Tuesday, July 3, 2012

Anti-Psychiatry Civil Rights Activists Drop the Ball

There is a fairly large and vocal contingency of people who protest the involuntary commitment and involuntary treatment of people who doctors label with the diagnoses of schizophrenia or other psychotic disorders. They think this practice is a gross violation of the civil rights of these patients, who are, they claim, being persecuted by society merely because they are different and do not fit in.  Such patients should have the right to, say, walk uninvited into their neighbor's house in the nude, or live in cardboard boxes on Skid Row if they so choose.

These activists also believe people who most of us would label as “psychotic” are merely misunderstood.  Delusions and hallucinations do not signify a brain disease, they say, because there are no gross anatomic lesions associated with them.  (You know, like early Parkinson’s Disease).  In fact, they really do not believe in brain diseases at all. 

So I have a bone to pick with them. I think they have really dropped the ball when it comes to people labeled by society with "Alzheimer's Disease." These unfortunate victims are often locked up in nursing homes and never, ever let out!  Ever! They too are often drugged against their will, just to keep them manageable and quiet for the comfort and safety of Hispanic and Filipina nurses aides who are taking care of them for minimum wage.

How can activists who claim to be so concerned about civil rights NOT come to their rescue? Why should these poor elderly defenseless individuals be persecuted just because they don't keep track of the date, or care much about what locations they find themselves in? Shouldn’t they have the freedom to wander wherever they want?  Should they be locked up just because their memories don't conform to societal norms?!?  This is outrageous!!

I must admit that I am  a little concerned that some people might get the mistaken impression that I am actually being serious here. In reality, it has been becoming more and more difficult to involuntarily commit, hospitalize, and treat the seriously and persistently mentally ill, and this has become an unmitigated disaster for many mentally ill individuals and their families.

And the results can be horrific. An excellent first person account of what misery can be created was recently published by the New York Times entitled, When My Crazy Father Actually Lost His Mind.    

I recommend reading the whole piece.  To just briefly summarize, the writer's father, a beloved family man with a solid employment record, had an episode of mania. He spent a long time acting crazy on the street.  He could not be committed because he was deemed to not be dangerous enough by the powers that be, even though he threatened to "haunt" his wife forever.  He was, however, sane enough to be arrested and nearly put in jail.  

The family in question
The author continues, "And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else." When the mania finally abated - on its own because he never did get treatment - he returned home.  He later "lamented the time lost with his family. 'Those are days I will never get back,' he said."

The increasing difficulty in committing seriously ill individuals has been largely due to two factors:  First, tight state budgets in the recession have led to the elimination of large numbers of psychiatric hospital beds, so there is often no place to send severely impaired mental patients. This trend actually started way before the recession. Chronically mentally ill people were supposed to be treated as outpatients by Community Mental Health Centers - but those were never funded adequately.

The second factor is the "patient's rights" movement mentioned above.  

Now, just so I am completely clear, this movement initially addressed some very real and reprehensible abuses by the states in the US, and by the psychiatric profession itself. The practice of locking up mental patients in "snake pits" and throwing away the key (and sometimes this happened to people who were not, in fact, mentally ill - at the impetus of family members who were, for example, trying to get their hands on some family money) was widespread and unchecked.

Stopping such practices was a very good thing indeed.  

But as usual, eventually the baby got thrown out with the bathwater.

The first major commitment law that stopped the abusive practices was California's Lanterman-Petris-Short Act.  The act went into full effect on July 1, 1972.  The law mandated only time-limited commitment of mental patients, at least until they were judged to be mentally incompetent to make treatment decisions by a court of law and placed on a conservatorship. 

The law also mandated judicial review for anyone who was held for more than 72 hours.  If a patient was to be committed, police or psychiatric professionals would have to fill out a "72 hour hold," also known as a 5150 for all of you Van Halen fans.

The grounds for commitment were, first, that the patient had to have a diagnosable mental illness (being suicidal was allowed to be presumptive evidence of mental illness for all practical purposes, even though one does not necessarily have to be mentally ill to be suicidal). Then, you had to either be a danger to yourself, a danger to others, or be something called gravely disabled - on the basis of said mental illness.

Grave disability was defined as the inability to provide for one's own food, clothing and shelter because of the mental disorder.

When the law was first implemented, there were plenty of psychiatric beds available, and the patients rights advocates seemed satisfied with how the law was being applied.  

The patient had to only loosely meet the criteria.  If you were homeless because you were too paranoid to find adequate shelter or get a job, you would be considered gravely disabled.

If you walked into your neighbor's house in the nude because the voices told you to (this is NOT a hypothetical example, by the way), that was enough to make you a danger to yourself.  After all, the neighbor had the right to shoot you, and just might do so.  Likewise if your delusions led you to jump out of a moving car, that would make you a danger to yourself, even if the car was barely advancing.  

Now, those sorts of situations might lead to you be quickly released from a hospital or, in some cases, imprisoned in a jail for lawbreakers.

Slowly but surely, grave disability as a criteria also became rarer and rarer.  If you had a cardboard box on Main Street to live in and you were eating out of garbage dumps because of mental illness (as opposed to say, chronic unemployment or poverty), you were deemed to have the ability to provide for your own food and shelter.  Not committable! This would be true even if, after proper treatment, you would run away from that scene in absolute horror as fast as you possibly could.

As I have pointed out previously on this blog, more severely mentally ill people are now incarcerated in prisons than in hospitals.  BTW, they get forcibly medicated there as well.

This seems to be what these bat-guano crazy, so-called "civil rights" activists want.  And they have the unmitigated gall to claim to have the moral high ground. Shame on them.


  1. It is good to hear that, in some cases, psychiatric commitment does make sense, from someone that cannot be suspected of ignoring the social factors in mental issues.

    That said, I wonder if the case for psychiatric commitment laws will not always be weak as long as it relies too much on a medical argument from psychiatrists ("being diagnosed with a mental illness"). Most mental issues varies along a continuum, and so the exact boundary for commitment or diagnosis will always be a social construct rather than a scientific one (and I consider that social construct necessary and healthy).

    I think we would make patients, families, psychiatrists, and the court system, a favor by restricting the input of psychiatrists to the question of whether psychiatric or jail commitment (or other more limited forms of probation/assisted-outpatient-treatment) is better to help bring back somebody's behavior within socially acceptable norms. But we should let the question of whether those social norms have been broken to the common law system.

    1. Mr. Holmes,

      We pretty much have that already. It's usually the police or a trained crisis team that bring the potential patient to an emergency room. A few cases are judgment calls, but most are pretty obvious. It has become rare that someone who is not either obviously completely out of touch with reality or clearly suicidal is committed. Some jurisdictions require two different psychiatrists or other mental health professionals to sign a commitment. And then the patient can always request judicial review.

      If it can be shown that actual malice was involved, the doctor can even be sued for false imprisonment.

  2. By your logic, then, why don't we force therapize dysfunctional families? They're a pain in the ass, too. The rest of us "normals" have to put up with their awful children, their missed days of work, their divorces, their guns and violence. No? Why not?

    1. Rossaa,

      Because they aren't psychotic, delirious, or demented. By your logic, we shouldn't be locking up the Alzheimer's patients either.

  3. I also read that article. I think it's important to distinguish between allowing people to live the lives they want to be living and abandoning people. My thought when I read the article was that it was very sad that our society would abandon someone who was that frail. Obviously, he was very feisty and physically active for an elderly gentleman. But his mind was frail. What he went through wasn't some well thought out philosophical decision. He wasn't just taking the road less traveled. He was self-destructing and our legal/medical system abandoned him. So it was ridiculous. The family tried abandoning him so that the legal or medical systems would get involved. But then those two systems would quickly abandon him and the family was back to square one. Oh dear. No clue what the answer is to all of that.

  4. Two things, I work with department of Mental Health Clients. The standards for hospitalizing them when they are doing very badly are kind of interesting. Some of these people are psychotic all the time, but they do okay with our help. If they have a guardian, of course, it's simpler, but the guardians are rarely involved.

    The Alzheimer's thing is tricky. I do think that far too many Alzheimer's patients are being prescribed antipsychotics to make them more manageable rather than for their benefit. My Mom just got an Alzheimer's diagnosis, and I find it kind of disturbing. The rate of antipsychotic prescriptions in my state seems to be higher than average, and I don't think it's psychiatrists with geriatric training who are doing most of that prescribing.

    1. Hi Eastcoaster,

      You are right - there's no question that the majority of anti-psychotic medications prescribed in patients with dementia are for chemical restraint, and not for psychosis.

      With nursing homes, the places are so expensive you wonder why they can't pay a decent wage so they could hire more or better help - so the drugs might not be necessary. Where is all this money going? I don't know, but I've got my guess.

  5. So Doctor what would you suggest for a person like myself who has witnessed my son repeatedly victimized by mental health professionals? Including 2 who perjured themselves and used fraud to have him Court Ordered? The Community Clinic that employ them shredded ALL the original Court Documents so it is obvious to me that lying to and lying about the people and the events which have occurred are considered acceptable behavior for professionals to have.

    the fact that it took me three weeks to convince my son he was safe enough into our fenced yard speaks volumes to me about how necessary drugging and controlling people in distress is. It is effective alright. It's a pity it isn't actually therapeutic for the person who is traumatized by it.