Most Americans would agree that we have problem with mental health in this country, but what many do not know when they consider that people who are in distress are not getting the help they need is that hospitals in this country are not giving people a choice when they are in the most need. This is based on laws that currently exist in 45 US States, which allow individuals to be petitioned into an inpatient psychiatric unit against their will if they are deemed to be a “danger to themselves or others.” I have worked for 3.5 years as a Peer Support Specialist within my local public mental health system, where I see this happen to the individuals I serve, on a regular basis. I myself have been forced.
Here’s where my own story ties into the issue I want to discuss, in regard to the essential need for advocacy within our system to support individuals who end up in these situations, and in regard to their prospects to recover and lead a meaningful life. If I did not have the support of my family, friends and doctors in this during my experiences with force, I would not be where I am today; working full time and living a fulfilling life. Many who meet me for the first time would have no idea that I have suffered from these types of circumstances, nor that I have mental health and neurological challenges.
The work I have done as a Peer Specialist is in a Case Management program providing services to young adults ages 18-26. In this job, I share my personal story and offer support to individuals who are living in poverty, having been hospitalized for mental health treatment, in many cases against their will. Some were or have also been incarcerated, have very little family or natural supports and often have lost all hope. These are people with dreams, just like you and me, and sometimes it is as simple as having a place to call home, or knowing where their next meal will come from.
In my work, I visit with people in Jail, attend court with them, see them in the hospital, attend Doctor’s appointments, support them in navigating systems, obtaining income, finding employment, going to school, and I often talk to them when they are in extreme duress. When I first learned about forced treatment laws and encountered individuals who were referred to our program from the hospital after being petitioned against their will, or being involved in circumstances where they were not “complying” with treatment and navigating the legal process when a person is “in violation” of their treatment order, I was shocked and unsure what to do. Is this fair? Should people be committed to the hospital against their will and picked up by the police if they are refusing to participate in the services we are offering? I voiced my concerns and spent much time with individuals who were under these circumstances, out of the hospital, over-medicated, oftentimes homeless, family having abandoned them and simply wanting to have the ability to take control over their lives.
What I have emphasized in my work to advocate both amongst my colleagues and with the individuals I serve, is that even under these circumstances people must be given a choice. I see on a regular basis that hospital ERs use petitions as a standard protocol if a person comes in in an extreme mental state, and if it seems they may not agree to treatment. A petition is a lot easier than taking the time to talk with the person and help them to come to a decision, which may end up being an agreement to treatment. Petitions also reduce liability for a hospital if someone refuses treatment, and then goes on to hurt themselves or others. So, if the hospital social worker and ER Physician are concerned about this, a petition protects them, even while suddenly involving the individual in a civil court process while in an extreme mental state.
I push hard in my job to assure that we can speak with the individuals we serve when they are brought into the ER, instead of finding out later that they were petitioned, or being asked to do one ourselves. Petitioning people against their will can potentially ruin their relationships with the people who are supposed to be helping them, who are now placed in a power position. This follows upon ER clinicians taking authority over them, and inpatient psychiatric clinicians doing the same.
The social services system, in addition to the courts, are the 3rd party associated with the enforcers. I can easily be seen as that since I work with the clinician who could have the person committed again within a 60-day window or any time before or after that if they are on a continuing order. I’m not going to lie, I have helped in this process when it was clear to me that as a non-clinician I had no authority. But when I knew the person, had heard their story and they had a chance to know a bit of mine, I used my best judgement and self-confidence to take all measures possible to assure that when it came to actually receiving the treatment, they would not be forced and would know their rights. Not an easy thing to do, and often quite painful for me, along with the Clinicians with whom I am on the team.
When you think about these laws and the complications that forced treatment can cause for someone to feel they have no choices and thus resist treatment or only participate because they are afraid of being taken back to the hospital, it’s clear that this is inhumane. Proponents of the laws say that this is the only way to get these people to receive treatment and otherwise prevent them from being a danger to themselves or others. What I am interested in given the current climate and that these laws are already in effect is how we can put systems in place to prevent abuse or misuse of the laws, and assure that individuals are given choices even when they are required to participate in treatment. This is what helped me and I have seen help others.
How can we make this happen? First, we must work with hospitals and other institutions that are often the first point of contact or are most often utilizing forced treatment as a measure of preventing individuals in a mental health crisis from being a danger to themselves or others. Many say that hospital ERs or law enforcement do not have the time to sit with someone whom they don’t have a relationship with, and who is in an extreme mental state, to help them understand what is going on and allow them to make a decision for themselves. I can say from experience that I have seen many people who have almost completely lost touch with reality, and it is not easy to have these kinds of conversations. Those who are best to do this are people who have been there; Peer Support Specialists who already work on Mobile Crisis Response teams alongside mental health clinicians. I strongly believe that this needs to be a standard for all emergency mental health services. Each individual who is in a mental health crisis where hospitalization may be considered needs to have contact with a Peer Specialist. When it comes down to it; involving courts, police, increased hospitalizations and lots more paperwork is costly. Some may say it prevents the cost of others being hurt and criminal proceedings taking place, but I would argue that people are being criminalized through civil laws for something that is not their fault.
In addition, these Peers who have contact with individuals like I do in my position can support them in understanding what is going on with them, how they can advocate for themselves in the treatment process, in learning that recovery is possible. When someone is forced, feels trapped, and fears what control the mental health system has over them, they need to know that they have a voice and that they are not alone. If they don’t want to take medications because they feel drugs are ineffective, or they want to work with their doctor to clearly identify what their diagnosis is and how it can be reasonably treated, they should be given that choice. I feel that in most cases we try to take that approach. No clinician likes to have to file paperwork which would lead to someone being picked up by the police and brought to the hospital and I don’t like to watch it happen. What we can do, while continuing to fight any further implementation or increased powers within these laws, is to assure that resources are dedicated to providing opportunities for individuals to choose, to be supported and to move on to independent lives free of any treatment mandates. Many have done it and put this part of their past behind them; meanwhile we must work hard to prevent any force from ever having to be used. It must be a last resort, with recovery and dignity at the forefront.
Finally, I leave you with an example as to how you can make an impact right away. Psychiatric Advance Directives are a tool to prevent force if they are utilized correctly. I was trained on them as a Part of my Peer Specialist Certification and when I noticed soon into starting my job, that some of the folks we served that had extreme life circumstances were a part of this revolving door between hospitals and jail, I spoke up. Soon I became the one to explain and/or complete a psychiatric advance directive with the individuals we served, as we were required to inform them of this right upon the beginning of services. (By the way, they also do have to sign an agreement for service, so this is an opportunity to explain their rights if they are under court order.) There are many gaps even within Advanced Directives, as, for instance, when the screening clinician does not know they have one and they do not ask then the appointed advocate would not be called. Thus that’s where the community providers must have the protocols in place to be truly person-first. It is possible; I have done it in the small way I am able, and we can do more even if the rights of individuals with mental health histories continue to be in jeopardy.