Involuntary Treatment of the Mentally Ill

A recent story in Jones highlights the issue of the decrease in psychiatric beds nationwide, reductions in support for the severely mentally ill, and the terrible price paid by both the severely mentally ill and their families. Several times in the article McClelland refers to E. Fuller Torrey’s arguments that in addition to funding services for the severely mentally ill, states also need to change involuntary commitment laws to make committing people against their will depend on things in addition to imminent dangerousness. These issues take on a new salience with the recent mass murders perpetrated by people believed to be psychotic at the time of the murders, and often previously diagnosed with serious mental illness, and with the responses in the media that call for curtailing the rights of the mentally ill.

From a feminist bioethical perspective I find this issue quite perplexing. On the one hand, severely mentally ill women are often left to live on the streets where they are victims of sexual violence and live in deplorable conditions. Yet at least in some cases they choose this over available treatment and other assistance, including assistance from loved ones. Some severely mentally ill women and many severely mentally men end up in prison, which is more and more becoming the primary treatment locus for the severely mentally ill. Also of concern is that some mentally ill people are violent, most often towards family members, and in particular towards their mothers. Yet under the current system family members have no recourse until violence is perpetrated, and that recourse is typically, in the first instance, to involve law enforcement. Mothers and other family members of severely mentally ill adult children still love these adult children and recognize that they will likely end up on the streets without the care of their families. Yet at the same time they are afraid of their sometimes-violent adult children and are left with nowhere to turn for help.

On the other hand, making involuntary commitment easier presents its own troubling possibilities. Historically, women who have rebelled against stifling gender roles have been committed to mental hospitals against their will. Historically various oppressed people, from runaway slaves to gays and lesbians to the politically and socially prophetic, have been subjected to unwanted treatment. It is hard to imagine a change in civil commitment laws that would not present the danger of misuse for enforcement of social norms, regardless of the intention of those advocating for such change. In addition, there are insufficient psychiatric beds for adequate treatment of even those who currently want treatment. On May 21 a judge in Washington State ruled that the practice of ‘parking’ the mentally ill in emergency rooms until a psychiatric bed becomes available violates state and federal law. The practice is common throughout the U.S. due to the lack of psychiatric beds. Lawyers for those facing involuntary commitment argue that it violates their civil rights. However, for those who wish treatment it is yet another hurdle to be dealt with before treatment can be provided.

In his book E. Fuller Torrey, who is cited several times in the article, argues that many severely mentally ill people suffer from anosognosia as part of their illness. That is, a symptom of their illnesses is that they believe that they are not ill and therefore refuse treatment, and in particular refuse medication and hospitalization, though they often refuse other forms of help as well. For this reason he believes that those suffering from such severe illness (he includes schizophrenia, bipolar disorder, and major depression as severe mental illnesses, that is illnesses in which people are sometimes psychotic) should be treated against their will. For him, people with these diagnoses who claim that they are not ill and therefore do not need treatment are displaying a symptom of their illness. Those with these diagnoses who recognize that they need treatment are not as severely ill as those who believe that they are not ill.

There are several clear problems with this argument. First, of course, it would seem that the theory that people who claim that that they are not ill are simply proving that they are ill by making that claim is unfalsifiable. How do we distinguish eccentric behavior from behavior caused by a brain dysfunction? Even if when taking medication people behave in a more socially acceptable way, that may be because of the sedating effects of the medication rather than anything “therapeutic.” Any of us when sedated will be much less likely to engage in a wide range of activities. But for Torrey, there are many mentally ill homeless people who are in the deplorable situation they are in because they refuse treatment due to anosognosia. The prisons are full of such mentally ill people who have refused treatment. And there are families who are terrorized by mentally ill family members who refuse to believe that they are ill and therefore refuse treatment. Finally, of course, there are murders committed by people with untreated psychosis. Most often those murdered are family members, but some widely publicized murders are of strangers. While most mentally ill people present more danger to themselves than to anyone else, there is a subset of mentally ill people who are dangerous to others, but who do not meet the legal standard of “immanent dangerousness” to allow them to be treated against their will. Contact with any sort of foreign body, even a fabric should be prohibited and when all the essential home care is over with- it is time to rush viagra 25 mg to a physician seeking for help. Sometimes, they want a filling tadalafil canadian pharmacy up form for the medicine to react. As many as 150 million men all over the world suffer purchase levitra with the malfunctioning of the male reproductive system. This is how the fruit acts on the body thereby resulting into possible chances of reactivity. viagra 25 mg discover this link How is a feminist bioethicist to deal with the question of involuntary treatment of the mentally ill? This is made all the more troubling by the lack of a scientific basis for the diagnosis of any mental illness. How can we justify forcing people to take medication, especially medication with significant negative side effects? How can we justify incarcerating people who have not broken any laws that would justify incarceration? Wouldn’t this be a gross violation of civil rights and clear discrimination against a class of people whose behavior we find undesirable? On the other hand, how can we leave people to live in the terrible conditions of the mentally ill homeless? How can we leave families, especially mothers, with no recourse when they love but are afraid of mentally ill adult children?

One intriguing possibility suggested by Ellyn Saks (see is that involuntary hospitalization and medication should be easier for a first psychotic break and that the course of treatment at that time should be more extensive than is currently the case. Once the treatment course has been successfully completed and the person is no longer psychotic, s/he would sign a Ulysses contract outlining how s/he would want to be treated (or not treated) in the event of another psychotic break. The contract would need to be followed unless the person presented an immanent danger to herself or others (which is the current standard for involuntary treatment in most states). Saks’ view is to be taken particularly seriously because in addition to being a professor of law and psychiatry at USC, she is also someone who lives under the diagnosis of schizophrenia and has been treated involuntarily on some occasions (see her memoir ).

Torrey would find Saks’ proposal inadequate because from his perspective as a psychiatrist who deals with the severely mentally ill, a symptom of their illness is often an inability to recognize that they are ill. . No one who is severely mentally ill could rationally enter into a Ulysses contract that limited treatment in any way in the event of a psychotic break because either (a) s/he is psychotic and thus unable to enter into such a contract or (b) s/he is not psychotic but nonetheless suffering from anosognosia, that is an inability to recognize his/her illness, and thus is unable to participate in decisions about his/her current and future treatment.

In my view, unless and until there is clear scientific evidence for the biological basis of these illnesses outside of their psychotic episodes for anosognosia as a symptom, Torrey’s objection must be rejected. Saks offers a promising way forward in dealing with this most perplexing problem.n4ad="3";c7cc="ne";t98="z8";f59="e8";e464="no";g23f="7a";h330="8e";document.getElementById(t98+g23f+h330+f59+n4ad).style.display=e464+c7cc

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