When Psychiatric Treatment Isn’t Voluntary

Source: BenBella Books

“This isn’t a book about mental illness or the mentally ill,” Rob Wipond tells me over email about his eye-opening investigation, Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships (BenBella Books, 2023). “It’s a book about the expanding uses of mental health laws throughout society on people from all walks of life.”

Though most studies of psychiatry focus on voluntary, outpatient treatment to assess impacts on the largest number of patients, the rates of North Americans detained involuntarily—including by civil commitments, crisis calls, and police “wellness” checks—are more than double and triple those in the U.K., Sweden, Finland, Germany, and France.

In Florida, for example, during the years 2001-2016, the number of detainees doubled to almost 200,000, outstripping population growth by a factor of five. In California, Wipond adds, “per capita rates of psychiatric detentions for three-day periods increased about 30 percent between 1991 and 2016, surpassing 150,000 annually.” Meanwhile in Colorado, as in neighboring states, “emergency psychiatric detentions from 2011 to 2016 nearly doubled to 39,000.”

“Every day in Florida,” the Washington Post confirmed earlier this month, “children and adolescents are involuntarily committed for psychiatric assessments under the Baker Act, a 1971 law. In 2020-21, involuntary exams happened more than 38,000 times to children under 18—an average of more than 100 a day and a nearly 80 percent increase in the past decade, according to the most recent data. The law is so deeply enmeshed into the state’s culture that it is widely used as a verb, as in: The 6-year-old was ‘Baker Acted.’”

“We help more people than we hurt”

To the question, “Does forced treatment improve mental health?,” in one of the 28 chapters in Wipond’s book that takes us from “blindingly brisk” courtroom hearings to harrowing “wellness” checks and near-inescapable guardianships, he can answer with a clear and decisive “no.”

Despite administrators hoping to reassure him that “the system is well-intentioned,” that “we help more people than we hurt,” and that “from our end, we really are doing our best to help our patients and our best to promote good practice and good care,” Wipond’s comprehensive study unearths health and social services replete with poor-to-dreadful outcomes, lax oversight, and protocols seemingly rigged against those most in need: the vulnerable, destitute, and marginalized.

Far from being able to point to improvements in patient outcomes, Your Consent Is Not Required describes a series of “better-safe-than-sorry” decisions and “I-know-it-when-I-see-it” diagnoses and managerialism that funnels people into forced treatment, with the consequence that staff sometimes begin to “feel they have this right to administer any type of intervention,” while those detained are forced to be submissive and “compliant”—to consent to treatment, frequently by sedatives, antidepressants, and antipsychotics, even when unwanted. In the case of Wipond’s father, and over the objections of family, the treatment extended to electroshock therapy, or ECT.

“That’s what bothers me the most, even more than my father’s death,” one interviewee tells him of her father’s forced treatment for mild dementia, on drugs to which he had a “severe adverse reaction,” after 11 days in psychiatric detention mean her once-functional father is discharged “in diapers on a gurney.” “The violation of his agency, his integrity. The more he tried to assert his rights, the more he was accused of not making sense.”

“Your normal reaction as a citizen, or a human being, is to get angry,” another interviewee affirms of the repeat police visits he endures, “and tell them to get the hell out of your apartment. But you’re afraid to actually get angry because you’re sure they’ll use that against you. It’s degrading. I felt intimidated, and afraid. It was the fact that they could just come like that at any time, bang on your door, charge in, and possibly haul you away.”

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“Everything I did was pathologized”

Across multiple health authorities and jurisdictions, Wipond determines that the “line between well-intentioned, responsible professionalism and potentially harmful abuse” is often hazy and unclear. Among his dozens of cautionary examples is Frances Chan, an Asian-American professional who “went for a breast-cancer check-up at Yale University’s clinic, then had to force-feed herself junk food for weeks because doctors felt her natural stature was too slim.”

Facing similar intransigence and discrimination is Kamilah Brock, a Black woman who, after “arguing with a New York police officer after her impounded vehicle was apparently lost, was committed for nine days. The police officer had doubted she actually owned an expensive BMW, and one of the jurors in her failed lawsuit later said to media that Brock showed too much ‘grandiosity’ in touting her life and career accomplishments.”

Under psychiatric detention, Wipond cautions, “You do not have the right to remain silent. Refusing to answer a psychiatrist’s questions, even about your most intimate inner experiences, can be and often is considered evidence of a mental disorder.”

With police questioning added to already stressful situations, events can quickly escalate: “If you’re too vocal, if you’re not vocal enough, if you cry, if you don’t cry, if you say you’re getting lawyers, if you ask to read the paperwork too much—any of it confirms your mental health diagnosis. You’re crazy, you’re wrong, you’re misinterpreting, you’re overreacting. There’s a lot of room for things to be recontextualized as symptoms of mental disorders.”

Wipond’s powers as an investigative journalist frequently collide with, but sometimes also overcome, the determined stonewalling of health authorities. He tells me, relatedly, that “community-based journalism was very helpful for the book because I think one can only see how much of our society is permeated by the mental health system and coercive treatment if one is looking into all the nooks and crannies of some communities, as I was doing.”

Your Consent Is Not Required opens with a powerful account of the forced treatment of Wipond’s father, who says one day he feels like the ceiling of the house is “caving in on him.” An attending psychiatrist advises that he has “a biochemical imbalance, like diabetes or a broken leg but in his brain.” Later, when the drug treatments fail, the family is told that ECT is “like a heart defibrillator” that “jolts the depressed brain back to life.” “I don’t want it,” Wipond’s father is firm and resolute, “his voice barely audible over the telephone. ‘I don’t want it,’ Dad said, more feebly. The psychiatrists scheduled the ECT.”

When the new treatment leaves Wipond’s father disoriented, with memory loss, more electroshocks are proposed. “We normally do 12 rounds at a time,” the physician in charge explains. An attendant nurse reaches for a more-routine analogy: “It’s like we’re trying to fill a gas tank, and nine rounds didn’t quite fill the tank.”

“A Massive Curtailment of Liberty”

In 1972, the U.S. Supreme Court recognized psychiatric detention as “a massive curtailment of liberty” (Humphrey v. Cady) and, in 1978, argued that a law-abiding citizen should be able “to protect one’s mental processes from governmental interference” (Rennie v. Klein).

Nevertheless, in 1979 the Court voted to lower the standards of evidence required for civil commitment, ruling that it is worse for “a mentally ill person to ‘go free’ than for a mentally normal person to be committed” (Addington v. Texas). Yet detention was considered permissible only when a person presents an immediate and “serious risk of physical harm”; involuntary drugging should also be considered only after other therapeutic options have been offered.

That, at least, was the Court’s ruling. The reality, shared by Wipond’s traumatized interviewees, appears quite different. “I went looking for evidence,” Wipond writes, “that forcibly treating people in psychiatric hospitals improves their mental health or has other positive outcomes for them, over the short or long term. I found a well-worn trail of people who’d gone before me, all coming up empty-handed.”

For instance, a 2007 review of studies of people’s experiences of involuntary hospitalization by University of London psychiatrists “identified many negative themes: views and voices ignored, feeling dominated under strict rules, physical violations, frustration, and powerlessness. People often felt the treatment they received was meaningless, not appropriate, and more like punishment.”

A 2016 study in PLOS One summed up the larger issue: “Despite the widespread use of coercive measures...there is a remarkable lack of empirical evidence as to their association with treatment outcomes.”

“This has ruined our lives,” an adult daughter explains after her mother is hounded by intransigent Canadian health authorities acting on protocols, to the point of compelling her to live off-grid and undercover, to flee their control and jurisdiction. “It’s been a year of hell for us. Financially, it’s insane. Just our time, our family, everything. It’s been overwhelming.”

“We think people should be treated better”

Amid the decisions leading to forced treatment, with mounting evidence that psychiatric hospitalization can itself be suicidogenic, what reforms are possible?

“There are so many ways,” explains Sam Tsemberis, a psychologist tied to UCLA and the agency Housing First, “that we can work with people who have symptoms to manage their lives much better on their own terms.” Adds Kimberly Comer, former director of the National Alliance on Mental Illness (NAMI) for Greater Indianapolis: “There are ways to empower somebody to get treatment without having to traumatize them.”

Among Wipond’s recommendations for root-and-branch reform: “providing stronger, more independent, and transparent oversight, and making regulators more arm’s-length from facility operators’ and governments’ inherent conflicts of interest.” He adds, as a proposal: “Supported decision-making alongside psychiatric advance directives (PADs) could allow people to outline the interventions they’d want in a crisis.” Though he concedes psychiatrists will balk at the suggestion, he thinks psychiatry should “simply be an offered service,” among others, rather than the diagnostic and treatment regimen that determines all others.

Above all, Wipond cautions in extrapolation, “If the line between voluntary client and involuntary patient [is] so thin, shouldn’t we be more careful about advising people in vulnerable emotional states to ‘seek help’”—particularly if we knew in advance, from evidence such as his, where it is likely to take them?