The Traumas of Involuntary Treatment
Involuntary treatment is a trauma.
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AFFIRMING PSYCHIATRY
I received quite a few emails in response to the article, “Involuntary Treatment of Mental Illness: Here We Go Again.” It seems I managed to write vaguely and provocatively enough to offend almost everyone in some way. “Perplexing,” “disappointing,” “evil,” and “lol” were among the responses.
Nobody Likes Involuntary Treatment
Patients, patient advocates, family members, psychiatrists, and legal experts all weighed in about our policies and practices of treating individuals against their wishes. The range of opinions expressed was quite broad—some felt we do not do enough to mandate treatment for those impaired by severe mental illness, others felt that any medical treatment of so-called mental illness is an assault. And yet I feel there was something deeply similar about every response. If I can be forgiven for a bit of speculation, what I saw in the subtext of all of those emails was anguish—an anguish that I myself feel about this subject.
Patients who have endured involuntary commitment never forget the indignity of losing their freedom and autonomy, even for a short time. Family members who have helplessly watched those they love spiral toward death will be scarred forever by society’s inability to take control of these out of control situations through legal and humane compulsion. Advocates endure unbearable frustration with a public and a medical establishment that respond in lumbering and clumsy fashion, when they respond at all. And psychiatrists, too, bear a painful burden from these experiences: Which of us psychiatrists has not been in the position of signing a commitment petition when we were deeply conflicted about what to do? How many of us have had the sick feeling of working with a patient who was not committable, yet appeared be headed toward destruction and death?
How Psychiatrists Feel About Involuntary Treatment
At the same time, the pain of this situation goes deeper for us psychiatrists, deeper even than the heavy burden of responsibility in regard to commitments. Because we are not just psychiatrists in regard to this issue, we are also individuals who suffer from mental illness. We are also family members and advocates of those who suffer from mental illness. We are not unfeeling or even impartial judges who sit above this issue and look down on individuals who may or may not need treatment against their will. We are in the trenches, shoulder to shoulder with our patients, with family members, and with advocates. It is not pretty down here in the trenches, but we are nevertheless all in it together.
I myself suffer from mental illness. I have close family members who suffer from mental illness. I have been in the agonizing position of watching a family member draw near to death and know that I would feel horribly guilty if I tried to force treatment, but also horribly guilty if I did not, and that person died as a result. I myself have been in the position of being unable to function due to mental illness, but so desperate and afraid that I could not seek help, or even admit my incapacity to myself or someone else. I know what those sleepless nights are like, those pangs of fear when the phone rings, those hopeless conversations that you know are going to make the problem worse rather than better. And there is nothing special about my experience. I simply know what so many other patients, families, mental health professionals, and advocates know from their own experience.
How We All Feel About Involuntary Treatment
Involuntary treatment is a trauma, just as some homeless advocates have said.1 Severe, untreated mental illness is a trauma as well.2 The tragedy of our current situation is that we have no adequate answer to this urgent situation. Ramping up involuntary treatment will traumatize individuals. Abandoning involuntary treatment will also traumatize them. Continuing to do what we are doing now will, again, traumatize them. We are in a true catch-22. We are damned if we do and damned if we don’t. And so here we all are, damned together.
I do not mean to suggest that we should give up and do nothing. There is plenty to do that would help. Most obviously, we as a society need to publicly recognize severe mental illness for the public health crisis that it is, and respond to it as a true public health crisis. About 4% to 6% of our population is disabled by severe mental illness every year.3 One in 20 individuals disabled constitutes a public health crisis. We need the best, most comprehensive, most humane treatment for those with the most severe illness. What we have right now is the opposite: Individuals with the most severe and life-threatening forms of mental illness get the least and the worst treatment.4 We need to ramp up housing support, financial support, family support, legal support, psychoeducation, psychotherapy, cognitive rehabilitation, peer support, intensive outpatient treatment, and yes—long term residential and hospital treatment availability. These are urgent needs, and everyone should be able to get behind an immediate push to meet them.
Meanwhile, for those of us in the trenches, the beat goes on. We struggle on as best we can with the tools and resources we have. Regardless of who we are or our position on this issue, we are all fighting the good fight as best we can. That is what I wish the public knew about this issue more than anything else: We are all struggling together. There is no ‘bad guy’ in this situation, only a bad situation. And what all of us in the trenches want, regardless of how we disagree, is for the day to come when everyone gets the help and support they need, and no one has to endure inhumane and inadequate treatment against their will, ever again.
Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.
References
1. Newman A, Fitzsimmons E. New York City to involuntarily remove mentally ill people from streets. The New York Times. November 29, 2022. Accessed March 21, 2023. https://www.nytimes.com/2022/11/29/nyregion/nyc-mentally-ill-involuntary-custody.html
2. Buswell G, Haime Z, Lloyd-Evans B, Billings J. A systematic review of PTSD to the experience of psychosis: prevalence and associated factors. BMC Psychiatry. 2021;21(1):9.
3. Morehead D. Science Over Stigma: Education and Advocacy for Mental Health. American Psychiatric Press; 2021:43.
4. Frances AJ. What drives our dumb and disorganized policies on mental health? Psychology Today. 2015;37(3). https://www.psychologytoday.com/us/blog/saving-normal/201510/what-drives-our-dumb-and-disorganized-mental-health-policies
