Psychiatry’s Balancing Act Between Coercion and Neglect

The pressure to respect freedoms and do timely interventions at the same time.

Posted Sep 18, 2020

In case you haven’t noticed, criticism of mental health treatment and the field of psychiatry has turned up a notch. Listen closely, however, and you’ll realize that it comes from opposite directions. Neither of these channels is really new, but it does underscore the continued tension in trying to pull off a balancing act the mental health community has been walking for decades.

From one side is the criticism that that the mental health system is too coercive, forcing people to accept questionably valid diagnoses, pushing medications that can have serious side effects, and taking away people’s rights and freedoms in the form of involuntary hospitalizations or even mandatory outpatient treatment. There are also increasing numbers of people contending that diagnoses like ADHD, depression, PTSD, autism, and schizophrenia don’t really qualify as an illness or disease at all (see other posts on that). In a nutshell, the message to psychiatrists and many other mental health professionals is back off.

At the same time is the loud cry from those who believe that the mental health system is too passive, even negligent, especially for people deemed to have “serious mental illness.” With resources spread thin, access into the mental health “system” can be very difficult with more intensive levels of care available only after a person has engaged in dangerous behaviors towards themselves or others, even when such behavior was entirely predictable. As shown in recent documentary films such as Bedlam, the portrayal you see is of a mental health system that sits idly by for too long until criminal justice organizations have to get involved, resulting in massive numbers of individuals who are getting punished instead of getting treated. The overall message from this side might be summarized as step up and get involved sooner rather than later

These dueling perspectives can frequently play out in a very real ways. An extremely common situation that occurs in emergency departments all over the country is that an individual struggling with psychosis, suicidal actions, or dangerous and aggressive behavior will be brought in by the police. That person for a variety of reasons might refuse the recommended treatment like a psychiatric hospitalization. The principle of autonomy is one of the pillars of medical ethics, and the vast majority of mental health professionals in these situations take the step of something like involuntary hospitalization quite seriously. When it does happen, however, individuals who are subject to these decisions can understandably feel coerced, imprisoned, and violated.

If the decision, however, is not to hospitalize, there is often a family member like a parent, sibling, or spouse, who has been trying to help this individual for a very long time and is equally distressed by what feels to them like an abandonment by mental health. They recognize the perils their loved one is in and have worked tirelessly to try to convince them to get help. If that person declines the help and the person is set out “into the street,” the family member can feel stuck in a system that won’t respond until their loved one winds up seriously injuring themselves, incarcerated, or dead.

There of course is a middle ground here and one that is often declared as the aspiration goal. Terms such as “person-centered,” “collaborative” and “holistic” are frequently invoked and, much more than people might think, accomplished during the treatment process. Myths certainly abound about how all this works. In my own practice, for example, I typically encounter much more resistance from patients and families during my efforts to reduce medications rather than to increase them, yet still am often typecast as the evil drug pusher who looks for pharmacological solutions to solve every problem.

Misperceptions aside, however, there remains this tightrope to walk at times between being too controlling and too passive. States, cities, and even specific clinics can come down in different places along this continuum often guided by laws that use words like “acute risk” that are open to quite a bit of interpretation. My state of Vermont is generally known to put a very high value on a person’s civil liberties but that doesn’t mean there aren’t people subjected to hospitalization or treatment against their will or people who think our mental health system is too paternalistic.

In the end, mental health clinicians are well aware that sins of both commission and omission are possible and that there can be serious negative consequences to intervening either too heavily or too lightly. Getting the general public more aware of these opposing forces may help build understanding and perspective so that the goal of mental health care that truly is person-centered and collaborative can be realized for as many people as possible.