Committed: The Battle Over Involuntary Psychiatric Care

Sandra Steingard, MD
65
2159

Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.

On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care. 

The book attempts to cover this topic from a multitude of perspectives. First of all, they tell the story of two women — true stories using pseudonyms — who had each been committed to a hospital, had good outcomes in the sense of being able to resume their usual lives, but had differing views of the experience. Both women identify themselves as having been in a psychotic state at the time of admission and they both agree that their level of distress created understandable concern for others. But one of them, Lily, is grateful that she was forced into a hospital and the other, Eleanor, remains scarred by the experience. 

These stories — which are introduced early and then returned to throughout the book — form the backdrop and frame one of the many conundrums addressed in the book: how can the same thing be both helpful and harmful? It also sets the tone; the authors try to represent varying perspectives and treat each source with respect.

After introducing the stories of Eleanor and Lily, they lay out the basic arguments both for and against involuntary interventions. They describe some of the history of the civil commitment laws in the US. They then walk the reader through the ways in which individuals may encounter force, starting with the role of the police, then moving on to emergency rooms, inpatient hospitals, commitment procedures, and involuntary drugs. In each of these chapters, they interview people directly involved and try to present their experiences and opinions with their usual down to earth tone.

They then discuss involuntary outpatient commitment (and to their credit, they did not adapt the euphemism of  “assisted outpatient treatment”), mental health courts, and the intersection of mental illness and violence. They conclude with some recommendations.

This is quite a feat in 265 readable pages. I applaud the authors for their work.

As I was reading it, I was thinking about this review (I was sent the book by the publisher with the agreement that I would write a review for Mad in America). I knew this topic would be contentious and I was thinking about how others might read it. I respected what the authors had attempted and accomplished, and yet I had this sense of uneasiness which I will try to articulate here.

Not surprisingly, even though multiple perspectives were represented, the book was written from a decidedly psychiatric perspective. By that I mean that the nature of the problems that beset the people who wound up facing involuntary interventions were conceived of as fundamentally medical problems, “mental illnesses.” This illness frame is accepted without question.

It reminds me of the famous story about the fish who asks “What is water?” When one is raised, so to speak, in a world in which these problems (paranoia, heightened disorganization of thought and behavior, marked elevations of mood and energy) are known to be illnesses, then the examination of the problem starts, in my view, midway down a road. The questions asked have to do with how to best treat the illness over the person’s objection. If, however, one starts from a premise of uncertainty — accepting that these are complex situations whose cause and etiology are unknown — then one might be more cautious about jumping into framing the problem as one of access to treatment. One might start from wanting to know more about the nature of the problem.

This difference in perspective was particularly striking in Eleanor’s story. In the midst of some major life stresses, she went into an altered state for the first time in her life. Her condition was only exacerbated by her surprising admission to a hospital where she felt her life was in danger. She was agitated and ended up getting forced drugs and forced seclusion. She was eventually discharged and, over seven years, has never experienced another episode like this. The hospital records include information about her mental state but little attention seems to be given to the antecedents to her condition or whether there are ways to be of help aside from getting drugs into her system.

Almost in passing, it is mentioned what to me is a shocking cocktail of drugs she was on at discharge: olanzapine 25 mg, aripiprazole 20 mg, haloperidol 10 mg. Three antipsychotic drugs, each at or above the manufacturer’s recommended dose! When her inpatient psychiatrist learns years later that she is doing well off medications, what is his response? “She’ll get sick again.” The unexamined confidence that so many of the psychiatrists in this book held for the treatments they were offering, while not surprising, was striking. The failure of any of them to consider treatment as something not entirely synonymous with drugs was also not surprising, but nevertheless disappointing. But these are the experts in these cases and that should give us pause.

To their credit, the authors admit that this book was transformative for their own thinking. In talking to people who had experienced forced care, they accepted that even if well-intentioned, this can do harm. They learned that this perspective was not readily acknowledged by their colleagues. Yet they point out how acceptance of the harm that can be done by forced care will change the way one thinks about it.

“If you begin with the idea that psychiatric treatment is in the best interest of the patient…then you do what is necessary to get that person help. If you begin with the idea that involuntary psychiatric treatment might leave the patient feeling distressed and traumatized for years, then you start with a different mind-set and a different propensity to take action.”

The end is telling. Dr. Miller describes how her belief that forced care is traumatizing led to her efforts to avoid it with the people under her care. To her knowledge, no one was harmed, but she still wonders, “if my work on this book clouded my judgement and endangered my patients.” I am not critical of this statement; I understand. I have similar worries. When one makes a decision to force a person into a hospital there are two kinds of errors one can make — to force hospitalization when the person without it would not have harmed himself or anyone else, or to not force and have the person go on to harm himself or others. It is hard to know for sure, but I think that most of the time, we are more willing to accept the first error than the latter.

I am not sure exactly what it is in our training or disposition that leads us in this direction, but I would be dishonest to not admit that I feel that pull as well. That difference in perspective may be one of the greatest divides between my profession and the most ardent critics of forced care.

As for solutions, the authors point out the limits of forced care and argue that it is not likely to solve many of the problems — homelessness or incarceration, for example — that proponents claim it will. They argue for more services, earlier engagement, more support for individuals and their families. Pete Earley writes an introduction and they refer to his story in the book. Earley talks about the lack of any care offered when his son was not deemed to pose an imminent risk. Initially, the only help offered was pleas for him to take his drugs. After my years of studying Open Dialogue practices, while I can’t predict a different outcome, I also can’t read this story without seeing that so much more can be offered. So much more.

Support MIA

Enjoyed what you just read? Consider a donation to help us continue to produce content, provide up-to-date research news, offer continuing education courses, and continue building a community for exploring alternatives to the current paradigm of mental health. All donations are tax deductible.

$
Select Payment Method
Loading...
Personal Info

Credit Card Info
This is a secure SSL encrypted payment.

Donation Total: $20.00

65 COMMENTS

  1. this warrants repeating- what is so special and all-powerful about psychiatry that an adult who committed no crime can be stripped of all of his/her rights and be locked up against his/her will? psychiatrists are not mind readers. they can never KNOW if a person will harm another person. and if someone happens to wish to harm himself that is actually his right. do psychiatrists truly believe they are gods? seems to me they do!

    • This is a tricky issue. If a person not in his/her right state of mind were brandishing a knife or doing something outright dangerous to those around him/her, you would want to seclude the person at least for a while.

      While you don’t know with 100% certainty, you can roughly assess the probability of such an occurrence and would rather take the side of caution.

      Put yourself on the other side of such a situation.

    • Absolutely agree.

      As a woman of 50 with no history of violence or psychosis, I was stripped of my human rights, and locked up in a psychiatric “hospital”. The trauma of it dumped me into my first and ONLY “major psychosis”, for which I was forcibly drugged with Olanzapine and Mertazapine. I was held in “hospital” and drugged for six weeks.

      Being so totally stripped of my human rights was the biggest trauma of my life and within four months of being released I had made a very serious suicide attempt.

      Twelve years later I am free of psychiatry and have been off the “drugs I would have to take for the rest of my life” for more than seven years, and have had no further “psychotic” episodes.

      However, I still have nightmares and my responses to stress are extremely difficult for me to deal with. I was unable to return to my former highly successful career.

      The psychiatric violence committed against me and total denial of my human rights (I was treated as a sub-human life form) changed my life…and not for the better.

      I had committed no crime, had no history of violence and psychiatry’s violent and abusive actions against me have traumatised me…no doubt at all.

      Being reduced to a sub-human life form without rights IS traumatic, it IS violence. It CANNOT be otherwise.

      It is NOT health care.

      • I agree with you, mlk, forced psychiatric treatment, and even coerced psychiatric treatment based upon the fraudulent “chemical imbalance” lies, that leads up to forced psychiatric treatment, all of it is morally wrong.

        An ethical pastor confessed to me, after reviewing a well organized edition of my medical records in conjunction with my medical research, that the psychiatric and psychological industries, long ago, entered into a Faustian deal with the mainstream medical community and the mainstream religions. He called this “the dirty little secret of the two original educated professions.”

        Apparently the psychological and psychiatric industries collectively agreed, long ago, to defame and drug up all those who had dealt with easily recognized iatrogenesis by the incompetent doctors and all those who had dealt with child abuse by the wealthy and/or leaders of the mainstream religions.

        Unbeknownst to me, at the time, my family had dealt with both crimes, and since I was in denial my child had been sexually assaulted and I was rational, not paranoid enough to assume a PCP would try to defame me for life and try to murder me, to cover up her husband’s “bad fix” on my broken bone, I had the misfortune of dealing with the insanity of today’s psychiatric system.

        The doctor who forced hospitalized and treated me was even eventually arrested for having lots of patients medically unnecessarily shipped long distances to himself, “snowing” patients, and performing unneeded tracheotomies on patients for profit.

        http://www.chicagotribune.com/news/local/breaking/ct-sacred-heart-hospital-verdict-met-20160304-story.html

        Now that the medical evidence is in showing that today’s antidepressants and ADHD drugs can create the symptoms of “bipolar.” and this has resulted in massive misdiagnoses, even according to the DSM-IV-TR, of millions, including a million children as “bipolar”:

        http://www.alternet.org/story/146659/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america

        And the medical evidence, which is still being denied by today’s psychiatric industry, but is already in, pointing out that today’s “bipolar” and “borderline” drug cocktail recommendations, particularly combining the antidepressants and antipsychotics, can cause the positive symptoms of “schizophrenia,” via anticholinergic toxidrome.

        https://en.wikipedia.org/wiki/Toxidrome

        And the antipsychotics (AKA the neuroleptics) can, all by themselves, create the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome:

        https://en.wikipedia.org/wiki/Neuroleptic-Induced_Deficit_Syndrome

        I think it’s time for the US psychological and psychiatric industries to end their “dirty little secret of the two original educated professions” Faustian deal, and utilize their malpractice insurance for what it was intended, if any of them want forgiveness for this deal with the devil.

        I do appreciate some psychiatrists are attempting to repent, and trying to make at least non-financial amends for the greed inspired collective insanity and improprieties of today’s staggeringly unethical, DSM deluded psychiatric industry, Sandra.

        But as a Christian, who dealt with hypocritical, Holy Spirit blaspheming psychiatrists and psychologists, it’s not up to me to offer forgiveness, it’s up to the God of the Holy Bible. And I do recommend the Holy Spirit blaspheming psychologists and psychiatrists do repent, and utilize their malpractice insurance for what it was intended, since blaspheming the Holy Spirit is the one and only unforgivable sin in the entire Bible.

  2. Dr. Steingard,

    It is not very rare that children or youth (say <26 years of age) who come from dysfunctional families with an abusive parent(s) end up in psychiatric wards, sometimes forcibly. This is because either they start lashing out due to helplessness or may be self-harming due to helplessness.

    What bothers me is, do psychiatrists understand the pain these people may feel when they end up in psych. facilities while the people who've done these things to them escape?

    How can a morally upright psychiatrist exclude himself/herself from true therapy (which is criminal justice proceedings on behalf of the harmed individual) in this situation? The psychiatrist would simply have to refuse to take up such cases or draw attention to the fact that it happens and he/she cannot engage in such practices.

    Also, what about the fact that such youth sometimes get labels which can make things even worse for them (bipolar, borderline etc.)?

    • The issue of violent children and teens is very complex. I doubt very much if anyone has parsed out the real statistics of how many of these kids are coming from which issues. Violent kids by no means all come from ‘dysfunctional’/abusive families and shouldn’t be lumped together as such (either literally or figuratively).

      Violence emerges from: developmental issues; family violence that develops AS A RESULT of the violent child’s violence; pregnancy or birth issues; head trauma; and more.

      I had the good fortune to be exposed to Ross Greene’s ‘The Explosive Child’ and discovered early that my child was experiencing developmental (prefrontal cortex) issues. I was then able to tailor my parenting accordingly. These kids will represent a huge percentage of kids who act out behaviourally. However, since nobody has the time, insight, or energy to deal with them properly they do all end up in the same place, and are all brutalized one way or another.

      But I must disagree with the author who suggests that psychiatrists want to do better by them. Psychiatry bears responsibility for their brutalization by having invented medical pathologies (ODD, IED) for them, which lead directly to them being medicalized and drugged. And then, as you mention, they get more and more labels and drugs (all without informed consent) tacked on as time progresses.

      To his great credit, Ross Greene resisted any diagnoses and labels (his weakness is in not condemning psychotropic drugs). He concentrated on helping them develop impulse control, flexibility, and such. But the post author is correct in that the dedication required to raise children like this is beyond what anyone imagines who has not done it themselves, which is why positions can’t be filled. Not surprising. Woe be the fate of the violent child without a genuinely caring guardian for a decade at least.
      Liz Sydney

      • Violent kids by no means all come from ‘dysfunctional’/abusive families and shouldn’t be lumped together as such (either literally or figuratively).”

        Agree.

        Violence emerges from: *other reasons*, family violence that develops AS A RESULT of the violent child’s violence

        I disagree with this blanket statement. While violent children (who come from decent families with caring parents) can make family dynamics go awry, trust me when I say children from violent and abusive homes can become extremely distraught and sometimes engage in violent behaviour. Some in relatively milder ways and some in harsher ways.

        I understand what you have written is from your experiences, and I am offering you a different view (which does not invalidate your own, but only adds to the reasons (which are in some cases applicable) you have stated for violent behaviour).

      • Liz I agree that many times psych professionals see violence in kids and conclude it comes from dysfunction in the family. I can’t understand why they automatically jump to this conclusion since temper tantrums are extremely violent and can reoccur at any time. When a kid’s hormones hit the roof during adolescence (science doesn’t really understand this too well) then it’s very possible for teens to have tantrums, too. Who hasn’t seen someone throw a cell phone at a wall, or honk their horn in utter rage? I doubt that means a darned thing about “dysfunction” in the family. Frankly I am very sick of the knee-jerk blaming, too. My shrinks did it without even meeting my parents! They even had them all diagnosed!

      • Is Greene the man who had the school where all the kids were violent and he worked with them so that they were off the drugs and functioning properly? This man was doing great things with the kids and then his funding was revoked and all the kids ended up back on the drugs and being violent all the time.

        • @Stephen Gilbert, No, to the best of my knowledge this is NOT the same guy. The Ross Greene, PhD I’m referring to was a psych prof with a private practice in family therapy somewhere near Boston. He discovered through his practice with violent kids that the fault wasn’t the family in most cases [nobody is denying the terrible prevalence of child abuse but it’s not the issue here] and realized that there was a developmental component going completely unnoticed. Completely different from the otherwise popular notion that the kids are choosing to be rotten or are in rotten homes. He wrote a couple books on these kids, and now has a busy non-profit devoted to furthering his methods.
          http://www.livesinthebalance.org/
          Liz Sydney

  3. Sandra,
    You said at the end what I was thinking from the very beginning of your article:

    So much more could be offered.

    Psychiatric involuntary commitment is a relatively minor issue when set against the backdrop of so little resources being available to help seriously distressed people in the USA outside of drugs. In terms of job training, affordable housing, individual therapy, family therapy, etc, the availability of these psychosocial resources – which in many cases could prevent the need to even consider committing someone – is sorely deficient by an order of magnitude (10x) or maybe even two orders of magnitude (100x).

    Involuntary commitment also makes only a small difference because it typically means locking someone up for only a few days or weeks. Not everyone is harmed, but many are harmed by being started on too many drugs and being traumatized by the force used. For those who are not harmed, like the woman who appreciated her experience, they might be kept safe, but a few days or weeks are usually not enough to address all the life circumstances that may be contributing to serious distress.

    And lastly, this part was also important,

    “When one is raised, so to speak, in a world in which these problems (paranoia, heightened disorganization of thought and behavior, marked elevations of mood and energy) are known to be illnesses, then the examination of the problem starts, in my view, midway down a road. The questions asked have to do with how to best treat the illness over the person’s objection. If, however, one starts from a premise of uncertainty — accepting that these are complex situations whose cause and etiology are unknown — then one might be more cautious about jumping into framing the problem as one of access to treatment.”

    I continue to be amazed to see psychiatrists writing about serious distress as if it were a brain disease, even in the lack of any objective evidence/biomarkers of biogenetic causation. It seems like this is the hallmark of thinking for most in the field: Assume your conclusions.

    I guess when you need to frame problems as illnesses to make your living and feel justified in prescribing drugs, that is what you do. But to me it is unethical and an example of living an unexamined professional life.

    • [The following was previously posted then “moderated,” apparently because of a sentence which may have been construed as “personal”; however I consider the essential point being made to be of collective import so I am reposting an edited version.]

      OMG Matt actually said this & I missed it:

      Psychiatric involuntary commitment is a relatively minor issue when set against the backdrop of so little resources being available to help seriously distressed people in the USA outside of drugs.

      “A relatively minor issue?” I think we just discovered the line between anti-psychiatry and “consumerism.”

  4. Thank you for this review. The closing sentences concerning Pete Earley’s introduction mimic my own view, as a parent who had similar experiences with his son. There is no care. Medication alone is not treatment and not care. As an earlier commenter wrote, this is “tricky.” When a person brandishes a knife or acquires a gun, it’s a game changer for a loved one or friend. What is in a person’s head? What will they do? What’s the proper course of action?

    My son was acquiring a gun. We discovered what was happening. We knew of two possibilities. Neither were we certain of. His temporary detention was a very close call in the judgement of law enforcement, experts, and the judicial system. In his prior history he had assaulted officers and resisted arrest while intoxicated. He had tried to commit suicide multiple times by different means. He had no job, was living at home, in a small town, and had just fulfilled parole in another state, where he had a diagnosis and was receiving treatment. We were requested to come get him. He had great difficulty coping with voices and thought disorders. Yet, he managed to convince a judge that he had acquired the gun for target practice. Technically, he had a right to the gun when he was released. He was very mad at us for contacting CIT and the involuntary commitment. The experience further hurt our relationship. Honestly, I was scared. Had I been a poor father? We did not know this person who we were living with.

    He was committed again. This time for a longer period. Seven days. This judge was less lenient. His commitment was all his doing, we literally made no comment during his hearing, other than we loved our son and were doing our best. After this release, he was worse than when he entered. At NAMI Family Support Group meetings, I had heard this routinely, weekly, for four years now. I now co-faciliate the group. I have friends who endure odd and thought disorders. Know many, many families.

    Our son has been stable, but super-isolated for two years now. He has no money. No longer drinks. Smokes and vapes during stressful periods, like holidays. Will not apply for SSDI, nor give us medical power of attorney. We’re his family and caregivers. He lives upstairs in our house. We have rarely seen him. All communication is very soft and through e-mail. He has done tasks for people remotely, quite expertly. His written communication is flawless. I do not believe his brain has atrophied.

    He is 27 now. All began at 21.

    I have come to accept that he might be right. Medication is wrong for him. It is his life and he did not ask for this life experience. Recreational drugs and alcohol abuse did not help him in his earlier years and may well have exacerbated his condition. He has expressed this sentiments to us. Therapists, doctors, medication, and hospitalization were not the answer for him. In NAMI, you typically hear otherwise. But, it is a good group, where people earnestly care for and about one another. We need a place to express ourselves as family members and peers.

    There is no one answer. I believe it is folly to think we will ever fully understand the mind. Not in this century. Yet, we are led by media and scientists in this direction. Science will figure it out and brain study is the key. I am a lay person. Not an expert. I am a father. Not a doctor.

    My background is biology and chemistry. I have heard many scientific presentations and read indecipherable papers. I know the difference between a good study and bad one. There are always at least two views and they compete for audiences and funding. And, it’s quite possible that neither is truth or fact, for long.

    What I do believe is that we have neglected a community-centric care orientation for the past century. Society moves at breakneck pace of expectation and achievement. Our level of human acceptance is very low. People deserve the right to live peacefully and be protected from harm. They should be encouraged to assemble freely and care for one another. Softly, lightly, gently. Objectives can still be set.

    I did not always think this way, but experience with mental illness does this to a person, family. We have neglected the social, cultural, and spiritual side of our human existence. The way we live and care about and for one another. I gravitate toward Soteria, Fairweather Lodge, self-managed care, and anything that limits the requirement for and the use of outside man-made agents, but maximizes coaching. We need coaches, support. Very labor intensive. Like Open Dialogue, which is brilliant.

    Personally, I am working on something called Hope Village, with five other families. We are just started. Our foundation is cohousing, where families form a neighborhood with the intention of looking after one another. A place of acceptance. I have been looking at different models for over three years now. We imagined a blend. For the first time I have begun to believe it will happen. Some college MBA students just finished a study for us. In their final presentation to us, you could see how touched they were at the opportunity to learn and study a complex situation from scratch.

    We simply have to do something different in our society. And, we can. We have to stop beating on one another politically. It does not solve anything. We have to find a way to channel resources into real projects, some maybe social experiments that will fail, that will examine and try community and co-existence. Again, what I have leaned out of six years of tragedy is that their is tremendous personal value to be realized for human beings. We do it every day. What’s missing, from my perspective, is community. We need more doctors of community.

    • You’re almost begging for a reply, @askforcor. OK, your son “…is 27 now. All began at 21” *NOT*. It did not all begin at 21. First, we’d need to look at all 4 of his grandparents, and then his 2 parents, (and any step-parents), THEN look at your sons’ life from conception. Did his mother drink alcohol, or smoke tobacco, or consume caffeine during pregnancy? For starters…. Then it gets tricky. The point is NOT to point fingers, or blame, or shame. The point is to look at *relationships*. Your relationship with your son, and his relationship with you. You say he drank and did “recreational drugs” during his “earlier years”. Does that mean middle school? High school? He did NO alcohol/drugs until 21? That’s not likely. Too many parents are clueless, ignorant, or in denial.
      You say he was “on parole” from another State. That usually means a felony conviction, and prison time. Misdemeanors, and local/county jails don’t usually result in “parole”, but rather probation.
      So let’s look at NOW: You’ve got a 27 yr. old man, who doesn’t work or collect Social Security Disability, so you’re his bank, and as you say, his “caregivers”. One thing I like about my own work-a-holic, alcoholic, abusive, and yet GOOD Father, was that he kicked me out of the house! There’s a word for parents like you: ENABLERS. You not “caregiving”, you’re enabling dependent behavior. You’re subsidizing it.
      NAMI is good at scapegoating, and victim-blaming, and making Black Sheep out of troubled kids. It eases the guilt of mom & dad.
      Know this. Psychiatry is a pseudoscience, a drug racket, and a means of social control. It’s 21st century Phrenology, with potent neuro-toxins. My parents took me to a shrink when I was in 10th grade. The bogus “diagnosis”, and the DRUGS, did far more harm than good. There’s a word for what you son REALLY has. I have it, too. It’s IATROGENIC NEUROLEPSIS. He’s not like he is *in* *spite* of the so-called “mental health system”! No, he’s like that BECAUSE OF IT. That’s the inconvenient truth you’ve been avoiding. I bet your son rarely exercises, correct? We don’t need more doctors of anything. We need more REALITY, and more COMMUNITY. The pseudoscience drug racket and means of social control known as psychiatry provides NEITHER….. Staying stuck with NAMI won’t really help you, or your son, in the long run….

  5. I would also not be surprised if you get more positive outcomes than negative, if any negative at all. Since there is a diagnosis for the “patient” that does not believe she was not helped but harmed. It is well documented that the way to appease and “get out of the hospital” is to go along to get along. It would be interesting after this positive case that you speak of starts having medication switched and increased dosages and new diagnosises, how she feels after say, a decade has passed and she finds herself unproductive.

    And of course the response from the doctor, to the effect of she’ll be back. Well no wonder, given that these drugs have withdrawal effects to the magnitude of 10X than the original episode. That doctor would have to look in the mirror and see how many years of education, experience and income being flushed down the toilet.

    The scientific basis for this is sub par by any scientific standard. They break all rules of the scientific method and statistical analysis, again and again and most of quickly apparent. So now we have the chemical imbalance debunked although 95% of the population has no clue that that is an urban legend, if you will. Now we move into the scarier realm of genetics which doctors have ascertained and made a basis for diagnosing a new patient. And even that avenue looks like there is no possibility but they are selling it nonetheless, and their patients swallowing it whole because of the MD at the end of the person’s name. Too bad common sense doesn’t come into it. Since the last statistic I heard on the mapping of the genome gave us 2000 possibility of mental illness. To identify that would be like winning one of those state lotteries where you pick 7 numbers from a lot of 50, about 40 times. And the odds are, that you would more likely get killed by a vending machine.

    From that I’m concluding is that the problem is one of sociology. If you put a person in extreme poverty struggling to make ends meet because we live in an oligarchy, then that’s just life. Yes a homeless person will not get the proper amount of sleep and be fully rested and yes, sleep deprivation will lead to psychosis. Violence will occur when a mother cannot afford to feed her baby but has to resort to crime and whatever violence that crime leads too. We in polite society wonder “how can you get to the point of hurting another human being” and to push it far from ourselves. We chalk it up to “mental illness.

    So the point it comes to is, it seems not to be a medical issue. It has been looked at, for too long and the “business” of pharmacology has become too big for us to look for another solution. The drugs they have can only shut off or turn on one item at a time, say serotonin or dopamine. There are too many functions that are controlled by dopamine, sleep regulation, goal seeking, sexual function and on and on for that to be a solution and they say so. But how much harm is it causing? Plenty. One is too many. Unfortunately, the doctors are just the salesmen in this equation. The real harm is the drugs. They have no business being in circulation.

    They are a safety hazard to the public at large.

  6. The first problem I have on hearing about this book is with the title. Is ‘involuntary psychiatric care’ care? I think the idea that it is ‘care’, or has anything to do with ‘care’, on the face of it, mostly presumptive.

    The second problem is that I would doubt the authors go very far outside of their comfort zone when dealing with the issue, that is to say, I think it must be a very limited production and view. Although the idea of such a book may be commendable, I can only see bias in the choice of Pete Earley to write the introduction. There are people who are more impartial, or at least, less partial, although perhaps also less sensationalist. Pete has done much to promote forced treatment, and little that I know of to protect anybody from it.

    “When one makes a decision to force a person into a hospital there are two kinds of errors one can make — to force hospitalization when the person without it would not have harmed himself or anyone else, or to not force and have the person go on to harm himself or others. It is hard to know for sure, but I think that most of the time, we are more willing to accept the first error than the latter.”

    Thomas Szasz often inferred that a person could no longer practice his type of psychoanalysis. Why was this so? Litigation. He was actually sued in one instance for not following standard procedures after a client committed suicide. This is a major reason, as you put it, “we are more willing to accept the first error than the latter.” If the person is incarcerated, then the person is not in a position to harm self or another, however, when people aren’t incarcerated, where violence occurs, and family and mental health professionals can be held accountable for their erring associates actions, that means litigation.

    The gist of what I’m trying to say here is that one reason people are ‘more willing to accept the first error than the latter’ doesn’t concern numbers or evidence, it concerns custom and consequences. It is easier for mental health professionals to accept that error because if they don’t, the chances that they will eventually get sued goes up astronomically. Another point Szasz was fond of making was how in the criminal justice system we go out of our way to protect the rights of the accused while due process is basically scrapped in the civil commitment system.

    Now that litigation is often used as an attempt to exact punishment from people who, for one reason or another, eluded punishment in the criminal justice system, this begs the question of whether it should be used in such a fashion. I still think fear of litigation is very much a reason that more people are forced to endure forced treatment than it is credited with being, which is to say, people are being held not because that is what’s best for them, but because if they were released, and something happened, professionals in the mental health system would be held responsible through litigation of one sort or another.

    • If you can get sued for not following standard practice (deviating from what’s in the college textbook), and you can’t get sued for following standard practice (drugging and “hospitalization”), practitioners are going to be much more likely to follow standard procedures than to try anything different. Doing so favors the medical or the disease model, of course, as that is what standard practice, as a rule, is all about (“meds”/drugs and “hospitalization”). Protecting people from such becomes all the more problematic when doing so, as it does, also puts one at risk for litigation. Buck the system, in other words, and you can get sued, or do everything by the book, and even if your client is screwed, you’re safe. Obviously, given this situation, there are ethical issues involved that are not going to make the light of day.

  7. Sandra

    I appreciate your willingness to wade into this extremely important and contentious issue of the use of ‘force.’

    It sounds like these “reformers” are still very much stuck within a paradigm of overall psychiatric oppression and defending Psychiatry as necessary institution within our society. I would guess that in the end they would still be so-called “reluctant” users of force and somehow justify its use in so-called “extreme” circumstances.

    I would urge you to read my blog “May the ‘Force’ NEVER EVER Be With You: The Case for Abolition” https://www.madinamerica.com/2014/10/may-force-never-ever-case-abolition/
    Here I make a strong case for “abolition” (from every possible angle) with no room for ANY exceptions. What follows is some concluding paragraphs from that blog:

    “So all of these arguments regarding the use of ‘force’ in the mental health system boil down to the following points:

    1) ‘Force’ causes FAR more harm than good.
    2) ‘Force’ violates every precept of human rights in a so-called free society.
    3)‘Force’ inevitably leads to more sustained psychiatric drugging and its related iatrogenic damage to the mind and body.
    4)‘Force’ leads to greater forms of social control using threats of future incarceration (in psych wards or jails) and coercive forms of monitoring within the community at large; this includes various levels of coercive psychiatric drugging.
    5)We have no way of proving where the use of ‘force’ will ever lead to positive outcomes, or where its lack of use has led to an increase in negative outcomes.
    6)We know for sure that force has caused great harm to some people, and ultimately fatal or permanent harm for far too many of its victims.”

    “A principled and uncompromising stand for the abolition of all ‘force’ in today’s “mental health” system creates the most favorable conditions to challenge and educate people about the true nature of psychiatric oppression. It shines a spot light on everything that is wrong with the “mental health” system and the unjust and abusive power that Psychiatry wields in today’s world. Such a stand unites with the highest aspirations of those people desiring true liberation and freedom from all human rights violations and forms of oppression.”

    “To all those survivors of Biological Psychiatry and those at risk of falling into its clutches, AND to all those working inside the Beast yearning for radical change, MAY THE ‘FORCE’ NEVER EVER BE WITH YOU!”

    Richard

    • Calling it “involuntary psychiatric care” is a misnomer, due to the use of the word “care”.

      What bothers me the most is that psychiatrists not only forcibly give drugs, but also mislead families and clients that these drugs are “medications” treating specific “illnesses” (e.g. schizophrenia / bipolar), even when no biomarkers exist for these supposedly discrete pathologies, and there is no clear evidence that severe distress caused by biology/genes primarily. So forced treatment can become a pathway along which people get led into becoming a chronic patient / a believer in the brain disease model.

      Psychiatrists should present their pills honestly as tranquilizers / numbing agents, which are exerting generalized effects without specifically treating any “illness”. They should admit how little is known about psychiatric diagnosis and that diagnosis lacks validity and has poor reliability.

      And of course they should not force people to take drugs, let alone misleadingly frame these drugs as medications treating a brain disease.

      Seclusions / restraint is another issue. I remain open to the idea that if someone is violent and about to harm another person, they should be forcibly restrained or secluded for at least a limited time. But as Oldhead wrote, this is a matter of violence and a legal response to it, not the province of psychiatry and its invalid diagnoses and questionable treatments, the latter of which should always involve choice as to whether a person wants to accept them or not.

      • Force is larger than tying a person to a bed, although that is an example of force. Also is forcing a person to attend AA or any forced therapy. Or invading the person’s privacy, such as forcing a bathroom door open and forcibly watching the person while he or she is doing whatever people do in bathrooms. Forcing a person to disclose private matters is also force. “Where have you been? What have you been doing? Who are you with?” Threats can also be force. “If you do not comply, I will send the police to take you to the hospital.” Contacting family members against one’s will could also be force. And just plain ole bossing a person around, “You MUST give up your bathroom scale and to prove you’re not lying, you have to bring it to me.” The forced weigh-in, whether done blindly or not, is force. Tube-feeding is rape, if it is inserted and kept in against the person’s will and done via force (security, or threat of use of Security if patient refuses to comply). Using force, and then calling it “care” is extremely confusing, contradictory, traumatizing and invalidating for those who have it done to them.

  8. Thanks Sandra and thanks for letting us know how and why you posted this. They wanted exposure to MIA but didn’t want to risk doing it themselves.
    Why don’t professionals who write in the so called ” Mental Health” field write books with their patients and not just their stories. This is co – opting people’s pain for profit. There have decades of these almost narcissistic books where patients lives are used and the “slaves?” stories are used to give them money and media presence and the nefarious coat of wisdom.
    Again, First Do No Harm is forgotten amid the rush to more money and celebrity.
    Where are the morals? Where are the ethics folks?
    Askforcor. I am so sorry for all your family and your son. Yes have him write here or anywhere. Also if you found some NAMI support lucky you! But you have a voice all especially those in power in ANMI and behind the curtain need to hear! Write more! Good luck with concept of community. I like it a lot although I still maintain heterogeneity is healthier than homogeneity.
    With my cousin who had Down syndrome was in both worlds. Her parents said that doing to much out of her Downie world would stress her and she needed to go back to her community. And she was very very well aware that she was different. She was a great rebel and out of the box person. So community needs to be balanced with other communities as well of all kinds. Balance. That is the question of the ages!
    How do well interact with who we have born with our birth tribe that will never not be and then the tribes and clans our lives have given or thrown at us? Can we all take off our masks some day and see we are more like than different.
    Sandra this is the problem I see with your profession though it was less so in some ways is the psychoanalytic days when all shrinks were supposed to undergo treatment at least the shrinks were walking around knowing they had their own issues. With the advent of biological psych this got thrown out the window so that the wall between doc and patient went up higher and higher. This also happened co-currently with the entire medical profession with the demands on paperwork and the disinvestment in society for caring professions.
    My question to you would be since I won’t buy their book. I would say boycott for their lack of courage. And letting you be their whipping child – the question would be did they understand the concept of therapeutic milue and were they well read with the more humanistic professionals such as Redl, Mahler, Fraiberg, Moustakas, Satir, Mosher?

  9. The Stanford prison experiment (SPE) was an attempt to investigate the psychological effects of perceived power, focusing on the struggle between prisoners and prison guards…

    A variation of that is what plays out every day in psych lockups.

    “Almost in passing, it is mentioned what to me is a shocking cocktail of drugs she was on at discharge: olanzapine 25 mg, aripiprazole 20 mg, haloperidol 10 mg.”

    I was ordered inpatient to take a dangerous cocktail like that and when I refused I was threatened with a forced injection, at that point I had no other real choice but to make my own threats basically saying that if anyone lays a hand on me I will assault them and vandalize their property some time in the future when I get out of the place. You guys think your so tough and in control in here what are you going to do when I catch you alone outside this place ?

    The drug cocktail they ordered was to much, no I am not going to just ingest that into my body causing my mind and body functions to be altered to that extent. I know how dangerous and horribly unpleasant that would be.

    What the hell, I go for help and it breaks down to the uncivilized level I have to threaten people to defend myself ?? Lay a hand on me, if your lucky you will see me coming when I see you outside this place and have a chance to run. THEN they threaten to call the police for my defensive threat. Go ahead, in jail no one is going to try and force drug me and I get bail and due process of law. Call ! Do it ! They did not.

    Of course readers want to know why was I in the hospital, my life was a mess back then, my mental crime was to have a nervous breakdown and turn to alcohol and drink for many days all day to the point I needed detoxification. When I went to the ER VOLUNTARILY instead of buying more alcohol (to feel ‘better’ just a little longer) From the ER I get transferred to a locked facility. I never even got Detox meds. I shook it out and paced it off, the anti psychotic pill overdose order and needle assault threats at me for refusing it came about 2 days in.

    Every day variations of that Stanford prison experiment plays out in those hellholes.

    P.S Its been many years since that happened and I have had no problems with alcohol or ‘mental illness’ If I listened to them I would still be in psychiatric pill zombie wasteland.

    Psychiatry: Got problems with alcohol ? We know damn well at leaste 80% of you are going to drink heavy again so hear is several psychiatric drugs that are dangerous to mix with booze.

    • P.S.S

      “Three antipsychotic drugs, each at or above the manufacturer’s recommended dose!”

      How do I explain to people who never lived it what its like to be handed a pill overdose inpatient and ordered “swallow this” ?

      Got to your medicine cabinet and take double the max dose of Advil 1600mg , Tylenol, And Aleve all at once, sound scary ? Wondering what will happen, what will it feel like ? Will I get sick, vomit, shake, twitch, blurry vision, slow or faster heart, palpitations, seizures, pass out, die ? Thats what its like inpatient when you know what they ordered is too much.

      Once again after writing about what happened I am left with the feeling that some readers think I ‘needed’ the drugs or ‘acted out’ and brought it on myself or simply over reacted. Thats the reaction I got from all the lawyers who wouldn’t help. Hospitals know a persons credibility is trashed just cause they were in the place.

      That reminds me of the most common threat I heard from other patients they violated and abused “I am going to sue this place!” heard that one constantly. Good luck with that.

      When this is over I will speak out, I kept my promise to me, I write on MIA and online every day. That atrocity they call help needs to stop.

      • Hi cat, I was also PRESCRIBED three antipsychotic drugs, all at the highest doses. These simultaneously, and at the same time, three anticonvulsants. I was not violent nor manic nor psychotic. Looking back, I think they noted that I wasn’t “responding to treatment” (because they never addressed the problem to begin with!) and so, they kept piling on the drugs.

        I am lucky because getting off that “cocktail” wasn’t too hard. What is harder, in my opinion, is shaking off overall reliance on physicians and others (including alternative practitioners) to boss us around, in other words, appointment addiction. If you are very hooked on appointments your entire outside social life (if you had one) erodes and disappears, so in throwing off the appointments you’re left with zero for a while. it’s very hard to find truly decent friends, people who accept you and aren’t users. Some communities and groups are extremely hostile and closed-minded. You just have to keep looking. Finding friends and a decent and affordable place to live, for me, was so much harder than anything to do with drugs, although it’s possible that economics (not having enough money) certainly made all those challenges ten times harder. I stay far from doctors’ offices and that, I think, is key to staying healthy.

  10. This is relevant to the dilemma of psychiatrists, but the idea of relating the intimate details of another, in this case, clients–whether under pseudonym or not–for professional gain, to prove a point, or to navigate one’s own internal paradoxes seems explicitly cold, dissociated, and dehumanizing to me. I wish even this practice would cease, as a way to show respect to one’s clients.

  11. the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry

    Just like the subjects of slavery and racially segregated bathrooms were undoubtedly “vexing, contentious, and troubling topics” for “liberal” slaveholders and racists. It’s hard to watch this “debate,” actually.

  12. One more BIG thing we need to keep an eye on here: the explosive growth of private, for-profit inpatient psych hospitals, with a business model based on maximizing involuntary hospitalization even for those who can’t possibly be said to need it.

    Rosalind Adams of BuzzFeed has summarized the issues conscientiously and brilliantly here:

    https://www.buzzfeed.com/rosalindadams/intake

    The chain she writes about, Universal Health Services, now controls about 20% of US hospital beds. But it’s by no means alone. Acadia Health is getting almost as large, and many smaller chains are forming to chase the outlandish profit margins (over 25% in most years) reaped by UHS.

    University-based experts and researchers are usually shockingly ignorant about these places, which deliver a lot more psychiatric “care” than do their own institutions. That’s why they tend to believe the Treatment Advocacy Center when they moan about how “difficult” it is to obtain involuntary commitment. In fact, it is disturbingly easy in most states, and getting easier.

    And while most university experts think a “private psych hospital” is a relatively scarce institution open only to the wealthy, outfits like UHS increasingly make their best money off poor folks: Medicaid, Medicare, and the foster-care system. The result is what a University of Illinois team, sent in to evaluate UHS’s Hartgrove Hospital, called “hospital-based trauma” — a whole new, treatment-generated burden for troubled kids to carry.

    Regional reporters in Florida, Massachusetts and other states have tried to take the wraps off this problem, as exemplified by the UHS chain. BuzzFeed is the first to attempt it on a national scale. It should be a massive wake-up call. I hope it is.

    • “UHS chain. BuzzFeed”

      In the BuzzFeed News investigation — which was based on nearly 300 interviews, including 175 current and former employees of the company, as well as a cache of internal documents — employees of 10 hospitals said they were under pressure to fill beds by methods that included exaggerating people’s symptoms and distorting their words to make them sound suicidal. https://www.buzzfeed.com/rosalindadams/lawmakers-sound-alarms-on-uhs-psychiatric-hospitals

      Thats what they did to me, my long testimonial above, that was a UHS place. F them hope the people involved loose everything go to prison. That place was just WRONG. No one was getting ‘better’ stuck there for weeks, they just held hostages till insurance was exhausted. I saw it over and over again, especially with young women, they would be all happy they were getting out then I would see them later or the next day crying as their unknown period of captivity in that UHS hell hole was extended.

      I was stuck there for almost a month, that doctor kept saying ‘inject able form’ making threats at me, as I stated above if they would have done it they would not like it when I saw them outside the place, I meant it too anyone uses violence against me watch the hell out when I see you on the street.

      F UHS

  13. Yes Johanna! Absolutely and include in that private prisons! It is the corporationization of the medical-industrial-gorvernment complex. I am thinking of Henrietta Lax here. Her cells provided millions to research and brought about so much for other c cancer patients and look at how she was treated. It was only after a book came out that there was some compensation for the family and even that was wrought.

  14. I am so glad I have read this article. Thanks, Sandra. You have given me perspective on what happened to me in September 2011 when I was forced into a “hospital” and then, nearly forced into State. I can only say what I am about to say with much hindsight on it all…..

    First of all, I was in some sense, committed, not via court, but by all means, against my will. I had just been horribly abused in Massachusetts General Hospital, a human rights abuse (deprived of drinking water for days, and I have diabtetes insipidus – DI, you can’t do that to folks with this kidney condition). As it turned out, I wasn’t being silent about it. I can see now, with the hindsight I have, that the MGH et al were extremely frustrated that they had been unable to convince me that it had been all “for the patient’s own good.” Nor had they been able to convince me that water deprivation was “necessary care.” What now? Obviously, the answer was forced silencing, because the patient wasn’t shutting up! What to do? While they were deciding, they forcefully locked me up in Hospital/Prison B. Meanwhile, they took measures to have me transferred to State. She ain’t shutting up yet! All that took time, due to “paperwork.” What I was told, meanwhile, was that I was being “held” at Hospital B and “cared for.”

    I knew I had no choice. Again, I recall the thoughts that went through my mind. It was early September. “I’m here. What can I do? I might as well make the best of things.” These thoughts, exactly. “Why fight it?” So there I was, rail thin, really only wanting answers, something other than being bashed by people I thought were my friends, but had turned out to be not on my side after all.

    I cried a lot. Some of the staff were wicked nice. I had no clue who was for me, and who was against me. Did anyone even care anymore? I was in this place to heal from what the other hospital did. But I was being kept at hospital B against my will. So I rationalized all that, telling myself that Hospital B was the Good Hospital, and MGH was the Bad Hospital. Only I knew it didn’t work that way.

    In the world of the nuthouse, since it is a cruel and terrible place, the only way we inmates can make sense of the fake world we live in is in terms of the Good Fairy and the Bad Fairy. We know this isn’t real, but we must force ourselves into believing it so. We make it so, to survive it all. So I did. Hospital B would erase what MGH did. Hospital B would fix it all. So I forced myself to believe that what Hospital B was doing was actually healing. I forced myself to love them. I forced myself to worship them. And that is actually how, to my utter surprise, I got better! or at least on paper…. However, unfortunately for them, they now had no provable grounds to send me to State, nothing that a judge would buy. Now they would have to silence me in some other way. They let me out on September 26, 2011.

      • Do what you do to get through it. The only fun I had in that hospital was finding a splinter of wood the right size to jam up the keyhole to that administration office then the next day watching those clowns one by one take turns with the key thinking they would be the one with some kind magic talent to get it open and then fail. It took the locksmiths a wile too when they arrived.

        Actually no, not just that, it was also funny as hell when another dude got a hold of their battery operated panic button that was stuck on the wall and kept pressing it to the point they had to place objects in front of the thing that makes noise behind the nursing desk, they thought it was just a malfunction.

        But a UHS Federal investigation! Been waiting years to hear news like that : ) And no doubt federal investigators are going to see the stuff I wrote online that prompted others to tell their stories. Screw U UHS !

        Alan B. Miller is a businessman who is the founder of Universal Health Services… Hope he gets federal prison even if its nicer then the hellholes he inflicts on people.

        Then there was that guy that was sitting on the floor in the dayroom back on the wall not bothering anyone, they gave him orders to get up and move and he ignored them the same way he ignored us when we talked to him. They dragged him to his room that was right across the hall put him on the bed pulled down his pants and injected him with something. His muscles kind of stiffened up with shaking for a bit then he was unconscious for a long time.

        With the threat of them sticking me hanging over at the time I can’t remember what ever happened with him. I was angry but also scared at the same time. Revenge later ain’t going to help if they attack now, that poison in my bloodstream.

        Been around institutional violence before but one friend I made, he was not doing well AT ALL in that environment and staff did not care AT ALL. They could have moved him or something dude was in full blown panic psychosis CAUSED by that place. I remember him on the phone like so many others, what a nightmare, the phones on the wall, UHS makes 1 billion dollars a year but patent prisoners in UHS hellholes can’t make ‘long distance’ phone calls and of course cell phones are confiscated and who has most numbers memorized? Those phones, “Family help get me out of here” No you have to stay and get help, “this is not help!” … Usually ending with FU family I hate you for letting these people treat me like this. Almost exactly the same back and forth over and over again one person after the next.

        All this for only $1200 a day.

        Then that lady with the memory problem going in the wrong rooms, I can’t find my room, they give her a hard time, they all look the same, all these mental health “experts” around and I am the only one that thinks to make a sign with her name and put it on her door!

  15. You were wrong to promote the book of these pigs. Your “criticism” is worth nothing. You have already accepted a free book, why not accept other gifts from the pigsty? Make a commercial link to Amazon to allow these pigs to earn money by spreading their propaganda. Well, you are from the same milieu, you support each other, even here, on Mad In America. You disgust me.

  16. I am not sure what I said was clear. I am more against incarceration than I am against anything that psychiatry does to people. This includes drugging. Psych incarceration in the #1 worst thing a person can endure, because it is not a hospital, it is imprisonment. Not only that, the patient is tricked into thinking it is a hospital, but is locked in. This is a horrible thing to do to a person who gets no trial, no jury, no judge, doesn’t get an informed choice (isn’t told ahead of time) isn’t told the real consequences nor how long the stay will be, gets his rights taken away, can’t communicate with the outside, and often, loses his job, loses housing on the outside, and his entire reputation as well as a result of the incarceration. Upon returning to the community he may find his life is never the same.

    This is a crime, and should never be done to a person. Never. It has nothing to do with “medical care.” it has no relation to “stigma” and no relation to an “illness.” It is a crime done to a person as an act of power. If I had my way I would do everything I could to stop it now.

  17. Does anyone know how the Quakers in their Moral Treatment dealt with violent people in their care? I would guess that people were held against their wills in the Quaker institutions but they were treated as human beings while they were there. I was just wondering what their answer was for this quandary that seems to trip everyone up when discussing what people should be allowed to do when they’re experiencing issues that are interpreted as “mental illness”.

  18. Must outlaw all involuntary treatment. Likely an initiative would be the way to do this, as well as trying to oppose any specific cases of involuntary treatment.

    Any “treatment” of juveniles should always be considered involuntary. Must report to juvenile dependency court of face felony prosecution under Child Abuse and Neglect Act. Must be under supervision of court. Otherwise it is just hired child abusers.

    Nomadic

  19. I am at a point of our journey where I am stepping away from commenting for various reasons, although still eagerly reading all these blogs and comments.

    I did, however, want to make a brief comment here about how grateful I am, Sandra, that you are willing to bring up and discuss involuntary care.

    Our own experience, is that involuntary care (both ‘lack of informed consent’ as well as situations of ‘force when there was ‘no consent’); completely changed things so that we ended up on a much more severe path.

    The worry and threat of possible involuntary care kept us living in a state of hyper – vigilance. and made it unbelievably MORE difficult to access services and to provide the healing environment we needed to provide to promote recovery.