The recent publicity surrounding the Justina Pelletier case has focused attention, not only on the spurious and arbitrary nature of psychiatric diagnoses, but also on the legitimacy and appropriateness of mental health commitments. It is being widely asserted that these archaic statutes are fundamentally incompatible with current civil rights standards, and the question “should mental health commitments be abolished?” is being raised in a variety of contexts.
Here in the US, each state has its own laws and procedures for pursuing a mental health commitment. Some states allow outpatient commitment as well as inpatient. There is wording variation from state to state, but in most jurisdictions there is provision to commit a person involuntarily for psychiatric treatment if there is convincing evidence that the person has a “mental illness” and as a result of such “mental illness” is a danger to himself or others, or is gravely disabled. The term gravely disabled is generally defined along the lines of being unable to care for oneself or provide for one’s basic needs. In recent years some states have expanded these criteria to embrace:
- Individuals who have a psychiatric history and are on a “deteriorating course.”
- Individuals who are being cared for by a family member, and this care is about to be terminated.
SHORT-TERM EVALUATION HOLD (72 hours)
Here again, the procedures vary from place to place, but in most cases the mental health center is involved. Typically the police bring the individual to the mental health center to be evaluated by a mental health professional. The professional evaluates the individual to determine if the legal criteria are met. If they are, he fills out the necessary forms, swears to their accuracy in front of a judge, who , if he agrees with the assessment, signs the hold order. The individual is then taken to the state hospital, or an alternative approved facility, by a police officer.
Before the expiration of the 72-hour hold, the hospital personnel decide whether to allow the individual to convert to voluntary status (which he can do by signing the appropriate forms) or pursue a longer-term commitment. The latter usually involves a formal hearing conducted in the local courthouse, or more usually, in a room at the state hospital. A judge presides, and both hospital and client are represented by lawyers. The hospital calls as witnesses psychiatrists and other staff who have worked with the client. Clients may also call witnesses, but seldom do.
The fundamental premise underlying all mental health commitment legislation is that mental illnesses exist, and that these putative illnesses cause people to think, feel, and behave in a problematic, and sometimes dangerous, manner.
It is my position that this premise is spurious. I have developed this theme throughout the website, and the details need not be repeated here.
It is also my position that psychiatric treatments, which almost always mean psycho-pharma drugs, and/or shock treatment, are for the most part unhelpful and disempowering, and usually damaging, especially in the long term! They generally reduce, at least somewhat, an individual’s level of agitation, aggression, and/or disruption, and this is the essential justification for their use in these situations. The notion that they are medications and are being used to treat illnesses is false. The stark reality is that the individuals are being forcibly drugged into quietude, and this is being done under the guise of providing “treatment” for an “illness.”
If the treatments that individuals received at state hospitals and other approved facilities were extremely beneficial, then one might be posed with an ethical dilemma. To illustrate this, consider the case of a person who has, say, a gangrenous finger, but is refusing treatment. The treatment would involve losing the finger, but saving his life. Refusing treatment will result in death. One could certainly make a case for enforced treatment, especially if his family, friends, etc., were petitioning the courts in this regard. But in fact, in the US, the general principle is that such an individual is legally entitled to refuse treatment, and die from his illness if he so chooses.
But mental health commitments are entirely different. Individuals get committed to state hospitals, not because they are sick in any conventional sense of the term, but because they are agitated, and/or aggressive, often as a result of conflict with family members, neighbors, local officials, etc… Usually they are people who have been committed previously, sometimes very frequently, and their social and other abilities have been severely compromised by a history of ingesting psychiatric drugs. Often their agitation/aggression at the time of the commitment is caused by withdrawal from psychiatric drugs that they had previously taken. In most cases they have received large quantities of neuroleptic drugs, over extended periods, the devastating side effects of which are all too obvious, and contribute to the perception that they are “different” and need to be locked up.
Because the agitation/aggression is conceptualized as a “symptom” of the putative illness, little or no attempt is made by the police or by the mental health staff to explore the reasons for the agitated, problematic behavior, or what remedies might be available. The individual is deemed to be “mentally ill,” and it is assumed that attempts at discussion or dialogue would be pointless. It is also assumed that the individual has zero credibility.
So the kind of ethical dilemma that might exist in the case of the man with the gangrenous finger, doesn’t arise here. We’re not having to choose between respecting the person’s civil rights vs. saving his life. We’re choosing between respecting his civil rights vs. forcing him to undergo procedures that will damage him further and will likely cause further deterioration in his relationships with family and other members of the community.
The Fifth Amendment to the US Constitution states:
“…nor shall any person…be deprived of life, liberty, or property without due process of law…”
The Fourteenth Amendment states:
“…nor shall any State deprive any person of life, liberty, or property without due process of law…”
In practice, the procedures outlined above for the 72-hour hold and for the 3-month committal are considered to be due process of law. Strictly speaking this is true, because they reflect the law as enacted by the particular state legislature.
The more fundamental question, however, is: do these procedures provide adequate protection for the civil rights of the individual who is being committed? In my view, the answer to this question is no, for the following reasons.
1. In practice, the 72-hour hold is decided by the mental health worker, often a fairly junior intake worker, who in many cases has been trained to think of involuntary commitment as the only reasonable response to a crisis. Even in cases where a judge’s signature is required, it is extremely rare to find a judge who will attempt to second-guess the mental health professional. The unspoken ethos here is that “crazy” people are fundamentally different from “ordinary” people; that they can only be understood by trained professionals; and that interference from non-professionals is likely to be counterproductive. This ethos, incidentally, is actively promoted by organized psychiatry. Indeed, I would suggest that it constitutes one of the fundamental pillars of psychiatric “treatment.” It is also false. People who are “crazy,” or despondent, or agitated are not fundamentally different from “ordinary” people. Their craziness, despondency, and/or agitation are usually understandable if one is willing to listen attentively and respectfully and patiently.
2. In practice the judge’s signature tends to be a rubber stamp, and there is no attorney present to argue for the client. There is usually not even a requirement that the client be present at the initial meeting between the mental health worker and the judge.
3. Although danger to self or others or grave disability is usually required by the statute, in practice a 72-hour hold can be obtained in situations that don’t actually rise to this standard. In most cases, if a client has come off his “meds,” and is agitated, a 72-hour hold will be granted even if his agitation is for some legitimate reason and is perfectly understandable, and even if he poses no particular threat to self or others. The tacit, and incidentally false, assumption is that his agitation/aggression will inevitably escalate unless he is sent to the state hospital for “stabilization.”
4. Once the 72-hour hold has been activated, the process is very difficult to reverse. The client is taken to the state hospital and is often “persuaded” to convert to voluntary status. The persuasion usually entails the threat that if he doesn’t convert, he will be committed. I suggest that this kind of tactic makes a mockery of the term “voluntary.”
5. If the client refuses to convert to voluntary status, he can be brought before a formal mental health hearing.
6. This is an improvement over the 72-hour hold procedure, but in my view, the individual’s rights are not adequately protected. As mentioned earlier, the hearing is often (perhaps usually) held in the hospital. This confers clear advantage to the psychiatrists. They can call all the witnesses they want. They’re on the payroll and just a few steps away. The client is at a marked disadvantage, in that any witnesses he might want to call are likely to be in his home area (usually hours away), and at work. The client is often unfamiliar with the procedure, and has had little opportunity to prepare his case. Usually he gets to meet his defending attorney for only a few minutes prior to the hearing, and, in some cases, his cognitive ability has been compromised by prior “treatments.” I recently received an email from a woman who has been through this kind of proceeding. She pointed out that:
“…having a patient address her involuntary status at a Review Panel while drugged and wearing hospital pajamas does tend to work against her. If you’ve decided that someone’s incompetent, that’s pretty much what you’ll see.”
7. If the client expresses the belief that he is not ill, and that he doesn’t need treatment, this will be interpreted (and sworn to by the psychiatrists) as convincing evidence that he is ill, and that he does need treatment. Imagine, in a criminal trial, if a plea of not guilty were routinely construed as evidence of guilt!
8. There is usually a great reluctance on the part of the defending attorney to challenge the psychiatrists and other professional witnesses, and in most cases the hearing endorses the psychiatrists’ recommendation – which is usually: keep him here until we say it’s OK to let him go.
9. Eventually, even the most heavily-drugged client realizes that the only way he’s going to get out of the hospital is to cooperate with the psychiatrists and staff. This entails saying things like: “I was a fool to go off my medication;” “I realize now that you people are just trying to help me;” “I’m my own worst enemy;” “I need to stay here until you people say it’s OK for me to go.” If he can keep this up for a week or so, he’ll probably be released.
So to get back to the original question: should this kind of practice cease? The answer is obviously yes. The recent Justina Pelletier case has drawn much-needed attention to the abuses inherent in the psychiatric commitment system. In particular, this case has highlighted the fact that psychiatry is a closed system that routinely rejects, marginalizes, and even pathologizes any attempt to challenge or even question its pronouncements. Such a system has no place in a democratic, transparent society.
THE WAY FORWARD
The most significant step forward at this juncture would be the removal of the concept and term “mental illness” from all statutes. The term has no explanatory significance, and no clear meaning. In the area of civil commitment, it serves merely as justification of enforced drugging for individuals who are agitated or aggressive or otherwise disruptive. It also serves as justification for denying these individuals some very basic civil rights.
Commitment is essentially a form of imprisonment. But it goes beyond ordinary imprisonment, in that it entails the forced administration of neurotoxic chemicals and electrically-induced seizures. What happens in practice is that the individual takes the drugs under duress in the facility, then semi-voluntarily in the community for a few weeks or even months. He then stops taking them, or tapers himself off, until the next bout of agitation or aggressiveness. This precipitates another trip to the state hospital, and this revolving-door travesty continues until he is too brain-damaged to live in the community. He then goes to a nursing home, where his “medication” is dutifully administered every day, until he succumbs to a premature death.
If “mental illness” commitments were abolished, there would be a need for a non-psychiatric crisis response team in each county/jurisdiction. How such a team would be structured and organized is a huge topic, beyond the scope of the present article. From a practical perspective, it needs to be noted that any non-psychiatric crisis response system will be resisted vigorously by vested interests and will not happen overnight. What we should focus on in the meantime are those parts of the present system that are particularly unjust or particularly destructive. These include:
1. Doing away with the 72-hour hold and replacing it with a formal hearing with mandatory legal representation in front of a judge.
2. Providing training to lawyers concerning the spuriousness of psychiatric concepts and the destructiveness of psychiatric treatments. This training should be geared towards empowering them to challenge mental health testimony in commitment hearings with the same force and vigor that they do in criminal proceedings. In particular, they should be knowledgeable, or have ready access to knowledge, of the adverse effects of the various psychiatric drugs in common use, and the abysmally poor long-term outcomes for individuals who have been repeatedly committed over a period of years.
3. Recruitment and training of non-psychiatric “talk-down” teams in every county. These could be part of the sheriff’s department or, preferably, separate departments in their own right.
4. Continuing to expose psychiatry as the spurious, destructive, and pharmaceutically-corrupted activity that it is. The major need in this matter is to expose the damage that psychiatry routinely perpetrates against those entrusted to its care, and the impact that this has on life expectancy.
5. Encouraging mental health centers to hire psychiatric survivors, especially those who don’t support the bio-medical model. A requirement of survivor representation on governing boards would also be helpful.
6. Requiring mental health centers to seriously review drug dosages on all clients monthly, and either reduce these dosages or explain why this can’t be done.
7. Requiring mental health centers to provide active training in social skills to all clients who have ever been committed to a psychiatric hospital.