Involuntary treatment

Man in restraint chair in an English asylum in 1869

Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without the consent of the person being treated. Involuntary treatment is permitted by law in some countries when overseen by the judiciary through court orders; other countries defer directly to the medical opinions of doctors.

Involuntary psychiatric treatment of individuals who have been diagnosed with a mental disorder and are deemed by some form of clinical practitioner, or in some cases law enforcement or others, to be a danger to themselves or to others is permitted in some jurisdictions, while other jurisdictions have more recently allowed for forced treatment for persons deemed to be "gravely disabled" or asserted to be at risk of psychological deterioration. Such treatment normally happens in a psychiatric hospital after some form of involuntary commitment, though individuals may be compelled to undergo treatment outside of hospitals via outpatient commitment.

Forms[]

Standard modern day restraints

Involuntary treatment can be used to treat a specific disease. In some countries, antipsychotics and sedatives can be forcibly administered to those who are committed, for example for those with psychotic symptoms.^[1] Those suffering from anorexia nervosa may receive force-feeding.^[2] In Czechia, men convicted of sex offenses are in practice given the choice of long-term detention or castration.^[3] Some countries have general legislation allowing for any treatment deemed necessary if an individual is unable to consent to a treatment due to lack of capacity.^{[4][5]: 108}

In some countries, involuntary treatment for mental health is not used to treat a symptom that is present, rather to reduce the risk of symptoms returning through the use prophylactic psychotropic medication. This is achieved through the use of outpatient commitment where a patient may be detained in hospital if they fail to take the medication their doctors have prescribed them.^[6]: 16

Effects[]

A 2014 Cochrane systematic review of found that compulsory outpatient treatment of those with severe mental health disorders "results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care."^[7]

A 2006 review found that as many as 48% of respondents did not agree with their treatment, though a majority of people retrospectively agreed that involuntary medication had been in their best interest.^[8]

A review in 2011 looked at people's experience of coercion. It found common themes of feelings violated, disrespected, and not being heard, commonly conceptualized as being dehumanized through isolation. A minority of narratives from people who had been treated involuntarily talked about the necessity of treatment in retrospect.^[a] Studies suggest that coercion in mental health care has a long-lasting psychological effect on individuals leading to reduced engagement and poorer social outcomes, but that this may be reduced by clinicians knowledge of the effects of coercion.^[6]

A systematic review and meta synthesis from 2020, that combined the experiences of stakeholders (service-users, informal carers such as family members, and mental health professionals), identified experiences of power imbalances among the stakeholders.^[10] The review found that these power imbalances hindered the respect for the service users' rights, will, and preferences.

Coercion in voluntary mental health treatment[]

Individuals may be forced to undergo mental health treatment legally-speaking "voluntarily" under the threat of involuntary treatment.^[6]: 98 Many individuals who legally would be viewed as receiving mental health treatment voluntarily believe that they have no choice in the matter.^[b] Studies show that 51%, 35% and 29% of mental health patients have experienced some form of informal coercion in the US, England and Switzerland respectively.^[6]: 100

Once voluntarily within a mental health hospital, rules, process, and information-asymmetry can be used to achieve compliance from a person in voluntary treatment. To prevent someone from leaving voluntarily, staff may use stalling tactics made possible by the fact that all doors are locked. For example, the person may be referred to a member of staff who is rarely on the ward, or made to wait until after lunch or a meeting, behaving as if a person in voluntary treatment does not have the right to leave without permission. When the person is able to talk about leaving, the staff may use vague language to imply that the person is required to stay, relying on the fact that people in voluntary treatment do not understand their legal status.^[c]

Szmukler and Appelbaum constructed a hierarchy of types of coercion in mental health care, ranging from persuasion to interpersonal leverage, inducements, threats and compulsory treatment. Here persuasion refers to argument through reason. Forms of coercion that do not use legal compulsion are referred to as informal coercion or leverage.^[6]: 98 Interpersonal leverage may arise from the desire to please health workers with whom a relationship has formed. Threats may revolve around a health worker helping or hindering the receipt of government benefits.^[13]

Ethics[]

In medical ethics, involuntary treatment is conceptualized as a form of parens patriae whereby the state takes on the responsibilities of incompetent adults on the basis of the duty to protect and the duty of beneficence, the duty of the state to repair the random harms of nature. The duty to protect is reflected in utilitarianism and communitarianism philosophy, though psychiatrist Paul Chodoff asserted a responsibility to "chasten" this responsibility in light of the political abuse of psychiatry in the Soviet Union.^[14]: 82 This duty to protect has been criticized on the grounds that psychiatrists are not effective at predicting violence, and tend to overestimate the risk.^[14]: 89

The obligatory dangerousness criterion is a principle that has been applied to some mental health law that holds that parens patriae should only be applied if an individual is a danger to themselves or others.^[15]

Paul Ricœur distinguishes two forms of self, the idem a short term experience of the self and the ipse a longer term persistent experience of the self. In mental illness, the autonomy of the ipse can be undermined by the autonomy of the idem which is at odds with the ipse, so mental health treatment can trade of one form of autonomy against another.^[14]: 90

Sociology[]

Medical sociology seeks to understand the social processes underlying decisions made in medicine.

Sociologist Jeremy Dixon, speaking in the context of the United Kingdom, argues that assessment and monitoring of risk is a core part of mental health practice^[16]: 126 by that this risk is often in conflict with broadly-defined goals of recovery including living a satisfying lives.^[16]: 129 He argues that this focus on risk causes mental health professionals to make decisions defensively based on reputational damage if there were to be any inquiry and that multidisciplinary approaches are used for this purpose.^[16]: 134 He cites research showing how mental health professionals may seek to shift the burden of responsibility onto individuals noting different behaviours for those with personality disorders because they are viewed as more responsibly for their behaviours, or on to other public health services.^[16]: 134 Risk assessments themselves are rarely shared with patients.^[16]: 135

Proponents and detractors[]

Protest graffiti against Involuntary treatment, Turin; TSO = MORTE means Involuntary treatment = Death

Supporters of involuntary treatment include organizations such as the National Alliance on Mental Illness (NAMI), the American Psychiatric Association, and the Treatment Advocacy Center.^{[citation needed]}

A number of civil and human rights activists, Anti-psychiatry groups, medical and academic organizations, researchers, and members of the psychiatric survivors movement vigorously oppose involuntary treatment on human rights grounds or on grounds of effectiveness and medical appropriateness, particularly with respect to involuntary administration of mind altering substances, ECT, and psychosurgery. Some criticism has been made regarding cost, as well as of conflicts of interest with the pharmaceutical industry. Critics, such as the New York Civil Liberties Union, have denounced the strong racial and socioeconomic biases in forced treatment orders.^[17][18]

Law[]

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United States[]

Mentally competent patients have a general right to refuse medical treatment.^[19][20][21]

All states in the U.S. allow for some form of involuntary treatment for mental illness or erratic behavior for short periods of time under emergency conditions, although criteria vary. Further involuntary treatment outside clear and pressing emergencies where there is asserted to be a threat to public safety usually requires a court order, and all states currently have some process in place to allow this. Since the late 1990s, a growing number of states have adopted Assisted Outpatient Commitment (AOC) laws.^[22]

Under assisted outpatient commitment, people committed involuntarily can live outside the psychiatric hospital, sometimes under strict conditions including reporting to mandatory psychiatric appointments, taking psychiatric drugs in the presence of a nursing team, and testing medication blood levels. Forty-five states presently allow for outpatient commitment.^[23]

In 1975, the U.S. Supreme Court ruled in O'Connor v. Donaldson that involuntary hospitalization and/or treatment violates an individual's civil rights. The individual must be exhibiting behavior that is a danger to themselves or others and a court order must be received for more than a short (e.g. 72-hour) detention. The treatment must take place in the least restrictive setting possible. This ruling has since been watered down through jurisprudence in some respects and strengthened in other respects. Long term "warehousing", through de-institutionalization, declined in the following years, though the number of people receiving involuntary treatment has increased more recently.^[when?] The statutes vary somewhat from state to state.

In 1979, the United States Court of Appeals for the First Circuit established in Rogers v. Okin that a competent person committed to a psychiatric hospital has the right to refuse treatment in non-emergency situations. The case of Rennie v. Klein established that an involuntarily committed individual has a constitutional right to refuse psychotropic medication without a court order. Rogers v. Okin established the person's right to make treatment decisions so long as they are still presumed competent.

Additional U.S. Supreme Court decisions have added more restraints, and some expansions or effective sanctioning, to involuntary commitment and treatment. Foucha v. Louisiana established the unconstitutionality of the continued commitment of an insanity acquittee who was not suffering from a mental illness. In Jackson v. Indiana the court ruled that a person adjudicated incompetent could not be indefinitely committed. In Perry v. Louisiana the court struck down the forcible medication of a prisoner for the purposes of rendering him competent to be executed. In Riggins v. Nevada the court ruled that a defendant had the right to refuse psychiatric medication while he was on trial, given to mitigate his psychiatric symptoms. Sell v. United States imposed stringent limits on the right of a lower court to order the forcible administration of antipsychotic medication to a criminal defendant who had been determined to be incompetent to stand trial for the sole purpose of making them competent and able to be tried. In Washington v. Harper the Supreme Court upheld the involuntary medication of correctional facility inmates only under certain conditions as determined by established policy and procedures.^[24]

See also[]

Related concepts[]

• Coerced abstinence
• Obligatory Dangerousness Criterion
• Political abuse of psychiatry (also known as "political psychiatry" and as "punitive psychiatry")
• Social control
• Specific jurisdictions' provisions for a temporary detention order for the purpose of mental-health evaluation and possible further voluntary or involuntary commitment:

• United States of America:

• California: 5150 (involuntary psychiatric hold) and Laura's Law (providing for court-ordered outpatient treatment)

• Lanterman–Petris–Short Act, codifying the conditions for and of involuntary commitment in California

• Florida: Baker Act and Marchman Act

Notable activists[]

• Giorgio Antonucci (elimination)
• Thomas Szasz (elimination)
• Robert Whitaker (reduction)
• E. Fuller Torrey (expansion)
• (expansion)

Advocacy organizations[]

• Mental Health America (reduction/modification)
• Mad in America (reduction/elimination)
• PsychRights (reduction/elimination)
• Anti-psychiatry, also known as the "anti-psychiatric movement" (reduction/elimination)
• Citizens Commission on Human Rights (reduction/elimination; founded as a joint effort of the anti-psychiatric Church of Scientology and libertarian mental-health-rights advocate Thomas Szasz)
• MindFreedom International (reduction/elimination)
• Treatment Advocacy Center (expansion)
• (expansion)
• NAMI (expansion)

Notes[]

References[]

External links[]

• National Mental Health Consumers' Self-Help Clearinghouse