Two items of news this week from what is now the fourth largest economy in the world and thus one of the wealthiest per capita, California. The governor has just signed a law expanding the definitions of mental disorder and legal incapacity so that huge numbers of people with chronic mental disorders, and drug and alcohol addictions, can be detained, placed under guardianship and/or forced to take treatment. This is largely directed at the state's 170,000 homeless people, many of whom are mentally-disturbed and/or addicted but who refuse treatment and cycle in and out of prison or rehab centres.
The second item is about the huge Los Angeles General Hospital which is said to serve a population of ten million. That's just a good story as there are other hospitals in the area but this one is for the people who can't afford private care, so that still leaves several million who have nowhere else to go. The psychiatry department is strong on physical restraint, meaning shackles, and uses them about fifty times more than the national average, which is already much higher than other western countries. The hospital says it is partly because the police bring in so many people who are violently psychotic due to methamphetamine abuse and because they have to transport patients from the hospital to their psychiatric unit about 25km away. However, their use of restraints is much higher than other public hospitals in LA, including seven times higher than Harbor-UCLA MC in South LA, and fourteen times higher than Olive View-UCLA MC, each of which has exactly the same patient population.
The problems are, of course, tightly interwoven: family breakdown and homelessness, unemployment, criminal records, mental disorder, and drug and alcohol abuse. That the problems are so bad and so very public in such a wealthy place says a lot about the staggering inequalities of wealth in that city but is locking people up the answer? Civil rights and many other groups are totally opposed to this move on the basis it will achieve nothing beyond make a lot of contractors and private hospitals even richer. The governor is driven by the politician's syllogism: "Something must be done. This is something. Therefore, this will be done." It would take a month to go through all the history and the ramifications but we can start with a question from a reader from last week. The reader, a retired psychiatrist of my vintage, asked:
1) Do you accept the need for involuntary detention under the Act?
2) Is there ever justification for involuntary treatment - and if so,
3) What sort of treatment?
These are critically important questions, so I asked him to contribute a brief response to them. His essay appears below. The entire basis of the state's approach to mental disorder is built on and around these questions. Such a pity, then, that there is so little research on them, even though it would be very difficult. But difficulty is not a justification for failing to try. The first thing to remember is that, regardless of what they say, politicians don't give a damn about mental disorder. They know they can't win votes by being nice to prisoners or mental patients, but they can lose votes by not being seen to be tough enough. That includes the current Senate enquiry into ADHD which I see as driven by nothing other than drug companies and bad science.
The second thing is that both psychiatry and the larger society are so used to locking people away that nobody questions it. Wikipedia says that an inspection of the Bethlem Royal Hospital in London in 1403 revealed:
...amongst other patients there were six male inmates who were "mente capti", a Latin term indicating insanity. The report of the visitation also noted the presence of four pairs of manacles, 11 chains, six locks and two pairs of stocks...
That's over six hundred years ago. For the next several hundred years, conditions in the hospital were a mixture of brutatilty, squalor, depravity and corruption, with staff regularly stealing or embezzling the miserable funds sent to care for the insane, and patients occasionally starving to death. Everybody knew about it, nobody much cared, which shows how little things have changed. But the central theme for nearly a thousand years has been detention of the mentally-disordered. Most people think mentally-troubled people are detained in order to treat them but no, it's the other way around: the detaining came first, the treatment is an afterthought. So whatever else, we can't say that the policy of detaining people and then imposing treatment on them is a passing fad. This is what society does: first, it detains them, then, it finds something to do to them to justify detaining them.
As for treatment, involuntary patients have no say in what is done to them, and what is done depends on whatever fashion has grabbed the attention of the psychiatrists. For hundreds of years, the "treatment" amounted to torture. Patients (who were actually known as 'prisoners') were subjected to a variety of regimens including emetics to induce vomiting, purgatives to induce diarrhoea, bleeding, various chemicals to cause blistering of the skin, ice baths (in winter, in unheated buildings in London), and a variety of other terrors. In fact, terror was used as a "therapeutic" measure. But the important point is that, at all times, the keepers of the insane (now known as psychiatrists) were convinced to religious intensity that they were doing the right thing. They were, and still are, hostile to any suggestion that their methods may be less than ideal. What we need, and what we don't see, is a valid, scientific or humanist explanation of why it is justifiable to deprive people of all their rights, including the right to end their lives, and subject them to treatment they don't want.
If detention and enforced treatment were invented today, they would never be approved. Can you imagine the explosion of outrage if, for example, single women were forced to undergo terminations? Yet what is done in psychiatry is a much greater offence against the person, it goes on an on and eventually results in a short, miserable life. Huge numbers of people objected violently to being required to wear masks, yet they are silent on the much larger matter of snatching people off the streets or from their homes and locking them up after a superficial and very one-sided "hearing."
It is important for every citizen to know that incarceration of the mentally-troubled is not a matter of scientific evidence. It is wholly a tradition that goes back to the Dark Ages. It is most emphatically not a humanist measure, and while the detention has been a constant for centuries, the "treatments" come and go, so it isn't just a matter of "We've got the treatment, now let's try it out." The only justification is the convenience of society, which may or may not be enough. Since the publication of the WHO/OHCHR Guidance on MH Legislation a few weeks ago (see Substack Oct 10th 2023), it's time to reconsider whether an archaic tradition has any place in modern society.
There is a parallel in the continuing disputes over capital punishment. In this and many other countries, it has been resolved in favour of abolition by two arguments:
- That's not what civilised people do.
- The consequences of executing an innocent person are so great that the risks outweigh any conceivable benefit.
The second of these applies to psychiatry. Depriving an unconvicted citizen of civil rights is an enormous step. In the case of mental disorder, the society has to be able to prove (not just believe) that the benefits of doing so are so great that they outweigh any conceivable disadvantage to either the mentally-troubled person or a person who is incorrectly labelled mentally disordered. I have never seen a convincing case for this, but I'm quite sure most people aren't aware of the issue. We will look at it again.
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From a recently retired and very experienced psychiatrist:
Involuntary detention and treatment of the mentally ill.
The involuntary detention and treatment of the mentally ill has long been a controversial issue in psychiatry and society. I have worked as a psychiatrist for over forty years (actually, he had nearly fifty years on the job) and my aim here is to stimulate discussion about the matter by presenting a brief review of what I regard as key issues.
It is common knowledge that obviously psychotic individuals have always emerged in society - individuals who at best, are merely a social nuisance, at worst, a danger to themselves and/or other people. In our society today, illicit substance ab/use and primary mental illness not related to drugs or underlying brain pathology, is usually the cause of the psychosis, and psychiatrists are usually left to deal with the problem.
At the severe end of the spectrum, individuals diagnosed with a drug-induced psychosis or primary psychotic disorder, will often require involuntary detention and sedation, for their own good and for the safety of others. Anybody who has worked in an Emergency Department (ED) or mental health unit knows how dangerous floridly psychotic individuals can be (especially individuals in a drug-induced psychotic state). No matter how much one may want to avoid restricting their freedom, something must be done to prevent them from doing harm to themselves and/or other people. It stands to reason that the task is left to psychiatrists, who are legally qualified to diagnose and ‘manage’ mental illness, and ‘management’ includes involuntary detention and treatment under the Mental Health Act (‘Act’).
Psychiatrists do not usually order the detention of psychotic individuals in the first instance. It is usually general practitioners and non-medically qualified, ‘authorized mental health practitioners’ (mainly nurses & community-based social workers) who order the referral of a person for examination by a psychiatrist, and the threshold for such involuntary referral may vary from questionable to fully justified. It is left to a psychiatrist to ratify or revoke the involuntary referral order. Most psychiatrists do not want the often-onerous task (with complaints from all quarters) of endorsing a patient’s detention under the Act. Any suggestion that they enjoy the ‘power trip’ is naïve and an unjustified slur. Most psychiatrists feel only a sense of professional duty in detaining someone under the Act, and in prescribing involuntary treatment.
Most health professionals and lay people accept justifiable detention and involuntary sedation with intramuscular or intravenous injection, but often have reservations about involuntary electroconvulsive therapy, which remains a more controversial matter even within psychiatry.
The question of whether certification is ever required or justified, can perhaps be answered best with reference to ‘moral treatment’ that was dispensed at the Quaker-run York Retreat, founded by William Tuke, and opened in 1796. York Retreat ‘moral treatment’ remains the benchmark for what is possible in the way of humane and ‘least restrictive’ treatment for mental illness. However, even Quakers, who did everything they could not to impose restrictive treatment, found it necessary to restrain (straitjacket) and sedate seriously psychotic patients. It is not facile to say that if Quakers found it necessary to restrain and sedate some patients against their will, then everyone will at times find it necessary to do the same. What are the alternatives? Should we allow, for example, dangerously deluded or manic individuals, to run amok and then pick up the tab for whatever injury they inflicted on themselves and/or other people? Probably not. All we can do, is to make sure that efforts have been made to manage their psychosis in the least restrictive manner first up, and if detention has become necessary, to ensure that every effort is made to comply with defined safeguards for their involuntary treatment under the Act - access to Advocates, legal representation, second opinion and Mental Health Review Board hearings. Nothing will ever be perfect or satisfy everyone, but I believe that involuntary detention and pharmacological sedation may be necessary for seriously psychotic individuals. A few more comments about the matter.
Physical assault by patients, on staff working in psychiatry (at every level), are higher than in any other area of medicine. Any assertion that this is understandable or justified because of the way the mentally ill are treated, is simply irresponsible and insulting. The reality is that so-called ‘seriously unwell’ psychotic (and even non-psychotic) patients are not infrequently dangerous to mental health professionals, but in my experience, mental health professionals, especially nurses who are routinely abused verbally, will often ‘go the extra mile’ to deal with such individuals in a least restrictive manner.
When I commenced training in psychiatry, there were no trained guards in mental health units or EDs. Today, guards are present daily in ED, secure and even ‘open’ mental health units, because of the risk of physical violence by some patients, towards other patients and staff. It is difficult to avoid the conclusion that psychiatric patients have become more violent.
A consideration that is seldom mentioned in discussions about involuntary detention, is the part not infrequently played by ‘significant others’. In Australia today, and no doubt in many other parts of the world, every psychiatrist has been confronted by patient partners and/or family members, who have threatened legal action if the patient in question is discharged from involuntary (and often voluntary) care. Not infrequently, parents of children abusing substances (especially methamphetamine and other psychosis-inducing drugs) have taken out a restraining order against their children and are firmly of the opinion that their children should remain in ‘medical custody’ for a long time. They have no doubt about the need for involuntary detention and will do everything they can to ensure that detention continues longer than can be legally justified. ‘Pressure’ and the threat of legal action may contribute to longer than necessary involuntary detention and to a community treatment order (CTO) on discharge.
In summary, have no doubt that involuntary detention and treatment will always be necessary for a small percentage of dangerously psychotic individuals, but equally, have no doubt about the need for ongoing vigilance to ensure optimal compliance with regulations that aim to minimize harm and optimize benefit. Other observers may have a different perspective and it is important to keep the matter under active discussion and review.
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With thanks.
Pleased to announce that after many adventures, this paper has finally been published:
McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human Psychology and Psychiatry, 25: 106-118. DOI: 10.1891/EHPP-2023-0008.
In brief, it says that psychiatry is engaged in a massive and very long-term exercise in deception. For anybody who objects to my assessment of psychiatry's integrity (or lack thereof), and unlike the editors of the mainstream journals who wouldn't touch this paper, the editor of EHPP would be pleased to publish a critical response.
Love your work!