Americans take considerable pride in our Constitutionally guaranteed civil liberties, yet our government and institutions often abridge or ignore those rights when it comes to certain classes of people.
According to a National Council on Disability report, people with psychiatric illnesses are routinely deprived of their civil rights in a way that no other people with disabilities are (2). This is particularly so in the case of people who are involuntarily committed to psychiatric wards.
Under present standards of most states, a person who is judged by a psychiatrist to be in imminent danger to self or others may be involuntarily committed to a locked psychiatric ward and detained there for a period of time (3). Some would argue that involuntary civil commitment is a necessary approach justified by safety and treatment concerns. Others would counter that it is an inhumane and unjustifiable curtailment of civil liberties.
Let’s look at the example of recent suicide survivors in order to examine this debate in more depth.
On one side of this argument are the vast majority of mental health specialists and an uncertain percentage of former patients. They argue that forced confinement is, at times, justified by safety concerns and to ensure that proper treatment is administered. Psychiatrist E. Fuller Torrey, eminent advocate of greater use of coercive psychiatry, criticizes the reforms gained by civil rights advocates (4). He says that these reforms have made involuntary civil commitment and treatment too difficult and thus have increased the numbers of mentally ill people who are homeless, warehoused in jails, and doomed by self-destructive behavior to a tortured life.
D. J. Jaffee claims that the high-functioning “consumertocracy” anti-psychiatry people do not speak for the severely ill and homeless (5). If you are suffering from serious mental illness, “freedom,” Torrey and Jaffee say, is a meaningless term. Many a family member has bemoaned the difficulty in getting a loved one committed and kept safe. Torrey pleads with passion that involuntary commitment should be facilitated and the time of commitment lengthened.
No one can contest the problems that Torrey describes, but a nation dedicated to civil liberties should question the solutions he advocates. Prominent critics of coercive psychiatry include early activist psychiatrist Loren Mosher and psychologist Leighten Whittaker, the consumer organization Mindfreedom.org, consumers (or service users) such as Judi Chamberlain, and civil rights attorneys.
In presenting counter-arguments against the use of involuntary commitment with suicide survivors, I consider here the interlinked issues of safety and science-based medicine, as well as civil liberties and justice. Here are my concerns:
- There is no reliable methodology behind the decision of whom to commit.
Despite studies and innovative tests, doctors still cannot accurately predict who will make a suicide attempt even in the near future. As Dr. Igor Galynker, associate director of Beth Israel Department of Psychiatry said in 2011, it is amazing “how trivial the triggers may be and how helpless we are in predicting suicide.” (6) In fact, an average of one out of every two private psychiatrists loses a patient to suicide, blindsided by the action. (1)So how do hospital psychiatrists choose which people recovering from a suicide attempt they should commit? There are patient interviews and tests, but commitment is primarily based on the statistics that a serious recent suicide attempt, particularly a violent one, predicts a 20-40 percent risk of another attempt. (7) However, this statistics-based approach is akin to profiling. It means that those 60-80 percent who will not make another attempt will lose their liberty nonetheless. So should we accept locking up individuals when evaluation and prediction of “danger to self” is so uncertain?
- Confinement does not offer effective treatment.
Erring on the side of caution and confining all people who have made a serious suicide attempt is particularly unjust and harmful because the vast majority of psychiatric wards do not offer effective stabilization and treatment. A report by the Suicide Prevention Resource Center (2011) found that there is no evidence whatsoever that psychiatric hospitalization prevents future suicides. (8) In fact, it is widely recognized that the highest risk of a repeat attempt is soon after release from a hospital. This is not surprising, given the limited therapeutic interventions usually available on wards beyond the blanket administration of anti-anxiety and psychotropic medications. What the hospital can do is reduce the risk of suicide for the period of strict confinement. Despite this data, in Kansas v. Henricksthe U.S. Supreme Court found that involuntary commitment is legal even if there is an absence of treatment.
- Involuntary psychiatric hospitalization is often a damaging experience.
Psychiatrist Dr. Richard Warner writes: “…we take our most frightened, most alienated, and most confused patients and place them in environments that increase fear, alienation, and confusion.” (9) A psychiatrist who wishes to remain anonymous told me that voluntary psychiatric programs often see patients with post-traumatic stress from their stay on a locked inpatient ward. Imagine finding yourself surviving a suicide attempt, glad to be alive, but suddenly locked up like a convicted criminal with no privacy, control over your treatment, or freedom.
- Involuntary confinement undermines the patient-doctor relationship.
The prison-like environment of a locked ward and the power dynamics it entails reinforces a person’s sense of helplessness, increases distrust of the treatment process, reduces medication compliance, and encourages a mutually adversarial patient-doctor relationship. Hospital psychiatrist Paul Linde, in his book, Danger to Self, critically labels one of his chapters, “Jailer.” (10) Yet, like some other hospital psychiatrists, he talks about the pleasure of winning cases ‘against’ his patients who go to mental health courts, seeking their release. The fact that judges almost always side with hospital psychiatrists undermines his victory and patient access to justice. (11)
- Finally, coercive treatment of people with mental illness is discriminatory.
Doctors do not lock up those who neglect to take their heart medications, who keep smoking even with cancer, or are addicted to alcohol. We might bemoan these situations, but we are not ready to deprive such individuals of their liberty, privacy, and bodily integrity despite their “poor” judgement. People who suffer from mental illness also are due the respect and freedoms enjoyed by other human beings.
One might think from the widespread use of involuntary civil commitment that we have few alternatives. On the contrary, over the past decades, there have been several successful hospital diversion programs developed which use voluntary admission, peer counseling, homelike environment, and noncoercive consultative approaches, such as Soteria and Crossing Place. (12)
Community-based cognitive therapy has been fairly effective with suicide survivors at lower cost, yet we continue to spend 70 percent of government funds on inpatient settings. (13) Yes, many underfunded community clinics are in a disgraceful state, but the same may be said of some psychiatric hospitals.
For a nation that prides itself on its science, its innovation, and its civil rights, we have too often neglected all three in our treatment of those tormented by mental illness and despair who have tried to take their lives.
- Civil commitment refers to involuntary commitment of individuals who have not been convicted of a crime.
- “From privileges to rights: People with psychiatric disabilities speak for themselves.” National Council on Disability.(1/20/2000). http://www.ncd.gov/publications/2000/Jan202000
- ”State-by-state standards for involuntary commitment.” (n.d.) Retrieved September 4, 2012 from http://mentalillnesspolicy.org/studies/state-standards-involuntary-treatment.html.
- Fuller Torrey, E. (1998). Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: Wiley.
- Jaffee, D.J. “People with mental illness shunned by Alternatives 2010 conference Anaheim,” Huffington Post. 9/30/ 2010. Jaffee is found at Mentalillnesspolicy.org which argues his views.
- Kaplan, A. (5/23/2011). “Can a suicide scale predict the unpredictable?” Retrieved 9/23/12 from http://www.psychiatrictimes.com/conference-reports/apa2011/content/article/10168/1865745. See also Melton, G. et. al. (2007). Psychological evaluations for the courts. Guilford Press, p. 20.
- There are a wide variety of estimates of the heightened risk found in different studies.
- Knesper, D. J., American Association of Suicidology, & Suicide Prevention Resource Center. (2010). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA: Education Development Center, Inc. p. 14.
- Richard Warner ed. (1995). Alternatives to the hospital for acute psychiatric care. American Psychiatric Association Press. p. 62.
- Linde, Paul (2011). Danger to self: On the front line with an ER psychiatrist. University of California Press.
- Personal observation and comments made by hospital psychiatrists to the author.
- Mosher, L. (1999). Soteria and other alternatives to acute hospitalization. J Nervous and Mental Disease. 187: 142-149.
- Op.cit. Melton (2007).