APA Annual Meeting 2017 (San Diego)

Interesting thoughts provoked by a session on outpatient commitment, or "Assisted Outpatient Treatment" yesterday...

When a court requires an individual to be "treated" although he/she truly and competently wishes not to be, are we trying to help that person, or are we controlling risks and adverse influences in the community? Certainly either purpose is legitimate. The two combined may even describe civilization itself rather fully.

But helping people and controlling them are distinct, separate activities. In psychiatry, especially involuntary psychiatry, they are hopelessly confused. And that may even describe the whole problem rather fully.

The session I attended featured seven speakers: Dinah Miller, M.D., from Maryland; Ryan Bell, M.D., J.D. and Kimberly Butler, LCSW-C, from New York; Erin Klekot, M.D., from Ohio; Mustafa Mufti, M.D., from Delaware; Adam Nelson, M.D., from California; Marvin Schwartz, M.D., from North Carolina.

Dr. Miller, the moderator, was the biggest reason that I actually came to this conference. She and co-author Annette Hanson, M.D. recently published a fascinating book, Committed: The Battle Over Involuntary Psychiatric Care (Baltimore: Johnson Hopkins University Press, 2016). They are also running a symposium today based on that book, at APAAM 2017.

Amost all my life, I've been an advocate for the total abolition of psychiatry. Many people interpret that to mean I am opposed to helping people with "mental illness" or opposed to medical treatment or science generally. None of that has ever been true.

My friend Tom Szasz said that psychiatry as we know it would wither away if it only lost its facility to acquire and retain "patients" using the police power of the state. I have long believed this is a compelling argument and a highly reliable prediction. In fact, it has primarily informed my career as a lawyer and my advocacy as an abolitionist.

Now an even more fundamental framework is occurring to me. Is "treatment" help, or control? If so-called "mental health professionals" could be required to honestly confront that distinction with their "patients" many things could improve.

When you have four security guards hold a woman down, struggling and screaming, for a nurse to force a needle into her body and inject a drug that will alter her mind against her will, there is simply no chance that your "patient" will experience it as help. You should not be allowed to call it help, or even to think that you are helping. Your lie will degrade you, and if your "patient" gets any wind of it she will hate you and forever dream of revenge.

On the other hand, precisely the same violence recognized openly and officially as control, while regrettable, may be an inevitable compromise in an imperfect society subject to disagreements and fears. That can be forgiven. It also may not require creation of elaborate bureaucratic machinery to protect falsehoods in the institutions where I practice law. 

Dr. Miller said yesterday that she doubts forced treatment can or should be justified as a public health measure. I absolutely argue the opposite: it must and can only be justified as a public health measure! The public has a right, and will always assert the right, to protect itself. If subduing a violent person (or even a merely obnoxious person) with antipsychotic medication were workable as public protection or community improvement, we would probably be confident in involuntary psychiatry as morally justified control.

But if you are a doctor and you honestly want to help a person in front of you, it will be necessary to find the insight and patience to treat that person only with his or her informed consent.

Dr. Bell, who had more direct experience with outpatient commitment (in New York) than anyone else on the panel, responded to a question I asked, about whether patients might occasionally change the minds of clinicians, even about such fundamental issues as what is wrong with them and what is needed. He told a story of a man he treated for some years. The end point was, yes, a human being's autonomy must be respected or help simply does not occur. 

This seems obvious and fundamental. There should be a rule or a law.