A Client Perspective of
Mental Health Courts and the Use of
Force and Coercion
A Compilation of Writings
Addressing the Issue of Mental Health Courts,
Coercion, and Recovery Approaches
Mental Health Courts: Pat Risser 4-9
National Mental Health (MHA-Mental Health
America) position on Mental Health Courts 7
Faulty Compliance Assumptions 9
MacArthur Coercion Study and IOC 10
Disability Rights Model vs Medical Model;
Disease vs Recovery Model 11
Opinion: William A. Anthony, Ph.D. 12
Additional Thoughts: Pat Risser 13
How the System Is Broken 14
Mental Health and Human Rights: Sylvia Caras, Ph.D. 15
A Fairy Tale: Coni Kalinowski, M.D. 16
Opposition to involuntary outpatient commitment bill
In California (March 2012) 17
NASMHPD, WHO study, Early Death 18-19
Psychiatric Drugs and Death 20-25
Against Forced Treatment: Robert Whitaker 26
WNUSP on Mental Health and Prisons 27-31
Terminology – Psychosocial Disability 32
Involuntary Psychiatric Interventions:
A Breach of the Hippocratic Oath? by Peter Stastny, M.D. 33-49
Mental health services in this country consist mainly of voluntary and involuntary inpatient stays, diagnosing, prescribing daily psychiatric drug regimens, day programs, entitlements, electroconvulsive therapy and ³treatment² that is either forced or coerced. These therapies are driven by the idea that emotional distress can be reduced to an abnormality in the brain or the unproven theory that there is a chemical imbalance. This medical model approach of seeing symptoms as evidence of disease or pathology has perpetuated a reliance on medication and symptom management as adequate responses to mental illness. The system¹s biological approach reduces human distress to a brain disease, and recovery to taking a pill. The focus on drugs obscures issues such as housing and income support, vocational training, rehabilitation, and empowerment, all of which play a role in recovery.
Our entire system of care for people with emotional distress is built around illness. This is a negative approach. We diagnose illness. We complain of illness. We treat illness. We label illness. Even wellness means an absence of illness so we treat the symptoms of illness. Recovery means getting over illness. The person who is ³well² is one who causes no community disturbance, no matter how disabled or incapacitated they may be (often as a result of ³treatment²).
The outcomes of this approach have resulted in a 25-year reduction in life span for people receiving public mental health services, according a study led by Dr. Joe Parks for the National Association of State Mental Health Program Directors. It has also significantly increased the number of people on Social Security Disability Insurance, the suicide rate, the incarceration rate and the homelessness rate, according to the National Association For Rights Protection And Advocacy and others who have studied results of mental health treatments. The most detrimental ramification of the current approaches to mental health services and treatment is that they tend to deprive hope.
Adherents to the medical model believe that a disabled person's problems are caused by the fact of his or her disability and thus the question is whether or not the disability can be alleviated. Advocates of the disability-rights model, on the other hand, believe that a person with a disability is limited more by society's prejudices than by the practical difficulties that may be created by the disability. Under this model, the salient issue is how to create conditions that will allow people to realize their potential.
We know outcomes improve if those seeking help from mental health facilities are aided by peers who have experienced firsthand comparable struggles and know the path to recovery. Such peer-to-peer relationships can provide critical mutual and empathetic support. Individuals in the peer role are ideally suited to facilitate the process of fellow consumers employing wellness tools such as yoga, meditation/mindfulness, movement and intentional exploration of the impacts of nutrition on states of mind.
Everyone working in the system needs to be educated to promote the belief that individuals labeled mentally ill will recover. They need to promote and encourage the creation of life goals and movement toward them. This creates a framework through which to direct one's treatment — rather than simply devoting time and effort toward analyzing, mitigating and correcting symptoms or problems.
We must reconsider relying on psychiatric-drugs as the first line of defense (particularly when treating children). Peer support — which offers self-disclosure as a tool that provides hope and suggested wellness tactics for individuals who welcome such information — must be available to every person entering any part of the mental health system. Support that is sensitive to trauma issues is necessary and creates places where people can feel safe to heal.
Mental Health Courts
(compiled and written by Pat Risser)
In advocating for mental health courts, Rusty Selix, the executive director of the Mental Health Association in California, wrote, "Unfortunately, across the United States, people with mental illnesses are overrepresented in prisons and jails. In California alone, it is estimated that between 20 percent and 25 percent of all California prisoners are afflicted with serious mental health problems such as schizophrenia and bipolar disorder." (http://www.nctimes.com/articles/2007/07/15/perspective/20_15_047_14_07.txt)
Mental illness is a concept subject to debate. There are no biochemical markers, no biological tests, no hard evidence at all, to "prove" the existence of "mental illness." Proof means the ability to demonstrate a reliable association between a clearly specified pattern of observables and other reliably measurable event(s) which operate as antecedents. (This is same level of proof used for TB, cancer, diabetes, etc.) In addition, it is not sound medical practice to label our thoughts, moods, feelings or emotions a disease, disorder or illness.
It is claimed by some that mental health courts will provide a stopgap to prevent mentally ill offenders from becoming part of the prison system. Part of my problem is that while we're allegedly seeking equality, we're also seeking "special" treatment. So SB 851 provides a stopgap for "mentally ill" offenders. What's next? A stopgap for offenders with blond hair and blue eyes? How about offenders who can wiggle their ears? Why should any "offender" be treated differently? Allegedly, mental health courts will offer alternatives to defendants with "mental illness." Isn't that everyone? Hasn't the DSM just about reached the point where we're all in there somewhere? Supposedly the law will target only those ³most seriously ill,² those with bipolar or schizophrenia. But, there is no training to allow law enforcement or judges to diagnose.
Most legislation for mental health courts claim that they will, when appropriate, offer defendants an opportunity to participate in court-supervised, community-based treatment in place of typical criminal sanctions. What is "community-based" treatment and is it, in reality, anything but forced drugs administered by the decree of psychiatrists? It's a shame to surrender the criminal justice system to psychiatry. I believe our criminal justice system belongs to and should remain the purview of those who have been trained in the law. Lawyers, judges and other legal advocates have a much greater awareness of peoples' rights and their obligation to defend and protect those rights.
Setting aside the "mental illness" debate for a moment, there are at least two other obvious solutions. First, law enforcement can choose to not arrest folks. There would be fewer problems if they turned an unseeing eye toward minor offenses. Shoplifting a candy bar because you¹re hungry or urinating behind a bush because you¹re homeless won¹t be solved by forcing people to be labeled and forcibly drugged. The other solution is that people (not just those labeled "mentally ill") should not break laws. Fewer broken laws equals fewer arrests equals fewer in jails and prisons. If people choose to break laws, perhaps they should heed the saying, "if you can't do the time, don't do the crime." We need outpatient services that include peer support and focus on recovery. With education, people can learn that there are alternatives to help get their needs met instead of breaking the law.
Another solution would be to have the police be able to call a peer case manager who could come to the scene and assess the situation. This peer could have the authority to release the officers back to patrol and save time, money, paperwork and efforts that tie up the officers. The peer could help deescalate the situation, calm the person and direct the person to aid and assistance that would not be coercive. The program has been highly successful in places where it's been tried (Citywide Case Management in Denver, Colorado, circa 1988).
Mr. Selix states that, "Effective mental health treatment is the missing element of corrections reform." The "system" has been working at getting better and more "effective" for many, many years. If their efforts are tied to the increase in prison population then I guess they haven't done a good job. The only folks I'm seeing get much better are those who are connected to solid peer supports and services. It seems a shame to refer people (or rather "sentence" them) to a system that the President's New Freedom Commission said is, "in a shambles." Of course, folks in California (like Mr. Selix) should be aware of that since Steve Mayberg (Mental Health Director of California) was on that Commission.
Psychiatry holds a legacy of over one-hundred years during which people identified as having serious mental illnesses were confined to institutions, often for the remainder of their adult lives. This period of institutionalization both gave birth to and perpetuated the belief that these illnesses were permanently disabling. As it turns out, what was permanently disabling was being confined to an institution, not the illnesses themselves. Since the end of that era, epidemiologic and longitudinal studies have found that many people do well over time, and that when they do well, they often see no reason to seek or utilize mental health services.
Mental health courts are segregationist apartheid. (I first heard this term used by Judi Chamberlin.) Any time we take one group and set them apart from everyone else, we are practicing discrimination. What's next? Separate drinking fountains and bathrooms and eating areas and then moving people into ghettos and then labor camps from which they are never heard from again? All done with the approval and acceptance of the law and respecting our 'rights.' What's needed is something where the treatment system is the one ordered to provide real supports to people to help them to live and thrive successfully in the community of their choice. (Federal definition of 'recovery' is, "a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.")
Mental health court should be the court of the mental health system and not the court of people being forced or coerced into treatment that doesn't work. It should not be the court of 'compliance.' Imagine jailing a diabetic for having dessert or incarcerating a person having chronic bronchitis for lighting up a cigarette or forgetting his/her inhaler. No one would find such a solution to public health problems acceptable because it violates people's right to choose their lifestyles and medical treatment. In virtually all other medical concerns, we have upheld individuals' rights in this regard irrespective of the possible risks to self or others. It is absurd to imagine jailing (or threatening to jail) someone for non-compliance with medical treatment. We wouldn't jail someone for not adhering to a diet and eating fast food. We don't treat people "for their own good" over their objections. If you have cancer, you have an absolute right to refuse treatment, even if it means you will die.
Mental health courts are courts of force and coercion and are
indicative of treatment failure and should not be used. Force isn't
treatment. A therapeutic alliance is impossible in the face of force/coercion.
Force and coercion are abuse. MH Courts are solely designed to "force"
medication "compliance." Sure, they claim to only be helping people
to comply with "treatment" but in this day and age,
"treatment" more and more consists solely of medication. People are
just plain contrary and generally non-compliant. Most people don't take the
full ten days of antibiotics as prescribed. They stop when they feel better.
There are endless other examples and studies of non-compliance for heart patients
and people with diabetes. However, compliance is the major concern of the
mental illness system and families who expect those in the mental illness
system to uphold a standard of compliance higher than everyone else.
While complying with 'treatment' consisting almost solely of medications, it's good to remember two particularly damning recent research studies. One found that mental patients in the United States are now living an average of 25 years less than those who escape notice by the psychiatric system. The other study by the World Health Organization found that third-world countries that practice far less 'western medicine' actually have far higher 'recovery' rates. Perhaps less invasive 'treatments' should be emphasized. Perhaps mental health courts should consider that they might be sentencing people to a death sentence of a shortened life span. A life cut by one-third is not a satisfactory outcome to justify the use of force and coercion in a broken system.
Mental health courts create another 'entrance' door into the system yet the system is chronically overcrowded and without enough corresponding 'exit' doors. Our courts are equally overcrowded. It is not the job of the legal system to adjudicate 'treatment.' The legal system lacks the knowledge and expertise to dictate terms of 'treatment' for people and the legal system incorrectly relies upon the medical model of psychiatric care to help people. The medical model of psychiatric care is a failure. Mental health courts are a wasteful diversion of people and resources from the mental health system to a criminal justice system that also lacks resources and connections to the community. And, what about the people who, because they are difficult to treat, will get labeled as 'treatment resistant' or 'non-compliant' and it is due to the inadequacies of the mental health provider or the treatment program. It is claimed that mental health courts are necessary to stop the revolving door of the mental health system and the criminal justice system. Yet, there are no studies to indicate that using the coercion or force of a court system does anything to reduce recidivism. There is no proof that forcing people into "treatment" either reduces recidivism in the mental health system or the prison population.
Mental health courts are typically funded by mental health funds. How did that happen? Was it put to a vote? And, does the mental health system have any obligation to the criminal justice system or should the funds of the criminal justice system cover their own? The mental health system is for those who are psychiatrically labeled and the criminal justice system is for those incarcerated for breaking the law. The two aren't the same and certainly aren't funded the same. Do we want the funds of the mental health system diverted to criminal justice? Doesn't the criminal justice system have lots and lots of their own funds? Besides, there really isn't any mental health system. There's only a mental illness system. People are labeled as mentally ill, treated as mentally ill and given mental illness drugs. As a result, we die an average of over 25 years sooner but hey, aren't we mentally "healthier?"
Mental health courts need to assure that they don't blame the
person for the failures of the mental health system. Instead of creating
courts to force medication compliance, we should spend our valuable time,
energy and resources creating true alternatives that work to divert people into
proven successful self-help programs (that they will desire and therefore
automatically 'comply' with). How do we get people 'out' from under the thumb
of the mental health courts once they are in? In Oregon, people can remain
under the PSRB (Psychiatric Services Review Board for following forensic
patients after their release) system for far longer than necessary. People who
are no longer considered a danger to themselves or others are often forced to
continue to comply with 'treatment' (forced drugs) despite the known dangers of
Most people who have been labeled with psychiatric disabilities have experienced abuse, neglect and trauma – it is wrong to label the result of those experiences as sickness or illness. It is also wrong in a similar way to label the control of the natural thoughts, feelings and emotions that result from abuse, neglect and trauma as healing, recovery or wellness and it is even worse to drug or shock those thoughts, feelings and emotions into control or submission. This IS the medical model and 'treatment' at it's worst. Mental health courts that force people into medication compliance do not consider the whole person and their background, history and other factors. Forcing someone into submission may cause him or her to no longer be a public nuisance, but there is no consideration of how miserable or incapacitated it may make him or her. There is likewise no consideration of how toxic his or her environment may be. Drugs do not help poverty, joblessness, homelessness, abuse and other social ills that contribute to the emotional distresses that cause people to come to the attention of the mental illness system.
The mental illness system deludes, diminishes, discounts and distorts the reality of consumer/survivors by diverting attention from abuse, neglect and trauma and victims' natural reactions. The mental health system shifts the focus to sickness/healing rather than remediation of injustice. While our children are locked in psychiatric units, the parents and other adults who abused, neglected and otherwise mistreated them are continuing their lives free of any consequences. While adults languish in hospitals or drug induced stupors in 'treatment' programs, those who originally abused, neglected or otherwise mistreated them are continuing their lives free of any consequences.
Part of the difficulty of coping with trauma issues can be an
overwhelming sense of hopelessness, helplessness and powerlessness. It is
impossible to learn how to cope with these issues while under a court ordered
³treatment² that induces an overwhelming sense of hopelessness, helplessness
The system blames the victim instead of seeking remediation and providing validation. The system often fails to acknowledge that the people it serves have usually been victims. The system 'treats' these victims by blaming them in the form of labeling them as 'mentally ill.' The system invalidates our experiences and us through the use of its language. Not only are the labels invalidating, so is much of the language. For example, the term 'side-effects' minimizes and trivializes the impact of the very real effects of medication and makes it easier to blame the person for non-compliance. Statements like, "Oh, it's just a side-effect," gloss over our very real suffering and refocus on coercing our compliance. It's tragic how often psychiatrists will dismiss tremors and other uncomfortable and even more serious maladies as "just a side-effect." Sometimes, even death is a "side-effect." In any other social structure, the use of seclusion and restraints would be considered torture and locking people up against their will would be called incarceration and not 'treatment.'
Family members also blame the victim and label behaviors as mental
illness rather than face the fact that the family dynamic is broken. Perhaps
the person was a victim of abuse, neglect or trauma but rather than admit
responsibility, the family will relieve their guilt by labeling the victim as
mentally ill. It attacks the credibility of the individual and if medications
can be used, it can even mask the memories and further cloud the individual and
make his or her to blame.
Drugs are not solutions. Psychiatric drugs need to be used with more caution and restraint. Underlying causes of people's distress needs to be addressed. We can't solve homelessness, poverty, joblessness, abuse and other social issues with a prescription pad. Drugs don't solve poverty issues and they don't heal emotional wounds. People who have poverty issues ought not have to be labeled mentally ill to get housing, meaningful employment, social opportunities, etc. Staff have been mis-trained to equate subduing a person with treatment; a quiet client who causes no community disturbance is deemed 'improved' no matter how miserable or incapacitated that person may feel as a result of the 'treatment.' Someone may go for years and years to a day treatment program where they live from cigarette to cigarette or measure time from Big Gulp to Big Gulp (a 7-11 soft drink) but they have no life. They are essentially 'soul dead' but as long as they stay out of the hospital and comply with taking their drugs, they are considered a success. We need to define success differently! Mental health courts contribute to the distress of people by becoming a 'compliance enforcement' branch of psychiatry. Mental health courts know little to nothing
about how psychiatry contributes to peoples' misery.
Re-traumatization is common.
Mental Health Courts don't really solve the criminalization of psychiatric disability. In many places, they are a well-meaning response to the discrimination and stigma of the regular court system, the lack of mental health care in the jails, and the tendency of police to arrest people with psychiatric disabilities in order to get them off the street. A better, although more difficult, solution is to educate judges and ensure that they do not treat people with psychiatric disabilities with contempt; make sure that jails provide adequate mental health care, and make clear to police that it is not their function to clear the streets of idiosyncratic people who make shopkeepers nervous. In other words, mental health courts don't solve the root problem. Part of the problem with the mental health system is that there is a lack of clarity regarding the product, goals, mission and purpose. It is unclear whether the primary task is to produce 'Medicaid billable units of service' or treatment hours or tenure in the community for the clients or cost savings for the agency. It is unclear for whom the clinicians work, whether it's on behalf of the clients or the agency or the system and whether their task is to help people improve their quality of life (as defined by the clients) with successful living in the community of their choice or whether it's to improve company profits.
The only way mental health courts might effectively work is if they became the court of the mental illness system. Rather than hold the individual to blame, courts should hold the system accountable. If a person is not getting their needs met by the system, it should rightfully be called a problem with the system. Mental illness courts might order the system to perform their duty and meet the needs of the person. Homelessness would be solved by finding the person a home. Poverty and unemployment can be solved by helping to set the person on a career path.
courts are usually only for misdemeanors, and minor ones at that. They
basically use 'crimes' like loitering or shoplifting less than $5.00 worth of
goods to sweep people into a treatment system. Some objections to mental health
courts might be muted if they were only used for major (i.e. death penalty or
life imprisonment) felonies.
People are not given much opportunity to exercise much in the way of informed consent over whether they will go to a mental health court or regular court. Additionally, mental health clients are not given the right to make mistakes (fail) without it being judged negatively. Thus, they are deprived of the growth opportunities that everyone else experiences through trial and error. People don't know when they 'consent' to mental health court that they may be caught in a web of force and coercion lasting many years longer than if they just dealt with the offense that brought them to the attention of the system. In addition, they may not realize that they might essentially be sentenced to a shorter life span by taking medications that can result in that shortened life span being filled with misery, pain and suffering.
The jurisdiction of mental health courts can go on much longer than a person would have served for the misdemeanor for which he or she was arrested. If the court requires that a person be involved in mental health treatment for anytime longer than the time required for jail and probation/parole, then the court is participating in 'unnecessary' coercive treatment. Mental health treatment should be a choice. Just as some people choose to be treated or not treated for certain medical problems, they should have the same choice regarding mental health treatment. It is a fairness in sentencing issue (although it is at the opposite end of what is usually presented as fairness in sentencing). I do believe that people with mental health issues involved in the justice system should be able to access treatment if they so desire. There is no 'treatment alliance' (that which psychiatrists claim contributes to 'success' in the mental illness system) in the court system.
Having worked in community mental health programs and having been a client of community mental health programs, I am also concerned about the people who because they are difficult to treat will get labeled as 'treatment resistant' or 'non-compliant' due to the inadequacies of the mental health provider or the treatment program. A program that 'fails' the client will result in blame and 'punishment' directed toward the client. A provider who 'fails' in their job will be ignored while the client will be chastised, penalized or sentenced.
In Florida, the judge in the mental health court got state appropriations for specific mental health treatment units to which she sent people who came before her court. Legally that violates separation of powers doctrine. While many praised this judge for her kindness and creativity, there is no guarantee that other judges will be as kind or creative in their efforts.
The system needs to be completely revamped. Clients are trained to be "mentally ill" and not mentally healthy. Efforts are focused on disability instead of strengths and abilities. Dependency is maintained under the guise of good care. The system is staff-oriented as opposed to client-oriented. The system is still heavily biased in favor of institutional based containment rather than community based supports. Many within the treatment system believe recovery is an unattainable myth.
Criminal records keep people from getting housing in the community, employment, interfere with parental rights, and can seriously affect eligibility for many social programs. Rather than operating as diversion from the criminal justice system, the mental health system is increasingly serving as the gateway into the criminal justice system. More and more as seclusion and restraints are reduced on inpatient units, mental health staff call upon the police to arrest and control patients. Outpatient systems call upon police for everything from "welfare checks" to enforcement of outpatient commitment orders.
Compliance is an issue of control, not treatment. People in general don't 'comply.' Many who were prescribed 10 days of antibiotics stop after a few days when they feel better. Few actually 'comply' with diets. We're just generally ornery and contrary and to expect compliance is to deny our basic humanness.
Three Faulty Medication Compliance Assumptions:
1. Psychotropic medications are effective (not true for many)
2. Psychotropic medications are safe (tardive dyskinesia and other harmful effects are all too common)
3. People stop taking psychotropic medications for inappropriate reasons (as you know, this is nonsense)
serious concerns about the checks and balances of the system. Where are they?
An attorney may represent the person in their defense, and if they determine
the program is not beneficial for their client, they may not recommend it.
However, for those people who do agree to the program, what happens if they
later disagree with the treatment, or if they have a grievance? What rights do
they have to disagree with their treatment protocol? To whom do they voice
their concerns? What are the treatment options? Is it solely medication? Is
therapy included? Will consumer-run and peer services be considered to be
treatment or part of the treatment? Can the person change their mind? Is
there room for alternative forms of 'treatment?'
There are no biochemical markers, no biological tests, no hard evidence at all, to 'prove' the existence of 'mental illness.' 'Proof' means the ability to demonstrate a reliable association between a clearly specified pattern of observables and other reliably measurable event(s) that operate as antecedents. (This is same level of proof used for TB, cancer, diabetes, etc.) Yet, the courts rely upon the opinions of voodoo practitioners (psychiatrists) who claim to be experts on 'mental illness.' I did a study back in the 1970¹s and found Christian Science hospitals to have as high a ³healing² percentage or better than other medical facilities.
There are many ways to interact with people. We can treat them as 'patients' or we can try to understand and see their world through their eyes. We can weigh the 99+% of the positive or we can look only at the less than 1% negative. Using mental health courts enforces the view of the person as 'patient' and negates the person. People should not be defined by a system that labels them as 'illness', 'disease' or 'disorder.' Courts that are part of the psychiatric system don't ask: What happened to this person? What is this person's hopes and dreams? What are this person's loves? Who are the people (good and bad) with whom this person has interacted? What experiences (positive and negative) has this person had? Why did this person end up following one path rather than another? What motivates this person? Who are this person's role models? What drives this person to get out of bed every day and proceed through the day? What defines this person's 'spirit?'
The MacArthur Coercion Study
³The amount of coercion a patient experiences in the mental hospital admission process is strongly associated with the degree to which that process is seen to be characterized by ³procedural justice.² That is, patients who believe they have been allowed "voice" and treated by family and clinical staff with respect, concern, and good faith in the process of hospital admission report experiencing significantly less coercion than patients not so treated. This holds true even for legally "involuntary" patients and for patients who report being pressured to be hospitalized.²
Involuntary Outpatient Commitment
€ Often instituted in response to tragedies (sensationalism)
€ Person alleged to have serious mental illness (scapegoating)
€ Person has a history of not taking medications outside of hospital settings (non-compliance)
€ Person has benefitted from medications in the past (mental health clinicians tend to equate subduing the person with treatment; a quiet client who causes no community disturbance is deemed "improved" no matter how miserable or incapacitated that person may feel as a result of the treatment.)
€ Without medication, person is at risk of becoming incapacitated or dangerous (although risk early death with the medication)
€ Person can be taken to mental health clinic for evaluation, but medication cannot be forced
IOC-Little Difference in Outcomes
€ Coerced treatment for Substance Use Disorders may improve rates of retention in treatment, but ultimate outcomes are similar for individuals in coerced treatment and individuals in non-coerced treatment (IOM 2005).
€ There is little difference in actual medication compliance between patients who perceived that medication was forced (³high perceived coercion²) and those who did not feel that they were forced to take medication (TAC 2011; Rain et al. 2003).
€ Cochrane of IOC review showed no significant differences in outcomes, except for rates of victimization
Disability-rights model vs Medical model
An Elephant in the Room – Editorial in
Psychiatric Rehabilitation Journal, Winter 2006
The idiom that there is an elephant in the room is used to indicate that some issue, which is perfectly obvious to some people, is rarely talked about. Furthermore, the use of the expression refers to an issue that can't be avoided, much like an elephant in the room, but often is. This phrase implies a value judgment that the issue should be discussed openly.
I sense the elephant in the room whenever we talk about the importance and beauty of the recovery vision while accepting the incompatibility and ugliness of the use of force in a recovery oriented system. The danger in not openly discussing this incompatibility is that eliminating the use of force will never be critically examined as a necessary goal in a recovery oriented system. As a matter of fact phrases such as outpatient commitment and forced medication oftentimes are seemingly paired in a naïve and incongruous way with the pursuit of recovery-oriented systems.
am not offering a single strategy as to how to get force out of the
system. I don't know the most effective and efficient way to go about
it. What I am proposing is that if we do not redouble our efforts to focus
seriously on the incompatibility of force and recovery, we will never figure
out ways of eliminating force from recovery oriented systems. Force elimination
is both a necessary and reasonable goal as we move further down the path of
recovery. Let us use our most creative minds to discuss this elephant in the
room, rather than spend time trying to regulate or reduce the use of force in
the hopes of making environments that use force more "humane". This
incompatibility must see the light of day. There is no such thing as
-- William A. Anthony, Ph.D.
Additional Thoughts From Pat Risser:
In 2002, Dan
Fisher was serving on President Bush's New Freedom Commission on Mental Health
and he was a member of the subcommittee on "Rights and Engagement"
with a focus on coercive treatment. He invited me to represent the
consumers/survivors side of the issue and provide testimony to the
I went to Washington to provide 'expert' testimony. Dan knew that I felt passionately about our rights and that I'd been to law school, was formerly director of Patients' Rights in a county in California and was President of NARPA (National Association for Rights Protection and Advocacy). The other members of the subcommittee were Ginger Lerner-Wren (Judge from the first Mental Health Court in the Country in Broward County Florida) and Henry Harbin, M.D. (Psychiatrist, CEO Magellan Behavioral Health and former Commissioner of Mental Health in Maryland). Providing testimony for the opposing viewpoint
(in favor of "compassionate coercion") was Steve Sharfstein, M.D. who was the incoming Vice-President of the American Psychiatric Association.
Much of the original draft of this document opposing mental health courts was developed in preparation for providing my testimony. I knew I couldn't just come out in opposition with Judge Lerner-Wren but what I'd noticed was that she held the system accountable. Rather than 'sentence' people to the treatment that was available from the system, she determined what would help the person and 'ordered' the system to provide for those needs even if they had to create something that would work. She was also very understanding and compassionate. Essentially, she 'sentenced' the system to meet the needs of the person.
When I gave testimony, I credited her as the reason why Broward County Mental Health Court works. However I also pointed out that she could not be duplicated elsewhere so there was no way to assure that other mental health courts would be successful. At that point, Steve Sharfstein poo-poohed with his typical psychiatric arrogance and claimed I didn't know what I was talking about. Then, Judge Lerner-Wren proceeded to chew him out royally and stated I was right! It was quite a show.
In any case, there are a number of reasons why the mental illness system does not work. By extension, a court system that forces people into a broken system that the New Freedom Commission declared is in disarray, would be akin to asking people to drive safely in a broken car. It just doesn't make sense.
How and Why the System is Broken:
Ø Clients are trained to be "mentally ill" and not mentally healthy
Ø Efforts are focused on "disability" instead of strengths and abilities
Ø Dependency is maintained under the guise of good care
Ø The system creates a suffocating "safety net"
Ø Clients are not given the right to make mistakes (fail) without it being judged negatively
Ø The system is deaf, dumb and blind to research and ignores it's implications in practice
Ø The system is staff-oriented as opposed to client-oriented
Ø School-based inculcation
is so strong as to be nearly totally immutable (people get stuck and stay stuck
in what they learned from 20-year
Ø "Mental Illness" is perceived by staff to be an intractable condition (recovery not possible) for at least 75% of the clients
Ø Severe and persistent disabilities associated with "mental illness" are grounds for assuming clients are incapable of choice
Ø Pervasive belief that "treatment" (symptom control) must precede substantive rehabilitation efforts
Ø Belief that impairment in one life area affects all abilities
Ø Absence of clarity as to
the product (what it is that the system is supposed to provide) precludes
evaluation and effective management
* There is confusion about mission, purpose and goals; What is the desired product?
-Tenure in the community?
-Quality of life? (as defined by whom?)
-Normalization? (as defined by whom?)
-Recovery? (as defined by whom?)
Ø Pay is too highly correlated with credentials that are not indicative of the skills required to do the job (academic degrees don't necessarily correlate to "people skills")
Ø Public dollars continue to subsidize the education and preparation of practitioners for the private sector with no pay back to the public sector despite some fairly massive workforce shortages
Ø Notable major advances are accomplished by rebels yet the system rewards conformity and punishes non-conformity
Ø The system subcomponents are underfunded and non-integrated
Ø The governor has minimal interest in mental health aside from cost-containment
Ø People argue about causes and attempt to make clients "compliant" instead of teaching them coping skills regardless of causes and in spite of them
Ø Legislators are naïve and pay more attention to providers' and family members' wants than to consumers' needs
Ø Provider Boards of Directors are inadequately trained to do their jobs. What little training they receive is generally done by staff within the agencies creating inbreeding that is not beneficial
Mental Health and Human Rights
(written by Sylvia Caras, Ph. D.)
There is no conflict between a position that generates the greatest good and at the same time does the least harm. Coercion does the least good, the most harm, and is disrespectful to human dignity.
Coercion deals with a social problem by punishing the victims.
By creating a sub-class, coercion readies the public mind for prejudice and discrimination.
Interventions without consent may ignore the problems of living that cause distress.
Disagreement with medical authority is not incapacity.
Self-management and personal responsibility save public money.
Governments have a responsibility to protect all their citizens. The way to do this is by strengthening self-definition and autonomy so we each define useful assistance and accommodation for ourselves.
Determining the needs of others by one¹s own needs is oppressive. The value "caring coercion" puts another¹s idea of what is good for me over what I would like for myself, whitewashes the violation of my personal integrity, dishonors my experience of my life.
The mental health system is a violent system, using force to impose its will, bullying patients by withholding privileges and threatening charting and isolation, subduing its subjects with leather and chemical restraints, and in general setting a harsh example of how humans should treat one another. What is needed is to overhaul a dishonest system.
Prompted by Sharfstein¹s title: Case for Caring Coercion, APHA 2006, Boston, and informed by internet exchanges with members of the WNUSP board and subscribers to ActMad.
Sylvia Caras, Ph.D., http://www.peoplewho.org
A Fairy Tale
Once upon a time in a land by the ocean, people lived in comfort and prosperity. Over time, they came to notice that some of the people among them had unusual experiences. Some heard voices, others saw things that other people couldn't see, others became very agitated or very sad, some became confused. At times these experiences caused people much pain, and they suffered and their families suffered with them.
The families went to the leaders of the people and cried, "Our sons and daughters are suffering. You must help us." and the leaders of the people saw the truth in what they said and undertook to find a cure for these ills. Whereupon they commanded wise and compassionate doctors and profitable pharmaceutical companies to bring before them new treatments - wondrous drugs that would heal people if taken regularly.
And so the drugs were administered to the sons and daughters who had these unusual experiences. But apparently an evil spell had been cast upon the medications, for they were far less effective and far more injurious than promised. Many sons and daughters were crippled by their effects. Many feared the medicine had been turned to poison. "This drug doesn't help me at allŠ.it makes me too tiredŠ.it makes my muscles stiffŠit makes me too jumpyŠI gained 50 pounds on itŠit makes me feel like a zombie," they were heard to say. The sons and daughters were frightened and disappointed, and they threw down the pills and returned to their unusual lives and unusual experiences.
Their families were enraged and returned to the leaders and the doctors. "You must help us," they said, "Our sons and daughters do not see how wonderful these medications are, and they will not take them."
"Never fear," said the leaders, "we will create a law that will compel your children to take the drugs they need, for it is clear that they do not have the insight and judgment to make this decision on their own."
And so a proclamation went throughout the land requiring people who were afflicted by visions and voices, mood swings and confusion to appear for their required medications. Thousands upon thousands of sons and daughters were forcibly, but compassionately injected and, Lo, they began to heal. Unburdened by their symptoms, the sons and daughters were able to keep their medication appointments and attend day treatment regularly.
And they all lived happily ever after, with minimal residual disability and fewer side effects than placebo.
Like I saidŠ.it's a fairy tale.
Coni Kalinowski, M.D.)
March 21, 2012
Subject: Opposition to involuntary outpatient commitment bill AB 1569 (Allen)(California)
We, the undersigned organizations and individuals, urge a ³no² vote on AB 1569, currently pending before the Assembly Health Committee. AB 1569 would re-authorize involuntary outpatient commitment under AB 1421 (³Laura¹s law², referred to as ³assisted outpatient treatment² by proponents) for six years and would eliminate all state oversight of such programs. Instead of extending AB 1421¹s sunset date, California should increase the availability of a full array of voluntary mental health services, expanding programs that have demonstrated success in saving lives and money.
We stand united in opposition to involuntary outpatient commitment (IOC) for the following reasons:
1. IOC violates or threatens to violate the fundamental human rights of a broad group of mental health clients who have a history of hospitalization or suicide attempts by forcing them to comply with court ordered treatment even though they are not currently a danger to themselves or others, and have not been found incompetent to make their own medical decisions.
2. IOC is inconsistent with mental health recovery principles of self-determination and empowerment.
3. The stereotypes, prejudices and irrational fears of ³violent² mental health clients on which IOC is based are not consistent with the facts. Mental health clients without symptoms of substance abuse are no more prone to violence than others living in their communities who do not have symptoms of substance abuse. (MacArthur Violence Assessment Risk Study, 1999).
4. IOC under ³Kendra¹s Law² in New York has targeted African Americans and Latinos in numbers disproportionate to their respective populations. African American clients are nearly five times as likely as whites, and Latinos twice as likely as whites, to be the subject of court-ordered treatment under ³Kendra¹s Law² (NY Lawyers for the Public Interest, 2005).
5. IOC remains unproven. Nearly ten years after AB 1421 became law, no empirical evidence comparing court-ordered community mental health services and supports with comparable programs offered on a voluntary basis shows any difference in outcomes. (RAND Corp., 2000; Steadman et al., 2001; Swartz et al., 2009).
6. IOC¹s use of coercion risks re-traumatizing clients who already have a high prevalence of trauma (Muesar et al., 2004), and driving people away from treatment altogether (Campbell & Schraiber, 1989).
7. IOC threatens to divert scarce resources from voluntary mental health programs with proven track records such as Prop 63 (Millionaire Tax) full service partnerships (FSPs, a highly successful approach to voluntary treatment that includes community-based recovery services, housing, and 24-7 emergency response), psychological counseling, peer support, and subsidized and supportive housing and ³Housing First² programs. Many people diagnosed with serious mental illnesses throughout the state are still being turned away from services they want and need. Increased investment in voluntary services is the most sensible approach to meeting this need.
California CARES Coalition
For every 100 who might get pushed to the head of the line for services because of a loud-mouthed family member pushing for IOC, 100 others will be pushed to the bottom of the line or out of the system where they will not receive services and will perhaps decompensate and create a greater problem.
³What does it mean that the life expectancy of persons with serious mental illness in the United States is now shortening, in the context of longer life expectancy among others in our society? It is evidence of the gravest form of disparity and discrimination.² --Kenneth J. Gill, Ph.D., CPRP
A series of recent studies consistently show that persons with serious mental illnesses in the public mental health system die sooner than other Americans, with an average age of death of 52.
(Colton, C.W., Manderscheid, R.W. (2006) Congruencies in Increased Mortality Rates, Years of Potential Life Lost, and Causes of Death Among Public Mental Health Clients in Eight States. Preventing Chronic Disease. Vol. 3(2).)
"Adults with serious mental illness treated in public systems die about 25 years earlier than Americans overall, a gap that's widened since the early '90s when major mental disorders cut life spans by 10 to 15 years."
Psychiatric Services 50:1036-1042, August 1999
Life Expectancy and Causes of Death in a Population Treated for Serious
Bruce P. Dembling, Ph.D., Donna T. Chen, M.D., M.P.H. and Louis Vachon, M.D.
OBJECTIVE: This cross-sectional mortality linkage study describes the prevalence of specific fatal disease and injury conditions in an adult population with serious mental illness. The large sample of decedents and the use of multiple-cause-of-death data yield new clinical details relevant to those caring for persons with serious mental illness.
METHODS: Age-adjusted frequency distributions and years of potential life lost were calculated by gender and causes of death for persons in the population of 43,274 adults served by the Massachusetts Department of Mental Health who died between 1989 and 1994. Means and frequencies of these variables were compared with those for persons in the general population of the state who did not receive departmental services and who died during the same period.
RESULTS: A total of 1,890 adult decedents served by the department of mental health were identified by electronic linkage of patient and state vital records. They had a significantly higher frequency of deaths from accidental and intentional injuries, particularly poisoning by psychotropic medications. Deaths from cancer, diabetes, and circulatory disorders were significantly less frequently reported. On average, decedents who had been served by the department of mental health lost 8.8 more years of potential life than decedents in the general population—a mean of 14.1 years for men and 5.7 for women. The differential was consistent across most causes of death.
CONCLUSIONS: Findings in this study are consistent with previous findings identifying excess mortality in a population with serious mental illness. The high rate of injury deaths, especially those due to psychotropic and other medications, should concern providers.
The World Health Organization (WHO) found that recovery from schizophrenia is at least 50% higher in emerging (third-world) countries that practice far less ŒWestern medicine¹ and there are almost no psychiatric services.
Two studies by the World Health Organization (WHO), one in 1979 and the second in 1992, compared the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized. They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.
 World Health Organization. Schizophrenia: WHO study shows that patients fare better in developing countries. WHO Chron. 1979;33:428.
 Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97.
Compared to the general population, recipients of public mental health care:
Ø Experience higher rates of medical disease
Ø Die in greater numbers each year (1 - 3.5% vs. 0.5 - 0.8%)
Ø Die 13 to 30 years earlier than expected
There¹s an elephant in the room Š
The impact of psychiatric drugs upon morbidity (illness rates) and mortality (death rates) of recipients of public mental health care is usually ignored or minimized
U.S.A. = 4.5 % of world population
Although the U.S. population comprises only 4.5% of the planet¹s human inhabitants, Americans account for a disproportionate share of the world¹s pharmaceutical sales:
90% of the world¹s stimulants
63% of the world¹s antipsychotics
51% of the world¹s antidepressants
41% of the world¹s anti-epileptics
[Source of sales data: IMS Health]
Numerous epidemiological studies (population based studies of human patients) have documented increased risks of cardiac disease among the users of psychiatric drugs. These risks have not been explained by the presence of other variables, such as lifestyle or pre-existing health conditions.
In other words, even after ³controlling for² mental illness severity and medical comorbidity,
and even after adjusting statistical equations for lifestyle factors (such as smoking, poverty, and/or lack of exercise), the use of psychiatric drugs has been a significant risk factor for sudden death and heart disease.
Antipsychotic drugs (APs) have been associated with a 100-300% increase in the risk of sudden cardiac death; and a 400% increase in the risk of heart attacks (myocardial infarction).
Antidepressant drugs (ADs) have been associated with a 50% to 260% increase in the risk of sudden cardiac death; and a 20-85% increase in the risk of heart attacks. (In some studies, as many as 8-11% of antidepressant drug users have experienced a heart attack during treatment.)
Just as psychiatric drugs contribute to elevated rates of heart disease, these pharmaceuticals also elevate the risk of stroke (acute ³brain attacks² > caused by impaired blood flow, bleeding, and/or changes in cell metabolism).
Antipsychotic drugs (APs) elevate the risk of stroke by 40-250%.
Antidepressant drugs (ADs) elevate the risk of stroke by 20-100%.
Antiepileptic drugs (AEDs) (aka, anticonvulsants) which are commonly used for ³bipolar disorder² elevate the risk of stroke by 150-270%.
The term ³diabetes² is taken from the Greek word, ³diabainein² meaning siphon. The implication is a gushing or overflow of fluid > specifically, of urine. Historically, physicians have identified and treated two major kinds of diabetes: diabetes mellitus characterized by sugar in the urine (mellitus = honey sweet); and diabetes insipidus, characterized by excessive urination (insipidus = without taste).
The information above refers to the #7 leading cause of death in the USA: diabetes mellitus (Type I and Type II). Childhood onset or Type I diabetes mellitus, is caused by an autoimmune deficiency which impairs the body¹s ability to make insulin. Type II diabetes mellitus refers to an acquired disease involving decreased insulin production and decreased insulin response (e.g., insulin resistance).
This information compares the rates of Type II Diabetes Mellitus in the general population of the USA (lifetime prevalence: 9%) versus psychiatric drug users:
At least 20-30% of antipsychotic drug (APs) users are developing Type II DM;
~10-20% of chronic antidepressant drug (ADs) users are developing Type II DM;
~30-50% of some anti-epileptic drug (AEDs) users are developing insulin resistance (pre-diabetes); of these, 1/2 are expected to progress to diabetes
Psychiatric Drugs and Death
Approximately 1% of the US population dies each year.
General population ~ 1% die per year
Public Mental Health System Recipients (1997-2000) up to 3.5% per year
Lithium 15% dead in 5 to 10 years
Anti-depressants 20% dead in 10 years
Anti-psychotics (in general) 20-33% dead in 10 years
Several studies of patients exposed to different classes of psychiatric drugs have shown high mortality rates: 15-33% of the patients have died within ten years.
106,000 inpatient deaths
199,000 outpatient deaths
305,000 deaths from Rx
In 2000, the prestigious Journal of the American Medical Association (aka, JAMA) featured an article by Johns Hopkins University professor, Dr. Barbara Starfield. Using data culled from a variety of inpatient and outpatient investigations, Starfield¹s analysis estimated that adverse effects of medication (i.e., ³therapeutic² doses of prescription drugs taken exactly as prescribed) account for approximately 305,000 deaths per year.
106,000 inpatient deaths due to pharmaceuticals
199,000 outpatient deaths due to pharmaceuticals
[Note: Given the fact that ³adverse drug reactions² are rarely reported, and given the fact that drug-related heart attacks, strokes, pneumonias, and cancers are seldom attributed by physicians or governmental agencies to pharmaceuticals, these estimates were absurdly conservative.]
U.S.A.: Psychiatric Drugs 2009
[Source: Express Scripts 2009 Drug Trend Report]
Antidepressants 10% 31,000,000
Anticonvulsants 4% 12,300,000
Stimulants 2% 6,754,000
*Antipsychotics 2% 5,526,000
*part of Express Scripts¹ ³mental/neurological² class: includes lithium, dementia drugs, substance abuse drugs
Express Scripts, a pharmaceutical benefits management company, produces annual drug trend reports. The information in this slide was obtained from the April 2010 Drug Trend Report. Approximately 10% of U.S. residents used an antidepressant at some time in 2009; 4% used anticonvulsants; 2% used stimulants; and approximately 2% used an antipsychotic.
These numbers exclude drug use by non-commercially insured patients, such as veterans and active duty military personnel; institutionalized patients (e.g., residents of nursing homes, prisons, jails, and state hospitals); and patients who rely upon publicly funded programs, such as Medicaid and Medicare.
How Did They Do It:
Prescription drug use was evaluated by examining pharmacy claims from two independent, random samples of approximately 3 million commercially insured individuals. The prevalence of use was calculated by dividing the # of insured members taking medications in a certain drug class by the total number of insured.
To place the aforementioned figures in context, the Express Scripts database revealed the following patterns of non-psychiatric drug use in 2009:
Pain killers 17.8%
Heart disease, hypertension 15.7%
High cholesterol drugs 12.1%
Asthma medications 8.7%
Ulcer disease (antacids) 8.2%
Against Forced Treatment
Are there sufficiently convincing arguments in favor of outpatient commitment laws and society¹s decision to force certain adults to take antipsychotics? The logic behind outpatient commitment laws is that antipsychotic medication is a necessary good for people with a diagnosis of severe mental illness. The medications are known to be helpful, but—or so the argument goes—people with ³severe mental illness² lack insight into their disease and this is why they reject the medication.
However, if the history of science presented in ³Anatomy of an Epidemic² is correct, antipsychotic medications, over the long term, worsen long-term outcomes in the aggregate, and thus a person refusing to take antipsychotic medications may, in fact, have good medical reason for doing so. And if that is so, the logic for forced treatment collapses.
In my foreword to Anatomy of an Epidemic, I told of how, when co-writing a series for the Boston Globe in 1998 on abuses of psychiatric patients in research settings, I stumbled upon two outcome studies that I found difficult to understand. The first such study was by Harvard researchers, who reported in 1994 that outcomes for schizophrenia patients had worsened during the past two decades and were now no better than they had been a century earlier. This outcome belied what I understood to be true at that time, which was that psychiatry had made great progress in treating schizophrenia.
World Network of Users and Survivors of Psychiatry
A Discussion Paper on Policy Issues at the Intersection of the Mental Health System and the Prison System
by Daniel Hazen and Tina Minkowitz
Center for the Human Rights of Users and Survivors of Psychiatry
1. Debunking the Myth: Prevalence of Psychosocial Disability in Prison - What Does It Mean?
It has become a commonplace of mental health advocates and criminal justice advocates, often without lived experience of incarceration in either system, to point to high numbers of people with mental health problems1 in prison, and argue for increasing transfer of direct control and supervision of such individuals to the mental health system.
We contest the implied assumption that the presence of people with mental health problems in prison is inherently shocking or problematic, as well as the recommendation of greater involvement of the medical-psychiatric system in social control as a response to this situation.
Given the traumatic backgrounds of people who end up in prison and the relationship of trauma to mental health problems, the prevalence of mental health problems by any measures should not be surprising. Trauma may be common among prisoners for reasons including discrimination in access to justice, discrimination in the definition of crime and in the establishment of penalties for different crimes, as well as factors influencing the commission of criminal acts.
The gathering of information on mental health problems, whether by self-reporting or diagnosis, may change over time for reasons unrelated to people's experience of distress. Diagnostic trends in particular change with the fluctuation of DSM/ ICD categories, and with the attention placed on mental health issues by authorities.
Given the traumatizing nature of prison – deprivation of freedom, toxic environment, bad food, strip searches, etc. – people inevitably experience distress and altered consciousness that can be labeled as mental health problems. The traumatizing nature of prison can be encapsulated in the degrading entry procedure, described from experience of a U.S. prison:
"Walking into a system where you are being given a number that becomes your identification. A barber shaves your head, they have you strip your clothes off and de-lice you, dropping this powder. There are 50 men in this line. It has a humiliating, degrading, punishing effect immediately. How trauma-insensitive that is, the anxiety that drives through your body is incredible. It reminded me of the concentration camps. They say that Germany was so bad but we're doing the same thing. They call it rehabilitation - they break you and rebuild you."
The number of people labeled with mental health problems in prison is sometimes compared with declining numbers in psychiatric institutions, as if to argue that the psychiatric system by failing to confine people with psychosocial disabilities is creating the conditions for these individuals to commit crimes and be incarcerated in the prison system. It is a tautology that incarceration of any demographic would stop those individuals from committing crimes. Human rights principles do not permit profiling and preventive detention based on psychosocial disability, any more than they would permit profiling and preventive detention based on race, gender or age. To the extent that the mental health system has been placed in the role of public safety official, with legal duties to confine individuals based on risk assessment of any kind, this is incompatible with the duty to serve the individual client and must be removed in order that the mental health profession may be able to comply with its human rights obligations. Moreover, mental health treatment is far from being foolproof, reliable or safe. Expansion of mental health treatment, even when community-based, has not resulted in decrease of mental health problems, but rather in an upsurge, iatrogenic problems in both physical health and mental health, and enforced dependency on mental health providers for services that maintain individuals in poverty and segregation.
2. Mental Health System is Coerced Compliance – Not a True Alternative to Prison
A. Diversion into Coerced Medical Disablement is Not a Viable Alternative to Incarceration
Diversion from the court system to coerced mental health treatment is also proceeding apace. "Mental health courts" in the U.S., although participation in them is voluntary at the outset, induct individuals into coerced compliance with treatment, in exchange for suspension of prison sentence. A guilty plea is required, and compliance with treatment is supervised by the court, with the possibility of a prison/jail sentence being imposed if compliance is not deemed adequate.
In Japan, a preventive detention law for people with mental disabilities went into effect in 2005. Under this law, a person accused of a crime and deemed by the court to have a mental disability can be diverted from a trial of their guilt or innocence, to a hearing before a mental health tribunal to determine whether civil commitment should be imposed. This means that a person labeled with mental disability is denied the right to be considered innocent until proven guilty, and unlike all other criminal suspects can have detention imposed without proof of having committed the crime. Unlike the U.S. mental health courts, this diversion is not voluntary but is decided by the court.
The use of diversion schemes has been promoted as an alternative to the punitive sentences imposed by the "criminal justice" system, however we cannot consider it in any way an acceptable alternative, particularly when there are penalties for noncompliance with the prescribed treatment. Mental health treatment appears to many people to be beneficial to all concerned, to society as well as to the person accused of crime. But when the mental health system is made to do the duty of public safety official, it promotes neither public safety nor mental health. Irreparable harm is done by the coerced ingestion of mind-numbing drugs (the main modality of forced treatment), and by the narrative of incapability that removes a person from responsibility for, and confidence in, making deliberate choices to shape his/her own life.
Proponents of restorative justice, and of any theory of justice that supports reintegration, need to consider the implications of the social model of disability for their work, and to go deeper in imagining systems of accountability that respect human dignity. Coerced mental health treatment of people accused or convicted of crime is not restorative, and it does not contribute to meaningful re-integration. It is furthermore a form of discriminatory violence that fits the criteria for torture and ill-treatment.
B. Double Discrimination Against People with Psychosocial Disabilities in Prison
People with psychosocial disabilities in prison experience double discrimination. In some U.S. jurisdictions a person who has been given a psychiatric diagnosis is not eligible for programs with early leave such as work release and military style or modeled shock camps – 6 months of military style discipline and training after which the remainder is served on parole. (This blatant discrimination extends also to people with physical disabilities, for example if a person is unable to run with their legs.) Men and women with psychiatric diagnoses who have physical illnesses such as cancer or diabetes are often not treated for the physical illness which is explained as a psychiatric symptom.
In addition, state systems have access to past records. Due to having received a psychiatric label/diagnosis in the past, upon entry into the prison/penal system, a person can be placed in solitary confinement until being ³seen² or evaluated by a mental health professional. This takes place in a segregated part of the prison, not the general population.
Forced drugging and confinement in a psychiatric unit within a prison can be similar to the way it's done in psychiatric institutions, but double discrimination emphasizes a person's status as being under the control of others.
"I felt, here I am a prisoner and mental patient. Those two things together left me with no liberty. I felt if I was captured by one, I could escape. Why would a judge listen to me not to medicate me, here I am a prisoner found guilty by judge and jury, there's no way I'm going to win a medication hearing or a retention hearing. The hearing was very short, about a minute. The psychiatrist said, "You need to take this," and that was it, bye, they send you back.
"There's no access to a lawyer in the penal system for psychiatric things. No access to a phone. The culture inside prison is often controlled by gang activity, underground crime. There are a lot less phones in the psychiatric piece than in regular prison - 120 prisoners inside the psych hospital in prison, and two phones. You can't get to the phone. And you have to be in programs all day.
"In the hospital they call you by name and not a number. You think you're a person again in the psych ward and not in prison. My thing was, you're getting out of one cage to be in another. This one's shinier, more buttons... but that doesn't make it not a cage."
A. Insanity Defense is Counter-Productive
Behind the schemes to divert people from courts and prisons into the mental health system lies a belief that people with psychosocial disabilities do not belong in a penal system, but instead need medical treatment in order to not re-offend. The traditional penal system objectives of retribution and deterrence are seen as inapplicable to people with psychosocial disabilities, who are considered uniquely unable to control their actions. The remaining objectives of incapacitation and rehabilitation (primarily in the form of compulsory medication and other incapacitating treatments) are intensified.
This is seen most clearly in the operation of the insanity defense and its equivalents in every legal system. This defense - that a person is not guilty, or cannot have responsibility imputed for a crime, because of his/her mental state at the time the crime was committed - is considered a pillar of our legal systems and a sacred right of defendants. At some times and in some places, where the objectives of retribution and deterrence were primary, it may have operated to allow people to avoid punishment that was seen as unfair given the circumstances.
However, ordinarily a verdict of insanity results in psychiatric rather than penal incarceration (and the Standard Minimum Rules on the Treatment of Prisoners so provide, in Rule 82). Whether it is labeled as punishment or treatment, the deprivation of liberty, lack of privacy, having one's daily life controlled by authorities, assaults on personal dignity and integrity from strip searches to forced medication have substantially similar effects on people in both institutions. Both institutions promote a negative self-image and submitting to authorities rather than seeking internal self-justification and conscience.
There is, furthermore, an overlap between the two systems that discloses their underlying unity. Despite the label of "treatment," the mental health system administers a wide range of punitive measures. These include "steps" or "levels" of increasing control, "privileges", and the imposition of coercive regimes in response to "failure to comply with prescribed treatment". Rehabilitation in prison, when imposed coercively, is substantially similar to forced mental health treatment (e.g. programs like "DARK", psychological intervention, coercion to attend self-help groups, and programs to "correct the personality").
The CRPD (United Nations Convention on the Rights of People with Disabilities: http://www.un.org/disabilities/default.asp?id=150) takes an opposite approach to responsibility of persons with disabilities for their own actions. Article 12, Equal Recognition Before the Law, provides that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life. Legal capacity implies both rights and responsibilities, and "all aspects of life" can encompass criminal as well as civil matters. As the Office of the High Commissioner for Human Rights has said, this requires abolition of the insanity defense and its replacement by disability-neutral concepts such as the subjective element of a crime (mens rea).
B. Community Responsibility and Support
Article 12 also provides that States Parties must provide access to the support needed by persons with disabilities in exercising their legal capacity. The Committee on the Rights of Persons with Disabilities has clarified that support "respects the autonomy, will and preferences of the person," and that States Parties must replace all substituted decision-making schemes with support.
What might support look like in relation to crime and punishment?
It could start with community members taking responsibility to help avoid the commission of a crime and defuse conflict situations. Two examples:
"I was in the Apple Store and saw a kid bend down and take some hardware or software for IPad, he ripped open the box and put it in his sleeve. I had two choices - I could tell the staff, assumed he was going to steal, maybe he was testing the staff. I said to him, 'What you got there?' He put it back and didn't take it."
"One gentleman was camped out in his parents' backyard. The county mental health director called me [as head of a peer advocacy center], didn't want to call police, didn't want to go through routine, asked if we would go over. The guy didn't want respite, didn't want any government thing. He didn't get locked up that I know of, and moved off his parents' porch."
These examples might also be understood in a restorative justice framework, and there is a great deal of congruency between the values of restorative justice and the social model of disability as enunciated in the CRPD. Both promote intersubjective and relational processes for arriving at decisions, respect for individual dignity and the equality of persons, autonomy, and reliance on community members rather than the state. Both encourage personal accountability and responsibility as a manifestation of mutual respect. Both encourage a holistic and big picture approach to justice, which is simultaneously grounded in lived experience: what do participants need, what is lacking (or over-present) in our social and economic system that impacts on the current situation, what is crime and what should be criminalized?
The prison reform and abolition movement, particularly including current and former prisoners, have a significant role to play in developing guidance and policy and in sharing their experience and wisdom with the community. Prisoners with psychosocial disabilities especially need to be consulted. This is a part of "reintegration" that is often overlooked.
The CRPD framework, restorative approaches to justice, and prison reform/abolition need to inform each other so as to transform our communities to promote social and individual healing, self-determination and mutual respect and accountability, for all people including people with disabilities. We need to reject one-sided approaches that either fail to address disability, or that address it from a medical model rather than social model perspective leading to increased discrimination. We need to fundamentally change both the legal framework for civil and criminal responsibility, and the relationship of responsibility to the law itself. We need to simultaneously build the capabilities of communities and ensure that the law reflects and enforces values of fairness, equality, freedom from torture and de-escalation of violence. The scope of the task should not overwhelm us, but inspire us to begin.
Kay Pranis, Restorative values, in Gerry Johnstone and Daniel W. Van Ness, eds., Handbook of Restorative Justice (2007).
Wanda D. McCaslin, ed., Justice as Healing: Indigenous Ways (2005).
James J. R. Guest, Aboriginal Legal Theory and Restorative Justice, in Wanda D. McCaslin, ed., Justice as Healing: Indigenous Ways (2005).
Tina Minkowitz, The Paradigm of Supported Decision-Making, presented at Eötvos Loránd University, Bárczi Gustáv Faculty of Special Education, Budapest, November 30, 2006.
Intentional Peer Support, www.mentalhealthpeers.com.
Center for the Human Rights of Users and Survivors of Psychiatry, www.chrusp.org
1 We have used various terms in this paper reflecting diverse ways that our community talks about our experiences. Please see the WNUSP paper ³Psychosocial Disability² explaining the meaning of this term as a preferred terminology. It is available at: http://www.chrusp.org/home/flyers
The preferred terminology of ³persons with psychosocial disabilities² should be used wherever relevant in legislation, to refer to persons who may define themselves in various ways: as users or consumers of mental health services; survivors of psychiatry; people who experience mood swings, fear, voices or visions; mad; people experiencing mental health problems, issues or crises. The term ³psychosocial disability² is meant to express the following:
- a social rather than medical model of conditions and experiences labelled as ³mental illness².
- a recognition that both internal and external factors in a person¹s life situation can affect a person¹s need for support or accommodation beyond the ordinary.
- a recognition that punitive, pathologizing and paternalistic responses to a wide range of social, emotional, mental and spiritual conditions and experiences, not necessarily experienced as impairments, are disabling.
- a recognition that forced hospitalization or institutionalization, forced drugging, electroshock and psychosurgery, restraints, straitjackets, isolation, degrading practices such as forced nakedness or wearing of institutional clothing, are forms of violence and discrimination based on disability, and also cause physical and psychic injury resulting in secondary disability.
- inclusion of persons who do not identify as persons with disability but have been treated as such, e.g. by being labelled as mentally ill or with any specific psychiatric diagnosis.
It does not mean:
- an affiliation with psychosocial rehabilitation.
- acceptance of any label that an individual may not identify with.
- a category to be used in addition to ³mental illness² or ³mental disorder².
- a belief in psychosocial ³impairment².
CRPD Article 1 refers to
³those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.²
In this context, the reference to persons with ³mental² impairments includes persons with psychosocial disabilities. However, for the reasons given above, national legislation implementing the CRPD should use the preferred terminology of ³persons with psychosocial disabilities,² which is in keeping with the social model of disability reflected throughout the CRPD, and the recognition that disability is an evolving concept as provided in CRPD preambular paragraph (e).
Given the fact that persons with psychosocial disabilities are included under CRPD Article 1, a provision that is linked to the purpose of the Convention and thus not subject to reservations of any kind, all legislation applicable generally to persons with disabilities must include this group, including anti-discrimination legislation (including reasonable accommodation); eligibility for subsidies, programs and services; and recognition of organizations of persons with disabilities for consultation purposes as required by CRPD Article 4.3.
NOTE: This position paper
originally appeared as section 2.q in the IDA CRPD Forum Contribution to the
OHCHR thematic study to enhance awareness and understanding of the CRPD,
focusing on legal measures key for the ratification and effective
implementation of the Convention, August 15, 2008
Involuntary Psych not Hippocratic
Ethical Human Sciences and Services, Vol. 2, No. 1, 2000
Involuntary Psychiatric Interventions:
A Breach of the Hippocratic Oath?
Peter Stastny, MD
Albert Einstein College of Medicine
Bronx, New York
In this article the author argues that involuntary psychiatric interventions are inherently dangerous and potentially harmful to their subjects, thus challenging the Hippocratic ethical principle of ³first do no harm.² Damages arising from coercion in common clinical situations are analyzed, as well as the motives of psychiatrists for persistently promoting an expansion of involuntary interventions. Alternate strategies to coercion are explored.
The controversy over involuntary psychiatric interventions is usually presented as a conflict between civil libertarian interests to safeguard personal autonomy and concerns about individual health and public safety. However, this view is problematic. The actual conflict may be between two contrasting definitions of health: medical/authoritarian and subjective/empathic. The paternalistic view in which health status is determined ³objectively² by a doctor conflicts with an empathic assessment based on collaboration between doctor and patient. Given that doctors in clinical practice remain primarily responsible for the health of individual patients and not of society as a whole, we should examine whether involuntary and coercive interventions by physicians are compatible with medical ethics as codified in the Hippocratic Oath. For the purpose of this article ³coercive² and ³involuntary² are used interchangeably, even though differences may exist between coercion as perceived by individuals and as sanctioned by law (see Monahan et al., 1995).
The relationship of involuntary intervention and medical ethics is becoming increasing relevant as, for instance, the power to impose psychiatric interventions is broadening under outpatient commitment laws, and patients who feel victimized are growing more insistent about having their damage recognized by the medical profession. This article argues that subjective and objective experiences of harm from coercive interventions challenge basic ethical principles of medicine. If coercive interventions indeed carry a significant risk of harm, then we must ask what alternate, non-authoritarian stance doctors could reasonably take when confronted with people in extreme emotional distress.
Discussions about involuntary interventions have been primarily legal or utilitarian, the former based on constitutional arguments, the latter on evaluations of outcomes (Chodoff, 1988; Wertheimer, 1993). These two approaches are insufficient to develop moral guidelines for psychiatric practice. Also, most studies of coercion ignore the issue of its concurrent or long-term effects on the health and well-being of patients (Blanch & Parrish, 1993). Even the well-publicized, recent studies on coercion supported by the McArthur Foundation have yielded only scant data on its actual effects (Lidz, 1998). Consequently, this article discusses how coercion and involuntary interventions may directly and indirectly cause harm.
THE CURRENT RELEVANCE OF THE HIPPOCRATIC OATH
The original, ³pagan² Oath of Hippocrates (about 450 B.C.) aimed to supplant a shamanic tradition in which ³doctors could as easily murder as cure, or could supply a potion for a man to murder his enemy² (Clements, 1992, p. 367). Undoubtedly, the Hippocratic tradition combined its ethical stance with a guild orientation aimed to enhance physicians¹ status in Greek society. By the Middle Ages, the Hippocratic tradition had been incorporated into the Roman Catholic medical ethic, as exemplified by the ³Oath According to Hippocrates as a Christian May Swear It² (Leake, 1975). Greek and Christian versions of the oath were based on the argument that ³expertise in knowing the good was possible, and the empirical world of natural events could be investigated to identify the good objectively² (Clements, 1992, p. 213). This tradition prevailed until the explosion of scientific knowledge of the 20th century: in 1966 about one fourth of American medical schools still administered versions of the oath to their graduates (Levine, 1971). However, by the early 1970s, as Clements (1992) argues, the Hippocratic principle of beneficence (which relied on paternalism and a fundamental trust in doctors to correctly diagnose and treat illnesses) was challenged by the principle of personal autonomy.
In recent years, social, political, legal, economical, and scientific forces have further impinged on doctors¹ ability to rely on their own judgments when prescribing treatments. Given this new complexity, in which some authors speak of ³systems² or ³health² ethics rather than medical ethics, one might question the relevance of ancient Hippocratic ethics to the issue of involuntary interventions (Clements, 1992). However, regardless of the number of systemic variables impacting medical decision-making, doctors should still be bound by a set of moral guidelines that govern their behavior toward patients, with the aim of eliminating to the greatest possible extent from their practice interventions that are harmful to patients.
INVOLUNTARY INTERVENTIONS CHALLENGE THE HIPPOCRATIC OATH
Paternalistic and self-serving as they may have been, Hippocratic ethics place important restrictions upon the behaviors of doctors. The famous section of the oath which admonishes doctors to refrain from harm, known in Latin as ³Primum non nocere,² reads in one translation as follows: ³I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them² (Jones, cited in Leake, 1975, p. 213). Edelstein (cited in Temkin & Temkin, 1967, p. 6) translated the original Greek differently: ³I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.² Despite differences, both translations concur that doctors have a responsibility to protect patients from harm stemming from their own treatment.
Further in the oath the doctor is again asked to foreswear injurious behavior: ³Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both male and female persons, be they free or slaves² (Edelstein, in Temkin & Temkin, 1967, p. 214). Jones (in Leake, 1975; p. 213) substitutes ³keeping myself free from intentional wrong-doing and harm . . . ³ for ³remaining free of all intentional injustice.² This dual admonition – to refrain from doing harm and to assure that no harm would occur from other sources – should be a key standard in assessing the impact of involuntary interventions. Hippocrates¹ writings apparently do not contain an explicit reference to the use of force by doctors in dispensing treatments.
The Hippocratic principle of ³First do no harm² has received scant attention in the literature on involuntary interventions. Wettstein (1987) refers to the ethical theory of ³non-maleficence,² but fails to consider in what ways coercion itself might be considered ³maleficence.² Most other authors who are apparently attempting to justify involuntarism, ignore the issue of non-maleficence, putting the entire weight of their arguments on the notion of delayed and secondary benefit (see Chodoff, 1988). Incidentally, the theory that coercion is justified since patients will ultimately be thankful for having been forced into treatment (Stone, 1975) is not supported by evidence, which shows that only a small minority of involuntary patients exhibit this change of mind (Beck & Golowka, 1988; Gardner et at., 1999). Curtis and Diamond (1997) provide an exceptionally balanced discussion of the ethical quandary of coercive interventions.
Contemporary versions of a physician¹s oath exist, such as the 1948 Declaration of Geneva, which barely resembles its Hippocratic ancestor and no longer includes a specific reference to refraining from harm. Instead, it states that ³the health of my patient will be my first consideration,² and ³I will not permit considerations of religion, nationality, race, party politics and social standing to intervene between my duty and my patient.² This is supplemented by the pledge that: ³even under threat, I will not use my medical knowledge contrary to the laws of humanity² (Leake, 1975, p. 277).
Crimes against humanity perpetrated by doctors in Nazi Germany made it clear that mere lip service to the Hippocratic tradition would not prevent medical atrocities (see, among many others, Breggin, 1993; Drobniewski, 1993). Indeed, it may be argued that leaving the definition of "good" and "health" to doctors can lead to medically sanctioned torture and murder. However, Cameron (1992) suggests that the Geneva revision lacks the religious and philosophical obligations which are central to the Hippocratic Oath, and is therefore even more vulnerable to infractions. In any case, the Geneva declaration mentions two instances when involuntary interventions run counter to their intended benefit:
1. whenever social forces outside the doctor-patient relationship intervene, and
2. whenever a doctor's intervention breaks with the "laws of humanity."
Outside forces and prejudice are almost always involved in involuntary interventions (e.g., pressures from police, family, community, etc.). For example, African American men are more frequently committed to psychiatric institutions than any other group, regardless of diagnostic and mental status variables (Chen, Harrison, & Standen, 1989; Tomelleri, Lakshmenarazanam, & Herjanic, 1977). Community sources of coercion have been identified as contributing more to perceived coercion than the behavior of hospital staff, including psychiatrists (Cascardi & Poythress, 1997; Pescosolido, Gardner, & Lubell, 1998). This suggests that doctors might be obligated to counterbalance the pressures stemming from community sources, instead of automatically acting on them. Furthermore, involuntary and coercive interventions might be considered human rights violations (Szasz, 1978). Indeed, in December 1991 the United Nations adopted a set of "Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care" limiting but not precluding involuntary interventions (see Rosenthal & Rubinstein, 1993). Of course, psychiatric interventions against political opponents are routinely considered human rights violations—unlike force used against persons with nonmainstream beliefs in psychiatric custody.
Clinical Harm From Involuntary Interventions
In reviewing studies that assess the short- and long-term impact of coercion on its subjects, it becomes apparent that virtually none address the interaction between coercive interventions and the emotional state of the coerced person. This omission is particularly significant given the assumption that a state of emotional or interpersonal crisis would increase vulnerability to harm from coercion. Investigators seem primarily interested in determining how various parties define coercion and what its victims think about it 30 minutes to 1 year later (Monahan et aI., 1993). While the John D. and Catherine MacArthur Foundation has funded a series of investigations on coercion, to date, these have focused on process variables leading to coercion, methodological issues in measuring the nature and impact of coercion, and posthoc studies of attitudinal and perceptual variables (e.g., Bennett et al., 1993; Gardner et al., 1993; Hiday, Swartz, Swanson, & Wagner, 1997; Hoge et aI., 1993; Monahan et aI., 1993, 1995).
Even studies that do examine the outcomes of coercive interventions fail to consider specific interactions between psychological variables and the impact of coercion, particularly for individuals who report negative effects (Hiday, 1992). Instead of further exploring these negative effects, some researchers have attempted to show that negative attitudes about coercion correlate with certain "negativistic" dimensions of illness or personality (Hoge et aI, 1990; Schwartz, Vingiano, & Bezirganian-Perez, 1988). The first American study focusing on the relationship between coercion and hospitalization outcome (Nicholson, Ekenstam, & Norwood, 1996) reports finding "no evidence that outcomes for 'coerced' patients were worse than outcomes for patients whose hospital admission was characterized by minimal or no coercion" (p. 214). The authors arrive at this conclusion even though 50% of all involuntarily admitted patients in their sample were excluded from the analysis (p. 208). A Scandinavian study using measures of coercion that were developed in the MacArthur studies (Kjellin, Anderson, Candefjord, Palmstierna, & Wallsten, 1997) found that 67% of "committed" patients experienced "some" or "only ethical costs." This was also true for 47% of voluntarily admitted patients, indicating that the negative effects of coercion are experienced even among patients admitted under ostensibly voluntary procedures.
A small minority of researchers have looked at the psychological effects of coercion, but without taking into consideration the patient's prior state of mind. Another recent Scandinavian study has actually demonstrated unfavorable psychological treatment outcomes of coercive interventions (Kaltiala-Heino, Laippala, & Salokangas, 1997). These authors conclude that "coercive treatment arouses negative feelings in the patient, creates negative expectations about the outcome of treatment, and fails to result in a trusting relationship between the patient and the professionals" (p. 318). Two theoretical concepts have emerged over the years explaining the various negative responses to coercion:
1. "reactance," which includes anger toward the source of restriction, an effort to restore freedom, and an increased attractiveness of foreclosed options (Brehm, 1981) and
2. helplessness, which often goes along with depression, anxiety, and the cessation of efforts to alleviate the situation, leading to the long-term pattern of "learned helplessness" (Seligman, 1975).
Few will dispute that most people who are subject to coercion are experiencing some type of crisis. Frequently, a coercive intervention arises from others' perception of an undesirable change in the person's behavior or attitude, which seemingly require psychiatric intervention. At other times, the individual is overwhelmed by internal or external events. A great variety of personal, interpersonal, and social problems result in the final common pathway of involuntary intervention. One way to begin disentangling this complex set of factors is to distinguish between those developments that precede first-time psychiatric interventions and those that affect people who have already been exposed to voluntary or involuntary psychiatric intervention. Almost half of all involuntary admissions affect people who have never been hospitalized before, indicating that many initial psychiatric contacts lead to coercive measures (Hiday, 1988).
Many first contacts with psychiatry occur during late adolescence, when children are expected to make steps toward adulthood, move out of the parental home, engage in romantic and sexual relationships, and prepare for their careers. It is also a time when many young people struggle with their identities and face major personal crises. This can take the form of extreme confusion, a search for meaning, introversion, depression, and family conflict. Some people experience "psychotic" symptoms, ranging from the fragmentation of physical and psychological boundaries to extreme internal preoccupation and hallucinatory experiences. Such occurrences are often very frightening to someone already undergoing a difficult transition (Arieti, 1974). To be confronted by coercive psychiatric measures in the midst of such experiences is likely to aggravate and pathologize the confusion, raising the specter of mental illness in the midst of adolescent turmoil. Without a great deal of empathy, respect and understanding, a young person in such a situation is likely to resist any form of intervention, wanting to pursue his or her search for meaning and identity, rather than being forced into a depersonalizing mold (Gutstein, Rudd, Graham, & Raytha, 1988). Armstrong (1993) has pointed out that when adolescents are forced into psychiatric institutions, their crises, which may have been transitional, are likely to be prolonged and aggravated by this type of coercion.
Someone experiencing extreme alterations of perceptions and thinking for the first time is usually in a state of considerable terror and is not likely to understand why he or she is being forcibly held in an emergency room or injected with mind-altering drugs (Sullivan, 1974). Anger and flight might be sensible responses but will usually escalate the coercion and aggravate the emotional distress. Another response might be capitulation to perceived punishment for one's emotional experiences. Either response is likely to have a deleterious influence on the further course of events, often resulting in "chronicization" –a persistent cycle of institutionalization and trauma.
People who are extremely sad, beyond, for instance, what is culturally accepted after the loss of a loved one, to the point of having trouble conducting their usual activities, often feel guilty and responsible for their "failures." This can take extreme proportions, as when a person feels like he/she is carrying the burden of the entire world or is responsible for all evil (Wolfersdorf et aI., 1990). To coerce someone in this state of mind is likely to reinforce the expectation of punishment, potentially triggering a suicide attempt (De Jong & Roy, 1990). Marcia Hamilcar's 1910 personal account of being forcefully removed from her home (in Peterson, 1982) and institutionalized for depression is one of many examples. In these personal accounts the mental institution and its "treatment" methods are often seen as legitimate punishment for the wrongs a person in such a guilt-ridden state believes himself or herself to have committed.
Repetition of Trauma
A growing body of first-person accounts (e.g., Deegan, 1994; McKinnon, 1994; Sonn, 1977) and scholarly reviews including research studies (Craine, Henson, Colliver & McLean, 1988; Muenzenmaier, Meyer, Struening, & Ferber, 1993; Rose, Peabody, & Stratigeas, 1991; van der Kolk, 1987) are drawing our attention to the problem of women (and to some extent also of men) with a history of childhood or adult traumatization who are experiencing abuses in the mental health system. The notion that people who struggle with memories of physical and sexual abuse should be adversely affected by physically coercive psychiatric interventions seems self-evident (Stefan, 1994). In the literature on posttraumatic stress disorder there is much evidence that any situation bearing resemblance to the circumstances of the original/earlier traumata can trigger extreme fear (McFall, Nurburg, Ko, & Veith, 1990), and in women who experience multiple personality or other dissociative disorders, it can lead to fragmentation and self-destructive acts (Doob, 1992). Why this should not hold true for instances of forcible drugging, four-point restraint, the process of seclusion which usually involves being taken down and stripped by male and female attendants, remains to be demonstrated by those who want to draw a line between "social and familial" traumatization and injuries inflicted in the name of "treatment" (Norris & Kennedy, 1992; Stefan, 1994).
Interestingly, coercion and institutionalization are not considered traumatic per se in the trauma literature, unless they are perpetrated for political reasons on persons not considered mentally ill (Chodoff, 1988; Koryagin, 1989; Stover & Nightingale, 1985). In fact, the possibility of traumatization by psychiatric interventions such as forced detention or drugging is not even mentioned in the most comprehensive, 800-page handbook on traumatic stress syndromes (Wilson & Raphael, 1993). Williams-Keeler, Milliken and Jones (1994) consider the experience of psychosis as one possible etiology for posttraumatic stress disorder. Forced psychiatric intervention, especially in someone with a history of significant earlier traumatization, can aggravate, unmask or even cause a form of iatrogenic post-traumatic stress disorder.
Fear of Persecution
Paranoia is the psychiatric term for the extreme fear of others, especially those in authority. This state of heightened alertness and sensitivity to danger, to the point of becoming convinced that sinister forces are scheming to inflict harm, can lead to withdrawal, sleeplessness, reluctance to eat and other potentially hazardous behaviors. Most individuals experiencing such fears are likely to stay away from psychiatric settings, shunning their intervention. This is precisely why they suffer incomparably when forcibly submitted to psychiatric intervention. Many, who are already terrified, are further panicked by physical restraint and forced drugging. Their worst nightmares come true when they are apprehended, restrained, and dragged into an emergency room where unfamiliar doctors ask them invasive questions, decide to keep them against their will, and place them in a ward full of other individuals in distress, many of whom could be perceived as threatening. Such perceptions often lead to altercations and further physical and chemical restraints. Numerous personal accounts of this type of experience corroborate its fundamentally traumatic nature (e.g., Cameron, 1979; Schreber, 1903; Trosse, 1741).
Panic and Mania
Another group of individuals who experience psychiatric coercion are those who suffer from extreme anxiety and panic states. They are likely to feel considerably worse when they realize that they are trapped. Finding themselves prevented from leaving until a psychiatrist has completed their evaluation, they easily become "agitated," thereby further aggravating their situation. Unfortunately, this outright consequence of coercion may be used retrospectively to justify the coercion which precipitated the behavior in the first place.
In the state of mind psychiatrically known as mania, the person is driven toward ever more daring acts in a kind of self-generated euphoria. Whenever such persons encounter obstacles, they tend to become irritable, even angry and possibly assaultive. Clearly, individuals in such states are highly challenging to their surroundings and to anyone trying to help. Not surprisingly, individuals diagnosed with bipolar disorder (mania and depression) tend to experience coercion more acutely than others (Pescosolido et aI., 1998). Intervention usually comes late and with extreme severity. These are the well known situations when a person is wrestled to the ground by a number of strong arms, tied down, and injected with large doses of tranquilizers. Many people have died during such psychiatrically sanctioned assaults (Appelbaum, 1999; Black, Winokur & Bell, 1988; O'Halloran & Lewman, 1993).
Persons planning or attempting to commit suicide are often victims of coercive interventions. The coercion in this instance usually occurs either because a concerned friend or relative has notified the authorities, or because the individual has decided to seek help. In both instances suicidal persons are detained until they have successfully convinced the psychiatrist that they are not about to kill themselves. This is considered by many professionals as the only way to take suicidal threats and sentiments seriously and to prevent charges of negligence should someone actually commit suicide after an intervention by a mental health professional (Appelbaum, 1988). But in most cases someone discloses a suicidal preoccupation to a friend or a professional precisely because he or she is afraid of acting on this impulse, wants to talk about it, and seeks a better solution. If such a person encounters mistrust resulting in commitment, he or she is likely to conclude that the next time a suicidal feeling recurs it may be better to stay away from "helping" professionals. This decision can increase the chance of a completed suicide.
Having been told by a professional that the only way to avert suicide is by being locked up, rather than by seeking alternate life-affirming strategies, these persons are also likely to further loose confidence in themselves. Thus, instead of bolstering their inner strength and self-confidence, psychiatry gives the message that they lack control and must be under surveillance. Some evidence on detrimental aspects of involuntary hospitalization for suicidal individuals supports these intuitive conclusions (Litman, 1991). According to various authors, involuntary commitment might actually increase the risk for suicide in the period immediately after admission (Roy, 1985; Sundquist-Stensman, 1987; Tsuang, 1978).
Many involuntary interventions occur when family members are in conflict. When coercion and commitment occur as a way of responding to family tensions and distress, including concerns about the well-being of the identified patient, family relations may suffer further. In the case of elderly family members placed in an institution against their will, severe depression and even suicide may result (Boucher & Tenette, 1989). The detrimental effect of commitment on family relations has been demonstrated by studies that provide evidence for the common occurrence of "closure," a regrouping of the family without the banished member, which renders the person homeless and without support, suddenly dependent on psychiatric institutions (Scott, 1967). When a family member petitions for commitment or signs consent for unwanted medications or procedures such as ECT, the coerced individual may react with great anger and long-term resentment. This can lead to irreversible family disruption, much pain and disappointment on both sides, and a downward social drift and loss of support for the new "ward of the state." This might also be a factor in precipitating violent acts toward family members that occur after forced treatment.
Forced Administration of Psychotropic Drugs
There is some evidence that the coercive intramuscular administration of psychotropic drugs is associated with a greater incidence of physical adverse effects, thus potentially endangering the life and health of the patient. Kjellin and associates (1993) report substantial differences in rates of adverse effects between committed and voluntary patients, as judged by psychiatrists (82% vs. 63%). Severe adverse effects were reported by 48% of the committed versus 30% of voluntary patients. "Rapid tranquilization"—the abrupt injection of large, toxic dosages of a potent neuroleptic drug, usually haloperidol—has caused serious concomitant side effects, including death from neuroleptic malignant syndrome (Lazarus, Dubin, & Jaffee, 1989). One possible mechanism for this drug-related toxicity is the massive rise of creatinine phospho-kinase (CPK), an enzyme produced by the destruction of muscle tissue, which can lead to kidney failure and other deadly complications (Keshavan & Kennedy, 1992). There is no doubt that the physical restraint of an actively resisting individual, followed by deep intramuscular injections, has caused injuries and deaths (Robinson, Sucholeiki, & Schocken, 1993).
Most coercive interventions aim to achieve the administration of psychotropic drugs in the short term and to enhance "compliance" in the long term (Geller, 1995; Miller, 1999). However, it is likely that forced medication often has the opposite result, discouraging patients from accepting treatment while hospitalized, and leading to avoidance or cessation of treatment in the community (Curtis & Diamond, 1997; McPhillips & Sensky, 1998).
Long-Term Effects of Coercion
Initial responses to coercion, such as a fight-flight reaction, are repeatedly broken down by involuntary interventions and ensuing conventional treatment programs. When the same person is subjected to further coercion, even without exhibiting active resistance, the repetitive acts of domination may induce a learned helplessness, submission to coercion becomes accepted as an unavoidable part of life. This process will render it increasingly less likely for the person to emerge from the status of a chronic mental patient and to assume a meaningful role in society (Lauterbach & Stecher, 1988). Thus coercive interventions can be seen on a continuum from "early spirit breaking" to "lifelong patienthood."
Bill Nordahl, an advocate from New Jersey, describes this pattern succinctly:
When I was involuntarily committed to a forensic psychiatric institution it was clear to me that the mental health system was saying to me in effect: 'You're crazy and you're dangerous.' When they offered no therapy that was helpful, they were saying in effect: 'Your situation is hopeless.' No matter how we fight against it, we all tend to believe what is said about us. To the extent that I internalized this message ... this was what I tended to create in my life. It is clear that this did not benefit me or society. (Blanch & Parrish, 1993, p. 14).
PSYCHIATRIC MOTIVES FOR COERCIVE INTERVENTIONS
Why do so many conscientious psychiatrists continue to practice coercive interventions rather than actively opposing them and searching for alternatives? Several possible factors, simultaneously present in various degrees, may account for this unique psychiatric persistence.
Promulgating the Medical Model
Consciously or unconsciously, psychiatrists may use coercion as a way to promulgate—indeed, to enforce—their view of the medical nature of the presenting problem (Chodoff, 1988). Without the power to enforce their interventions, psychiatrists might be less successful in convincing their patients and the public of the medical/biological nature of emotional distress. It is to be expected that the greater the level of uncertainty and complexity in psychiatry, the greater the degree of paternalism which underlies coercive interventions.
Psychiatry embodies medical uncertainty par excellence. It is the only medical specialty that has continuously suffered from the lack of a "substrate" or a clear biological basis for the conditions it has set itself up to treat. Ironically, whenever a bona fide substrate has been identified, as in the case of syphilitic encephalitis, psychiatry has had to forfeit the entire disease and its treatment to other medical specialties. Consequently, psychiatric practice currently rests—at the scientific level—on uncertainty bolstered by the hope for irrefutable and yet "non-neurologic" substrates. Under these conditions of fundamental uncertainty and paradox, psychiatrists practice their particular brand of medicine, based on the ability to forcibly diagnose and treat (see Valenstein's 1986 discussion of psychiatry's perennial attempt to compensate for this dilemma with fantastic, often tormenting interventions).
Patients' Denial of Illness
Underlying many, if not most, coercive interventions is the premise that the person cannot or will not accept the idea of being ill as an explanation for his or her situation. "Denial," "lack of insight" and other such deficits are widely seen as features of the person's illness (especially psychosis). They are used to justify forceful interventions including the recent expansion of outpatient commitment laws (Cuesta & Peralta, 1994; Geller, 1999). Of course, whether actual deficits or alternate coping mechanisms are at work in the so-called denial, and whether coercion is likely to improve or worsen these ostensibly morbid processes, remains speculative.
In all of medicine there is not one example where force is justifiably used to help a patient accept a medical diagnosis and where such force is considered by doctors to be an essential element of treatment. One apparent exception is the threat of contagion from persons with infectious diseases who refuse treatment—but here the goal is not to develop insight: it is to protect the public from extremely communicable diseases, such as tuberculosis. So far this has only been applied to airborne pathogens (for a perspective on contagion which analogizes it to mental illness, see Wertheimer, 1993). In psychiatry we have no qualms about handcuffing someone to a chair without charging him or her with a crime and then, amid protests, injecting the person with an unfamiliar substance in order to combat the symptoms of a morbid condition the person probably does not appreciate, accept or interpret in pathological terms. Could this really be the only way to drive home that this person may be suffering from a "mental illness," or is this type of approach more likely to harden the resolve to keep things private, to distrust doctors, to fear for one's life, and to withdraw from society?
The Power to Control
It is of course true that some persons who come to the attention of psychiatrists have in one way or another challenged the authority of the state or the rules of civility. In our society, having made the distinction between those infractions that are punishable by law, and those that are attributable to psychiatric conditions, psychiatrists are charged with asserting the power of the state by enforcing treatment conditions. This power to control individuals who are perceived as out of control is a very formidable tool, which psychiatrists employ whenever they find justification in the person's behavior or in reports by others. We do not know whether the practice of psychiatry promotes authoritarianism or whether physicians inclined toward paternalism are more likely to choose the specialty of psychiatry. This is not a frivolous question. Whether the element of coercion in psychiatric practice is seen as part of the public health/parens patriae function, or rather as a gratuitous, if not sadistic trait, is an important question that needs to be seriously addressed, given the numerous perspectives of users who have poignantly expressed their extreme fear and rejection of involuntary treatment.
Fear of Legal Liability
A major constraint on psychiatrists to hold someone involuntarily is the fear of liability (discussed extensively by Appelbaum, 1988). Several successful lawsuits have charged psychiatrists with malpractice and negligence due to the release of a patient who may have later committed suicide or harmed someone. More recently, however, a number of cases have been settled or adjudicated in favor of plaintiffs who felt they were being detained inappropriately and harmed by this intervention (Appelbaum, 1995). This may tip the balance of liability back toward less coercive interventions. On the other hand, it may simply lead psychiatrists to be more careful when justifying coercion (Miller, 1992).
A "Burning House"
The argument that certain conditions, in particular psychotic states, are inherently harmful to the person and the surroundings, has been put forth as a major and frequent justification for early, and if necessary, involuntary interventions (Wyatt, 1991). This recommendation rests on the assumption that if left "untreated," that is, not treated with neuroleptics, these conditions will invariably lead to deterioration and dangerous behavior, much as a burning house is likely to destroy itself and its neighborhood. This argument assumes that non-coercive methods are not likely to have beneficial effects in these situations. The work of Loren Mosher and others (Mathews, Roper, Mosher, & Menn, 1979) contradicts this point, as do studies looking at persons with schizophrenia who have survived with adequate support in the community without forced interventions (for example Gillis & Keet, 1965; Harding, Brooks, Ashikaga, Strauss, & Breier, 1987).
Lack of Alternative Resources
A lack of adequate non-coercive resources, such as crisis services and assertive case managers, has been cited as a major rationale for the use of coercive interventions. This argument is ethically unacceptable. If psychiatrists are truly compromised in their ability to administer the appropriate non-coercive clinical treatments, they should refuse to work in such settings. Doctors working in medical emergency rooms that lack essential resources have had the courage to walk out of such untenable conditions. The Italian experience, where psychiatrists led the way toward abolishing dehumanizing long-term institutions including many coercive practices, is an example of doctors standing in the way of prevailing doctrine (Mosher & Burti, 1989). John Connolly's program of institutional treatment without mechanical restraints in the 1840s, when virtually no chemical methods were available, stands as a pioneering effort against psychiatric coercion (Connolly, 1973). More recently, Michael Ford and other psychiatric administrators in New York State have begun to regard the use of restraints and seclusion as an indicator of failed treatment (New York State Commission on Quality of Care, 1994). By doing so they succeeded in reducing these practices in their institutions dramatically in comparison to other facilities where the use of coercive interventions remained considerably higher for similar patient populations.
The prevailing doctrine of psychiatry fully authorizes and encourages the use of coercion whenever "clinically indicated." In fact, there is no mention of the Hippocratic principle—"first do no harm"—in the ethical guidelines promulgated by the American Psychiatric Association. Even a chapter dedicated to the topic of involuntary commitment in the authoritative volume on psychiatric ethics makes no mention of the possibility that coercion may be harmful and therefore unethical (Bloch, Chodoff, & Green, 1999). It is part of psychiatric lore, if not science, that one of three reasons to commit almost always exists—a potential for danger to self or others, a denial of illness, and a lack of capacity to consent voluntarily. Given these unswerving assumptions among their peers, it is not surprising that only a small minority of psychiatrists have taken an active stand against involuntarism and have searched for non-coercive alternatives.
Toward a Noncoercive, Hippocratic Psychiatry
Legal or programmatic alternatives outside of psychiatry that may ameliorate the situation described in this paper, and even result in virtually coercion-free systems of care, have been considered elsewhere (Blanch & Parrish 1994; Mazade, Blanch, & Petrila, 1994; Stroul, 1991; Sydeman, Cascardi, Poythress, & Ritterband, 1997). The primary concern in this article is what psychiatrists can do to reduce or eliminate the use of coercion.
The first and widest-reaching measure would be for psychiatrists to withdraw from front-line interventions where the temptation to use coercion is the greatest. In other words, psychiatrists could refuse to work in clinical settings where they are asked to utilize coercion, unless they are prepared and authorized to do everything within their power to prevent this. Psychiatric emergency rooms and triage units are basically unsuited for the practice of non-coercive psychiatry and should be eliminated from the panoply of mental health services. It may be ethically and clinically sounder to separate restrictive functions from therapeutic activities more clearly. In this case, actions which are punishable by law could be dealt with through the court system along with proper protection of due process, while voluntary treatment could be provided all along.
Psychiatrists could refuse to prescribe psychotropic medications to persons who are physically restrained. The combined experience of restraints and neuroleptization often results in severe muscular dysfunction and is among the more traumatizing medically sanctioned interventions. In addition, psychotropic drugs are often ineffective in restraining a highly agitated individual (Anderson & Reeves, 1991). Refraining from these practices would require that psychiatrists become familiar with nonviolent techniques to assist persons in extreme emotional distress, which could include non-coercive holding, talking down, creating a physical outlet, and the conflict resolution strategies. Soteria House is a good example of how such techniques can become an effective component of treatment for acutely psychotic individuals (Mosher & Vallone, 1992).
Lastly and most important, psychiatrists should be at the forefront in the search for non-coercive interventions. In fact, there is a small, but significant tradition of advocacy for non-coercive alternatives among psychiatrists, starting with the 18th century British hospital superintendent John Conolly who proved that his institution could run entirely without physical restraints (Connelly, 1973). Leonard Stein (1976) and Loren Mosher (1994) are two psychiatrists who made it their mission to provide non-coercive, non-institutional alternatives in crisis situations. Some lesser known pioneers are Edward Podvoll (1990) who initiated the Windhorse Project in Naropa, and Paul Polak, who proposed the use of foster-family crisis intervention as an alternative to hospitalization (Polak & Kirby, 1976). Thomas Szasz (1978) has devoted a great deal of his writings to arguments against coercive interventions by psychiatrists, as did Peter Breggin who proposes conflict resolution and empathic treatment as alternatives to coercion (Breggin, 1992, 1997).
Some of the most important lessons for psychiatry today come from different quarters—the movement of ex-patients and survivors of coercive interventions, who have made it their aim to prevent coercion for themselves and for their peers and who are in the process of developing non-hospital, non-coercive alternatives which merit our fullest support. Crisis-residential settings are being developed by survivors in California, New York, Connecticut, The Netherlands, and Germany, among others (Dumont, 1993; Wehde, 1991). Comprehensive community support alternatives are being designed and developed by survivors of coercive interventions (Chamberlin & Rogers, 1990). Various forms of advanced directives are being promoted and field-tested by survivors at risk for involuntary interventions (Lehmann, 1993; Rogers & Centifanti, 1991).
Considering this rich trove of alternatives to coercion, it is not acceptable for psychiatrists to claim that they can do nothing to change the system. Existing models have demonstrated significant success in this area (Breggin, 1991; Breggin & Stern, 1996; Neugeboren, 1999). New models need to be developed in collaboration with survivors of coercive interventions. Psychiatrists could be at the forefront of these alternatives instead of trailing behind as the principal advocates for increased coercion and outpatient commitment.
We now return to the Hippocratic Oath to present one interpretation of its controversial passage, "First do no harm." It would seem that as medical doctors, psychiatrists should be obliged to safeguard patients from damaging interventions that might be initiated by practitioners who do not subscribe to this oath. Whereas in the days of Hippocrates these might have been called shamans, today they are the public officials and mental health professionals who believe that forcing people into treatment "helps" them. Therefore, any physician wanting to observe the Hippocratic Oath must stand in the way of these practices and do the utmost to search for non-coercive solutions. Perhaps these "conscientious objectors" would then be considered, as Ron Thompson (1994) has suggested, "Hippocratic Oath Practitioners" in contrast to those who practice social control under the guise of psychiatric treatment.
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Acknowledgments. This paper benefited from the input of Andrea Blanch, Dian Cox, Dick Gelman, Edward Knight, Jacqueline Parrish, Susan Stefan, Ron Thompson and Laura Ziegler. Ron Thompson deserves special credit for independently arriving at the notion of Hippocratic psychiatry.
Offprints. Requests for offprints should be directed to Peter Stastny, MD, 75 Morton St., New York, NY 10014.