should be forced into treatment. Where I live community mental health treatment is considered the care of last resort, and only those with schizophrenia, and bipolor will be helped, most will be put on a wait list. Those w/ major depression can be considered for help if they have tried to take their life, but only if it is a serious attempt. They too will have a wait list depending on the seriousnes of the attempt, in some cases people have been kept in ER’s for days for the lack of community psych beds(there are empty beds for people with money but not for those who lack insurence-so they stay in ER). No other mental illness will be helped in the community setting. Yet the state hospital is full of people who have been forced into treatment many of them have other mental illnesses(PSTD-most common) but they have criminal records-mostly minor. What does this say about us as human beings? I do not believe we are at a place in human growth where we can decide that another human must under go treatment, unless they have the intent driven by an illness to do harm to another person.

  12. It IS complicated. But if someone presents a threat to others – that becomes an issue quite different than merely being miserable alone. Altho – if they truly put themselves at risk of death or injury, does not compassionate care require some degree of coercion?
    I have met individuals who chose not to accept help despite serious diagnoses – and at least for the time I knew them, they survived OK. But I also have known other – a schizophrenic woman who was violent towards her parents (and to her psychiatrist)making their lives a living hell (hers was a hell also – but would it have been a worse hell with meds?). A young man diagnosed as manic depressive who trashed a foster home and assaulted the foster mother. Sorry, folks, this does happen. Would forced treatment really be the worst alternative? These all happened when there were more community services available – they weren’t turned away; they were aggressively and compassionately recruited for treatment. Which is as it should be.

    If we didn’t have medications that help to control severe symptoms, we would go back to the horrendous days of treating severely ill people like animals, herding them together in hospitals that would be ever more packed. Or add to the burgeoning population of chronically homeless.
    I can remember offering services to a young woman whose unusual behavior was a red flag – but not hostile or dangerous. She provided her diagnosis, explained how she was living (dumpster diving, and it was warm)and declined to accept a referral. So – seriously mentally ill – yes. A danger to anyone, no. Forced treatment – no. A comfortable decision – no, but that’s not the criteria. She was, after all, very aware at that point.

    The call for coerced medication or other treatment – court ordered, even physically forced in extreme situations, becomes justifiable when behavior becomes dangerous for the family, the community and the individual. And if the mental health community declines to handle this as treatment, the criminal system steps in with a combination of cruel negligence and harsh force. I really think that when I was working I saw many, many more people who should have been hospitalized for psych reasons and were not, than the opposite.

  13. Sorry about the double post – a glitch. I felt the need to add a comment to Lauru – arguing that there is a need for some form of forced treatment – is not arguing for inhumane treatment, what you experienced. That is horrendous and inexcusable. we need to expand community resources and also to maintain an emergency residential treatment system to meet needs of people of all ages in safe and intelligently run centers. Your report reminds me of a friend who spent 7 days in a jail – related to a mental health issue- where his meds. were taken, not dispensed, and not returned until 3 wks after discharge, where there were 70 men to a single toilet – and no protection from predators. And this is 2012, not 1892

  14. My grandmother was a violent alzheimers patient…..she beat up my grandfather with her cane & destroyed everything in their house by the time we were able to get her to a safe care place. There were times there when her violent anzheimers came out against the care givers also…..& the only solution they had was to give her drugs to calm her down. My Grandfather visited her every day, so it wasn’t that she got dumped off in a poor care giver place & ignored…..the place was one of the best in the area & clean & spotless with the best care givers I have ever seen who had patience for the elderly who also suffered from dementia, alzheimers & other illnesses.

    I am sure that my grandmother’s treatment was involuntary on her part…..she had no idea what was going on by that point……but if you stop all forced treatment….then you would stop treatment for people who suffer like this also…..& that would NOT be right for them either. There has to be a solution that is better than just a blanket this or that…..everything is on a case by case basis & when we start to generalize, we start to make very unwise decisions…..but like I commented before….I think that the involuntary care needs to be controlled to a higher degree & standards need to be made & enforced so that the dignity of the person can be maintained to the utmost level of care

  15. I think the point is the person who has lost their mind has lost their free will too, by forcing competent treatment you’re not taking freedom away, you’re seeking to restore it by returning the person to health.

    I’m bipolar, thanks in part to forced incarceration in mental health facilities I’ve been well for many years and am known at work as “the only sane person here” if they only knew many years ago I’d attacked moving cars (totally evil, planet destroying cars, in my view at the time) with an umbrella, needless to say I, and possibly other people, could have ended up dead if the police had not thrown me in the loony bin!

    Society also has has a right to protect itself from people like me when we are raving mad, in some societies the only defence at hand is to kill mad people, forced treatment is better than that at least. I don’t think it’s possible to do nothing about such disruption, I don’t see how it can be delt with without force of some kind.

    No doubt forced treatment can and has been abused, I’m against forced shock treatment. I also think, ideally, a patients family/friends should be able to say no to forced treatment with any particular professional they don’t want, if they seem incompetent, negligent, evil (the helplessness of the incarcerated mentally ill can attract evil people in my experience, more often nurses than doctors) etc, though often there may be no choice in a small community.

    Cheers, interesting topic

  16. I was given ECT voluntarily but was told I would only lose about 4 weeks of memory. I lost 4 years of memory and that included all of my 4 year old granddaughter’s childhood! I forgot I even HAD a granddaughter! I’ve also experienced horrible side effects from medications, especially from Klonopin which caused me to become catatonic. The very idea that some ignorant psychiatrist or doctor could force me to take a dangerous medication horrifies me. Would the fact that I now have a Medical Power of Attorney, a family member, stop a doctor from having that control over my life?

  17. Perhaps convincing a panel of mental health professionals that commitment in necessary should be a step in the road to involuntary treatment. Logistics would be difficult, but the district attorney convenes a grand jury… Perhaps something similar could be used in lieu of a judge’s decision (or perhaps in addition to).

  18. Mark:

    The situation you describe was of you being harmful to others (or at least their property). Nobody’s saying that if someone becomes a threat, that they shouldn’t be taken out of society and placed somewhere that they can’t do harm. But being mentally ill doesn’t necessarily mean you don’t have free will, and forced treatment isn’t giving free will, unless you agree to yourself that you need the treatment. If someone doesn’t think they need the treatment and never sees it as a good thing, their freedom is taken away.

    Again, if someone is harmful or seriously disruptive, that’s one thing. But just because someone might need treatment doesn’t mean someone else should be able to decide what that treatment is. Again, drugs and ECT can have serious consequences. Even if a person isn’t thinking rationally, s/he should have control over his/her body. Perhaps a person who some think needs forced treatment could be offered a choice: Jail or a mental hospital (but not forced meds, except *possibly* in the case where they may need to restrain someone and aren’t able to do so physically). Individual cases have to be examined individually, but in most cases, I say no, forced treatment is wrong. There are other ways to handle such people.

  19. It is fascinating how people rationalize competency and responsibility is left to legal matters, be it arrests or civil matters decided by judges. Again, I would like to hear from someone who has been on the receiving end of chaotic and dangerous behaviors by people who seem to be suffering from mood/thought disorders, who at one point had the capacity to make responsible and appropriate choices, but didn’t, and if left to Dr Grohol and supporters, these people are just left to their own devices or jails/graveyards.

    talk about kicking the can down the road like the “Fiscal Cliff” crap ongoing, jeesh, do people really understand what is the usual situation where someone is deemed needing involuntary commitment for at least 72 hours? And by the way, I have released people who were hospitalized after an involuntary commitment within 72 hours. Being admitted does not infer all are inpatient for weeks to months.

    Accountability and liability, are readers choosing to ignore that aspect of mental health behaviors at risk to the public? Ask the owners of the movie theater in Colorado what they think.

    • Oh, and by the way, I haven’t done inpatient work in a few years now outside brief temp work for a state hospital, but last I did acute inpatient care work, the increasing percentage of addicts using inpatient facilities for detox or escape from responsibilities, some of these folks get involuntary committed while intoxicated or in acute detox, and they are not very cooperative once they get some lucidity in place.

      Don’t confuse them with true primary Axis 1 patients.

    • “I would like to hear from someone who has been on the receiving end of chaotic and dangerous behaviors by people who seem to be suffering from mood/thought disorders, who at one point had the capacity to make responsible and appropriate choices, but didn’t, and if left to Dr Grohol and supporters, these people are just left to their own devices or jails/graveyards.”

      I’m the mother of an adult son diagnosed with schizophrenia and have been on the receiving end of such behaviors. I’ve been struggling with this for over 7 years now. I’ve reached the same conclusion that Dr. Grohol has. I do think you’ve mischaracterized his position, because he seems to advocate some kind of intervention in the case of imminent danger. I would distinguish between forced treatment and involuntary detention btw.

      My views on this are shaped by my interactions over many years and in many crisis situations both with my son who is dx’d with sz and with my adopted son whose issues are more along the lines of PTSD and some kind of personality disorder. In these situations I’ve used a variety of resources, including family/friends, neighbors, crisis hotlines, police, and mental health and medical professionals (i.e., the emergency room). I’ve had my son involuntarily hospitalized. I’ve forced him to sign himself into the hospital. I’ve had him arrested and taken to jail.

      What I’ve learned:

      1. The single most important thing in determining the outcome of a crisis is how calm I remain.

      2. The single most important things in determining how calm I can remain are how well I’m caring for myself and how much support/resources I have.

      3. The best way to avoid the kinds of situations that lead to crises is to have a trusting relationship and a safe, stable living situation.

      4. Forcing treatment doesn’t lead to trusting relationships. It fosters paranoia and drives the vulnerable person to avoid the people who care most about him and are in the best position to keep him safe.

      5. When I reflect back on various crises, even the ones that seemed the most threatening and dangerous at the moment, there isn’t a single one that I don’t think could have been resolved better if I had acted calmly rather than out of fear or anger.

      I suspect that one of the assumptions behind forced treatment is that the problem is within the patient. I’ve come to realize that this is simplistic. The problem is often as much to do with the relationship, the interaction, or the environment.

      I strongly believe that I changed the trajectory of my son’s life by changing my approach to him and to his illness. He went from literally believing that I was trying to kill him to trusting me to advise him. As a result he now sees a therapist and a pdoc regularly, takes his medication, takes care of his physical and mental health, manages his finances, and is trying to move his life in a more positive direction.

      This didn’t happen overnight, and it wouldn’t have happened at all if I hadn’t come to the realization that I was never going to win in the battle to force him to swallow medications he didn’t want and didn’t see the need for. And thank God I couldn’t win that battle, because the damage to our relationship far outweighed any advantages of medication. We all need safe environments and healthy, loving relationships – especially emotionally fragile people. As long as my son and I were engaged in this battle over medication, he had neither.

      I guess the emergency room doctor or the mental health evaluator called in for an involuntary commitment or the police officer arriving at a family blow up can only use the tools they have to defuse the situation. They’re confronted with a wild and/or irrational person and frightened and/or angry family members demanding that they DO something. But these professionals are only seeing one teeny tiny piece of a much larger picture. It may seem that the source of the trouble is obvious, and that if the mentally ill person can be kept medicated, the problems will abate. Neither is true. The crisis is most likely just the eruption of ongoing simmering problems within the environment – not just a random insane misfiring in the mind of one individual. And keeping the mentally ill person medicated is no guarantee that there will be no blow ups. (My son had his two most serious incidents during times when he was being forcibly medicated.)

      In my view, the mentally ill person needs a safe living environment, caring relationships characterized by mutual respect, and the chance to be genuinely heard and taken seriously.

      • Your final paragraph is just right.
        For fifty-eight years I have lived with family and friends who have various degrees of mental illness. My wife and I agreed to take into our home people with serious problems, mostly some form of mental illness.

        The trusting, loving home, and our support made a difference. People gradually in a couple of years were able to manage their illness. It would have been much easier if the mental health system was cooperative. It often, indeed, usually made things worse. Some of our friends who didn’t live with us, were in an out of the hospital, unnecessarily, I believe; but there weren’t supportive places to live with people who would care.
        For the last thirty-five years my spouse, Diane, has been key to our involvement. Working from her own illness, she has developed a vast resource of knowledge and advocacy. And, apparently both of us have made some enemies in the system.
        Both of us oppose forced treatment, but also try to protect people from danger.

  20. Hello,

    After reading the article and most of the comments, I was thinking, if the justification for forcing treatment on someone is that a psychiatric patient isn’t in their right mind, not recognizing illess, etc, then way don’t people who have a risk for developing psychosis or mania or depression that would require intervention because of say, threats of suicide have the conversation about what they would like done to them before they lose the ability to think rationally. If you know you might end up in a situation where you would have your rights taken away, you could have a document on you that says what treatment decisions you planned out when you had all the info in front of you and time to think about it. Or in the very least, allow the person to choose their long term course, after meds were used to initially treat them.

    Personally, I feel like our treatment focuses on eliminating the symptoms that are disturbing to society in the quickest manor possible. Medicines have taken on that role, despite lack of evidence that says they work as doctors claim they do. If I were in a situation where I needed immediate help, I would still resist meds in the long term. I have the right to navigate the world under my own devices, even if I have been diagnosed with a reoccurent mental ailment. I know what I’m up against, and I know I will have to plan around it. A doctor forcing meds on me would be more of setback than a help. That’s my opinion. I’m not antipsychiatry, but I have a lot against how treatment is given now.

  21. Dr. Hassman:

    You keep saying Dr. Grohol and those of us against forced treatment are against it in all cases, even if a person is violent. That’s not what anyone’s said. We understand there are times when someone is a danger, and we need to protect the people they’re seeking to harm. But we need to do that in the most absolute of cases. We need extremely strict guidelines and rules on how to manage extreme and violent cases. If a person is not violent, but is seriously disrupting the home, that person may need to be forced out of the house, but that doesn’t mean they need to be forced into treatment. They should be offered a choice, such as, “You’re not welcome to stay in this home, but we will accept you for mental health treatment, if you’re willing.” The family certainly has a right to kick out someone in their home who is harmful or belligerent. The family may not wish to do that, but everyone’s rights need to be respected, not just the “normal” people’s.

    Finn: Do you mean a Psychiatric Advanced Directive? You can find information on those here: http://www.nrc-pad.org/

  22. The same commenter, Hassman, talks about the risk to providers.

    The preponderating weight of violence on this issue is done against mental patients, by those “carers” and “providers” whose safety you worry about, not by them against these “carers” and “providers”. If the patient hits a psychiatrist or a psychiatric nurse, this is deemed as violence, but when the psychiatrist or nurse abuses with far graver consequences for the health of the patient, we as a society call this “treatment”.

    This double standard seems to imply the existence of a hitherto unacknowledged doctrine in psychiatry, that of a kind of psychiatric antinomianism, the non-applicability of moral law to those who practice the psychiatric faith.

    If the rest of us did what psychiatrists and their subordinates often do, this would expose us to the odium of the populace as well as moral and legal scrutiny. The moral laws that govern our conduct do not apply to psychiatrists, seemingly. They con people (usually very vulnerable people of all ages, sexes, colours and creeds), incarcerate the innocent, deal toxic drugs, force people to take toxic drugs, many of them present perjured testimony in a court of law etc.

  23. Interesting article, undoubtedly sensible and certainly an issue that is so ignored as to somehow not even be on the radar screen when it comes to discussing the rights of the mentally ill. I agree with all your points. Let’s take it one step further – Is there really something called “voluntary admission” to a psychiatric facility? I would argue NO. As a licensed social worker and a person in recovery who has been “voluntarily” admitted, I realize that this word means nothing more than “we will let you go into the hospital under your own volition, however, once you are there, it will be next to impossible to sign yourself out.” If you refuse voluntary, well then good luck avoiding the involuntary route. I was never able to sign myself out as a voluntary admission. I was told that it would take three days and meeting with an advocate (or an attorney) to sign myself out. The “doctors” then made every possible attempt (including mild or not so mild threats) to keep me in the hospital. Three days, turned into six days, etc, etc. So let’s also consider what “voluntary” as well as involuntary commitment means for a psychiatric admission. The bottom line is – power is lost once an authority feels that a person needs hospitalization. If a person is not a danger to himself or others, then the “voluntary” method is used to achieve the same end.

  24. Least Restrictive practices are the way to go. We emptied the mental institutions and opened the doors to prisons with out ‘get rid of the whole thing mentality’.

    Saying let them just die if they so choose is a political talking point of the libertarians. Most are bombastic and long winded with plenty of rhetoric as you can see some of them posting here. But this is an understated, and every so compassionate in voice.

    I’m in perfect agreement with least restrictive practices. These kind of things can be worked out. Abandoning people who ‘act’ mentally ill, who may not even be mentally ill is wrong.

    I’m very well aware of the excesses and I chafe at them. Filling our prisons with people who suffer, who are terrified of accepting they have a problem, and terrified of what treatment might mean for them, (if they can even get it) is a blight.

    Prison is not the place for the mentally ill, abandoing them is not the answer.

  25. I just found this article when i was searching Forced Treatment. I am a patient Advocate and see Treatment and Forced hospitalization on a regular basis. The disturbing issue is these are not Mentally ill patients nor are they a danger to any one. If any one reads this, from this site please contact me at the email i provided. I would be happy to share this information with you. I believe this is a violation of civil and human rights, I am told this is not and it can happen to anyone. Would like your advice as , what to do with this information. Thanks

    • Again, to reiterate what many people have said here: forced treatment is WRONG, straight up. As someone who has passed through the mental health system and spent two months in an institution, I can only describe the experience as truly dehumanizing and certainly detrimental to my already frail state of being.

      I maintain that shoving someone in to such a horrendously depressing, degrading and humiliating place is only depreciable to someone suffering from severe depression/ mixed episode. People with this mood disorder already feel disgusted with themselves, and largely defeated. Putting them in to a place that essentially re-emphasizes this is simply worsening an already terrible situation.

      I have no words to describe the so called “imminent danger” institutionalization posed to me. As someone who was a high achieving student, well liked and set to go in to business only a year after my first major episode occurred – I can say with complete honesty that institutionalization – and particularly the so called professionals within it – made me feel as though my dreams were invalid due to my disorder and experience. It was enough for them to take away my freedom, dignity and voice . Taking my dreams from me was possibly the worst thing i believe the staff could ever do, and I remain disgusted at their mindsets.

      In the ICU section where I spent 7 days at the age of 20, there was a male ex-prisoner in the same locked facility. One day, when I was really lowly, he asked me to give him a blow job. In my self-loathing and deprecating state, I swore at him and tried to defend my honour. I still had enough self-respect to throw in his face, but I again, hold nothing but utmost contempt and disrespect for the treatment of those in MHC. To put incredibly vulnerable and terrified young girls without a crime to their name in to the same locked room as a male ex-criminal who beat his fiance is an absolute disgrace.

      I never once posed a threat to another human being when i was ill. Only myself – and yes, I made a suicide attempt. I’ve recovered now, but I maintain that given the pain and thoughts I was experiencing, this was entirely valid. Never have I doubted the reality of what I felt in those moments.
      As someone recovered, I can look back at this moment in time and justify that attempt entirely without ever believing there was no validity to the pain. The only difference now is that it is no longer there, thus I can live life as “normally” as everyone else. A psychologist/psychiatrist has no place in invalidating what I felt then as “crazy”. If he were to feel how I had felt, then he would find himself wanting death equally as much. Most will not believe this concept though, for love of their own supposedly superior mental health.

      Thankfully I did go in to business, and I did everything I was told I couldn’t do and more.
      This system has to change – no qualms. It is disgusting and beyond unjust.

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