“I am not mentally ill and I do not need medications.”
When psychiatrists hear these words, it is a cause for concern. It could even be a cause for mental health commitment. What is the mental illness? Well, saying that you are not mentally ill is a delusional statement. What is the dangerousness? Someone can become a danger if they are not on their medications. Psychiatrists learn early on not to believe what a mental health patient would say, but could the statement be true?
When I first met Leo, he was living in a group home in a small town in western Wisconsin. I was there to do a routine examination for extension of his mental health commitment. When I met him, the first thing he said was, “Are you going to tell the truth?” Leo immediately said that he has never been a danger to himself or others. He had been under a mental health commitment for many years. It was routinely extended year after year. He always followed the prescribed program; he took his medications as directed; he was a law-abiding citizen; he was very religious; he attended Catholic mass on a daily basis.
Leo went on to tell me that he did not feel he needed mental health commitment and he did not feel he needed medication. I completed the interview, asking about his background and current status, mental status, along with any past history. Soon after I met with Leo, I was able to obtain medical records from his past hospitalizations and outpatient treatment records. I scoured the records trying to determine why he was placed on antipsychotic and antidepressant medications. There was a reference to an incident that took place many years ago when his ex-wife told social workers that he was suicidal and had made a suicide attempt. There was another incident where Leo was found to be very disheveled and he wanted to walk to his brother’s house which was 2 hours away. At that time, he was hospitalized and it was then that he was placed on an emergency detention and then subsequent mental health commitment.
I could never find any information that led me to believe that he was ever psychotic. He certainly had some need for help in the past. If one has mental health challenges at some point in their life does that mean they need commitment and forced medications for the rest of their life?
Leo had been placed under commitment due to possible danger to self or others, but it was not clear that it was imminent risk, which is the standard for a mental health commitment in Wisconsin. He was thought to be perpetually psychotic, however. His delusions were that he did not believe that he was mentally ill and did not believe he required medications.
At one point, he was even picked up by police for an infraction of the commitment order which allows one to be taken to a hospital if they are not compliant with their commitment order. He had no psychiatric symptoms, but once again he was thought to be psychotic because he said he did not believe he needed medication and did not believe he was mentally ill. The attending physician in the hospital did not see any need for the hospitalization and put in the medical record; “There must have been some mix up here.” She thought that there was a problem or a misunderstanding because he certainly was not psychotic, nor did he have any kind of psychiatric symptoms that would have required hospitalization. He was quickly discharged.
I had several conversations with his social workers who were aghast at the suggestion that he was not mentally ill or requiring medication, but I was able to make some inroads asking them to try a very small medication decrease. Since no other psychiatrist would provide that type of care, I took him on as an outpatient in a county where he had to travel about 1-1/2 hours, but the social workers actually brought him to me and I made very slow reductions of his medication. He tolerated those reductions well. He was eventually able to get off commitment and off medications. He had always wanted to return to the county where he originally grew up, which was prohibited by the mental health commitment. After he got off commitment, he returned to the county where he wanted to live, where he had family members.
This brings me to the story of Mark, who lives in Wisconsin and was under a mental health commitment for many years due to depression and inability to care for himself. Mark, in fact, did have episodes in his life where he stopped bathing; he did not eat; he would let his house go; he would receive some mental health intervention and home health care; and then he would recover from these episodes and go on to do fine. He is an engineer, has his own business doing consulting work, and is actually quite functional most of the time.
He ended up being placed under mental health commitment after he was found to be not appropriately caring for himself with poor hygiene and dehydration; he even had some altered kidney function tests due to dehydration. After he was treated briefly on a medical floor he was transferred to a psychiatric floor where he was diagnosed with schizophrenia, although he was never outwardly psychotic with delusions or hallucinations.
Mark was an older man who had never married. He had always lived alone, but he had the support of some cousins and other family members who were always concerned about him and always ready to help him recover from his episodes where he would not fully care for himself appropriately.
At one point, his social workers placed him in an assisted living facility where he was in a basement room which flooded frequently and was next to a hazardous trash bin. He felt the food at the assisted living facility was inedible. They would serve fish that was undercooked. He was getting sick from the food. He was placed on an extended release weekly dose of Prozac at double the adult dose, which in my opinion was way overmedicating him and causing him dysphoria and discomfort.
Mark was placed in another facility and eventually ended up going back to his own home which he owned, and he did well, returning to work at his consulting business. He continued to stay under mental health commitment, receiving a monthly injection of Invega Sustenna. Frequently, he would tell the prescribing psychiatrist that he did not need medication anymore and was not mentally ill. The prescribing psychiatrist was really offended by these statements.
At one point, Mark was placed on an emergency detention because he was psychotic—in this case, that meant he did not think he needed medication and he did not think he was mentally ill. At the time, Mark was fully functional and working in his business. Nevertheless, he was placed on an inpatient psychiatric unit for 10 days due to supposed psychosis, not believing he was mentally ill or needing medication. He had no psychiatric symptoms. Mark was placed in a psychiatric unit for 10 days just because he angered his psychiatrist!
That particular hospitalization led Mark to the idea of trying to get off of commitment, and he hired his own attorney. Through the eminent psychologist Toby Watson, I was referred to help the attorney terminate the mental health commitment that Mark had been on for several years. At this time, Mark was living in his own home. He was working at his consulting business, but he had to see his psychiatrist and receive an injection every month.
I worked very closely with Mark and his attorney to prepare for a jury trial in order to help Mark get out from under the burden of a mental health commitment which was not needed. The attorney and I both felt we had a very good case and were looking forward to a fight in court. However, the county attorney contacted Mark’s attorney and said that if Mark would agree to 6 more months of commitment the matter would then be dropped. Mark agreed to this, thinking that after 6 months he would no longer be under a mental health commitment and he was satisfied with the agreement. In my opinion, this was a face-saving way for the county attorney to get out from under the possibility of a jury trial which he most likely would lose. No trial or hearing was held; Mark agreed to the last 6 months of commitment.
When it came time for that 6-month period to end, Mark’s psychiatrist petitioned the court for further commitment. In spite of the fact that Mark was not supposed to undergo a recommitment evaluation or hearing after 6 months, his psychiatrist attempted to keep the commitment going.
Mark contacted his attorney, who contacted me, and we prepared for a hearing for Mark’s mental health recommitment. In order to fully fight the efforts of persistent mental health commitment, one strategy that lawyers have been successful with is to exercise the right to a jury trial to ensure fairness in the process. In the state of Wisconsin, every psychiatrist will, of course, recommend further commitment; the judge will follow the recommendations of the examining psychiatrist, so it is not an easy process to terminate the commitment process, even if there are no or minimal psychiatric symptoms that would require the onerous status of being under a mental health commitment.
Mark’s attorney requested a jury trial. I was contacted to once again submit a report to the court and update Mark’s status. At the time, Mark was doing extremely well. He was working at his consulting business. He was living in his own home. He was appropriately caring for himself. He was not psychotic or depressed. His mood was good. He was very optimistic about his current living situation. He was complying with the monthly Invega Sustenna injections. He always felt they did not help him nor hurt him. He was actually quite neutral about the idea of the monthly injections. It was clear, however, that they were unnecessary. Mark has never been psychotic, but he was receiving an injection monthly of an antipsychotic medication.
Mark’s attorney scheduled a deposition for the social worker that was the case manager for Mark in Dane County. I had never heard of depositions in a commitment case. Usually a public defender attorney shows up a few minutes before the scheduled hearing, meets the patient for the first time and the recommitment process takes place. All parties rubber stamp the recommitment papers and there is generally little defense present for the patient.
I have worked with attorney Elizabeth Rich who will request a jury trial, which is one of the rights accorded to individuals going through the commitment process. She believes that the chances are better for dismissal with a jury than a judge. It is our experience that the county judges generally will rule in favor of the county.
After the deposition was requested for the social worker and my report was submitted to the court, the county fully dropped the matter. It was clear that there was little merit to the case. Mark’s private attorney would have provided a very aggressive defense. The outpatient psychiatrist petition for extension of the commitment was dismissed.
Mark and his attorney were delighted with the outcome. Mark was very pleased that he could go on with his life and make decisions based on what was best for him. Mark’s attorney was very eager to continue to do this kind of work. He told me that he wanted to help individuals that were trying to get out of assisted outpatient treatment or mental health commitment in Wisconsin in a pro-bono fashion. He said that his law firm allows him the ability to do some pro-bono work and this is something he very much wanted to do.
I have since sent the attorney one case of a young man who was under extensive conditions for his commitment. The commitment order and extension were dismissed, with his help. I learned from Mark’s attorney that exercising the full due process rights for an individual can be very helpful.
Both these cases are examples of people whose only symptoms were stating they were not mentally ill and did not need psychiatric medication. They both certainly had problems at some time in their lives, but the one size fits all system of commitment and mandatory medication did not fit their needs at all. Does having mental symptoms in the past mean that one should have a lifetime of mental health commitment and forced medications?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.