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Bar News - July 7, 2006

Morning Mail: Lex Loci Comment Stereotypes People with Mental Illness

Charles DeGrandpre’s casual observations about In the Matter of B.T., (Lex Loci, Spring 2006 Bar Journal) raise issues about the involuntary treatment of persons with psychiatric disabilities that are worthy of comment.


The B.T. case, decided February 15, 2006, reaffirmed that persons who do not present a danger to themselves or others cannot be forcibly confined or medicated, even when it is clear that they have a mental illness. The writer laments that under B.T.’s holding, a non-dangerous person would be allowed to make choices about her own psychiatric treatment, terming it “[a]nother sad example of the results of our current legislative social concepts . . .”


A preliminary comment is in order about the writer’s portrayal of B.T. as one who is condemned to some sort of pitiful existence in the absence of compelled treatment: he states that she will “remain wandering the streets with a schizophrenic disorder, untreated, but harmless. . . ,” judging the result “nonsensical.”


DeGrandpre’s words appeal to a cruel and inaccurate stereotype about people with mental illness. Many people with even serious and chronic mental illnesses live self-sufficient and fulfilling lives. Indeed, B.T.’s life is nothing like that suggested by DeGrandpre.


B.T. lives independently in an apartment she has rented, buys her own groceries, and helps to care for her father in a neighboring town. She is quite opinionated about current events and protective of her independence. Her life represents a result that is hardly “nonsensical”—a citizen who presented no danger to anyone was permitted to retain her dignity, autonomy, and control over her bodily integrity. Of course, DeGrandpre does not know anything about the case or B.T. herself beyond what is in the reported opinion. He assumed the worst and, in the process, reinforces the prejudice and stigma toward citizens with mental illness.


DeGrandpre’s opinions about the folly of allowing people with mental illness to decline psychiatric treatment, unfortunately, reflects the thinking of much of the general public, some policy makers and even several of those who have significant power in the judicial and mental health systems.


The belief is that it is ethically defensible to forcibly administer medical treatment to someone when the person makes what seems to be an objectively wrong decision about that treatment. A reasonable view at first reading, but it is a principle that we do not apply in other similar circumstances. We do not force treatment upon the diabetic with undisciplined eating, the alcoholic who continues to drink, or the smoker who keeps smoking.


It can be difficult to stand by as someone neglects a medical condition of any sort, but we regularly allow people to do so when their decisions do not affect public health or safety. That is the principle in the B.T. case and which generally underlies the law of involuntary admission to the mental health system: those who present no danger to themselves or others will not be forced to undergo psychiatric treatment simply based on the conclusion that they would benefit from the treatment. This is, of course, consistent with the high value placed on personal liberty in our system and the limited circumstances under which we allow the government to restrain it as reflected in the due process clauses of federal and state constitutions.


Those who believe that compelled psychiatric treatment should be permitted even with non-dangerous individuals often labor under one or more misconceptions about people with mental illness:


  • That mental illness equates to incompetence to make medical decisions. In fact, mental illness is rarely a completely disabling condition—although about half of us will have some degree of mental illness at some point in our lives. And, about 14 percent of Americans have moderate to severe mental illnesses, the overwhelming majority of those are competent to make decisions about health care and other important aspects of their lives.
  • That no sensible person would decide to forego psychiatric medication. To the contrary, decisions about psychiatric treatment are often agonizing choices, and treatment is frequently declined for good and rational reasons. The history of psychiatric treatment is a tragic one that is filled with abusive, dehumanizing, and destructive treatment, some of it in recent memory. The side effects of even newer antipsychotic medications can be debilitating, even life-threatening, and sometimes result in permanent neurological damage. A recent study showed that two-thirds to three-quarters of patients taking the newer medications discontinue them within 18 months due to lack of effectiveness, intolerable side effects, or both (Lieberman JA et al, “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia”, New England Journal of Medicine 2005; 353: 1209-1223).
  • A commonly held misconception—even by those in the judicial and mental health systems—is that compelled treatment in the community results in a general improvement in mental health. In fact, the most respected studies of forced community treatment find that it does not improve levels of participation in treatment, later hospitalization rates, or objective measures of quality of life (e.g., “Final Report: Research Study of the New York City Involuntary Outpatient Commitment Pilot Program”. Policy Research Associates, December 4, 1998). What does make a difference is the quality and intensity of services provided to patients. Unfortunately, too much of the intensive services caseload in this country is made up of involuntary patients, causing proponents of involuntary treatment to mistakenly conclude that it is the coercion rather than the treatment quality that makes the difference.


In any consideration of compelled treatment it must always be remembered that there is a significant cost exacted in loss of autonomy and trust whenever people are forced to submit to psychiatric treatment. The loss of freedom is no less a loss simply because it imposes the will of someone who believes they are acting in someone’s best interests. Essential to a fulfilling adult life is a sense of autonomy and independence. Few of us would trade our freedom for a life of perfect health. In most contexts we consider it understandable, even admirable, when people risk health and safety to maintain their freedom.


Particularly in the psychiatric treatment context, compulsion can destroy trust which is the basis for effective therapeutic relationships. Force leads to resistance, and the threat of forced treatment leads to the avoidance of services altogether. Often the person with mental illness understands the compulsion as undervaluing their worth and their humanity.


The importance of self-determination in effective psychiatric treatment is recognized in the 2003 report of the President’s New Freedom Commission on Mental Health. That report notes that “services and treatments must be consumer and family centered, geared to give consumers real and meaningful choices about treatment options and providers.” Also, that “care must focus on increasing consumers’ ability to successfully cope with life’s challenges,” and, that “regaining control of one’s life is often vital to recovery.”


Richard Cohen
Executive Director
Disabilities Rights Center, Inc.


Michael Skibbie
Policy Specialist
Disabilities Rights Center, Inc.



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