John Hunt (born 16 July 1981) is an Irish citizen who was involuntarily detained as a psychiatric patient. The conditions of Hunt’s detention have been the subject of a sustained campaign by his former partner and mother of his child Gráinne Humphrys. He was committed as an involuntary psychiatric patient in 2005 and was detained at a secure psychiatric unit at Our Lady’s Hospital in Cork until August 2011 when he was transferred to the Central Mental Hospital, Dundrum, Dublin. Until 2010 he was not granted leave for any temporary release from the Cork facility to visit his family. As a result of the campaign of his former partner that year, the Cork hospital allowed Hunt six hours of unsupervised leave every two weeks. Later, following a violent altercation with a psychiatric nurse, this leave was rescinded, and Hunt was transferred to the main Irish forensic psychiatric unit in Dundrum.
John Hunt and Gráinne Humphrys.
As of 2013, Humphrys is still being quoted in the Irish press about Hunt’s apparently ongoing psychiatric detention:
“I am very critical about how his admission was dealt with – it was with the use of force and coercion. He didn’t want to take the medication at the time of his admission and I thought, fair enough. I couldn’t understand why there was not a better method of communication that we could use with him, like open dialogue.”
Early Life
At the time of Hunt’s birth, his family lived in the small, coastal town of Greystones in Wicklow, Ireland. His father was a violent alcoholic and his mother had few supports in raising her children. His four-year-old brother drowned when he was eleven years old. Thereafter, Hunt began getting into fights and taking drugs. Humphrys attributes these behaviours to his history of trauma and low self-esteem. His first breakdown occurred shortly after the end of his relationship with his first long-term girlfriend. Humphrys has expressed the view in relation to Hunt’s history that, “trauma and loss, amongst other factors, form the bedrock of John’s problems — his so-called attachment disorder and paranoid schizophrenia.”
Involuntary Committal and Medication
John Hunt was a resident of Cork, Ireland. He experienced a breakdown while his then partner, Gráinne Humphrys, was pregnant with their child, Joshua. Frightened for his safety, Hunt’s mother, Marion Hunt, instigated committal proceedings against her son. As he was deemed a danger to himself, this led to his involuntary committal in 2006 at the Carrig Mór Centre, a Psychiatric Intensive Care Unit (PICU) in Shanakiel, Cork. The Carraig Mór Centre is a two-storey building that was formerly part of the now defunct Our Lady’s Hospital (Cork District Mental Hospital). Hunt was under the management of a forensic psychiatric team in an 18-bed unit for involuntary patients deemed to have behavioural difficulties arising from their mental condition. Subsequent to his admission, he received a variety of diagnoses including drug-induced psychosis, bipolar disorder and schizophrenia. Family visits at Carraig Mór were carried out in a small CCTV-monitored room at the facility that has been described as “cramped” and “uninviting”.
Since his committal Hunt has been forcibly medicated with a diverse range of psychoactive drugs including the typical antipsychoticszuclopenthixol and chlorpromazine, the atypical antipsychoticamisulpride, benzodiazepines and sleeping tablets. They have had various adverse side effects and Humphrys expressed the view that he was “completely over-medicated”. The hospital authorities at Carraig Mór considered Hunt a ‘chronic’ patient and ‘suitable’ for long-term hospitalisation.
Campaign
In 2007, Humphrys began a campaign seeking to end ‘The Incarceration of John’. The Irish Examiner has noted that she gained substantial attention to his case, powerfully portraying him as a lost soul imprisoned against his will and cut off from his family.
In the summer of 2010 former Green Party Senator, Dan Boyle, visited Hunt at the Carraig Mór facility. Senator Boyle acknowledged that Hunt was ‘physically cared for’ but expressed concern ‘about the overriding culture of excessive medication there’. He also noted that Hunt ‘was only allowed minimum contact with the outside world’ and that he did not have access to a rehabilitation programme. Humphrys argues that Hunt’s treatment at the facility damaged him mentally and physically and she has characterised the mental health system as punitive and fostering dependency in patients. She has also alleged that her former partner suffered in the facility as he has been perceived as non-compliant.
Three days after Senator Boyle’s visit to Hunt he called for a debate in the Seanad on ‘the culture of mental health and psychiatric care services’ in Ireland. In his address Senator Boyle referred to his visit to the Cork psychiatric hospital and the fact that Hunt had only seen his son outside of that institution once in the previous four years.
Later in 2010, following the campaign’s expanded media presence and Senator Boyle’s visit to Carraig Mór, Hunt was granted day release without supervision. Hunt was allowed a six-hour pass every two weeks and, according to Humphrys, this reconnection with the world outside of the secure psychiatric hospital gave him ‘new hope for his future’. Reflecting on Hunt’s experience of the mental health system as a patient and her own as the partner and advocate of a psychiatric patient, Humphrys wrote to the medical authorities of the Carraig Mór Centre in early 2011 outlining her grievances, which was reproduced in the press.
Transfer to the Central Mental Hospital
Hunt’s fortnightly passes were rescinded following an incident in June 2011 when he struck a male member of staff. The authorities at the Carraig Mór Centre also barred all visits to Hunt by non-family members. The context and causes of the incident, surrounding an attempted phonecall to his son, and whether it was properly investigated, were highlighted and contested by his family. The authorities at Carraig Mór reported the incident to the Gardaí (the Irish police force) and also sent a report to the Mental Health Commission, who directed that the incident should be addressed by a Mental Health Tribunal. His family and solicitor were not allowed to attend and were not consulted. The tribunal ruled that Hunt should be transferred to the Central Mental Hospital, Dundrum, the main forensic psychiatric facility in Ireland.
The Irish Health Service Executive has responded that it is the goal of the mental health services to “work in a collaborative way with patients and their families to ensure the best outcome possible for people who need mental health services”. They also stated that, “All patients detained under the Mental Health Act have access to independent legal advice. Their detention under the mental health act is reviewed at regular intervals by an independent mental health review tribunal. This tribunal has the power to end the patient’s detention”.
Prior to his transfer Humphreys stated that she and Hunt’s family were apprehensive about the plan to relocate him but that they remained hopeful that better rehabilitative services would be available to him in Dundrum than were accessible at Carraig Mór; she said Hunt was very worried about it but also it may be something new, though he was concerned he would never be released. John McCarthy, a mental health campaigner and the founder of Mad Pride Ireland, likened the facilities of John’s detention as a form of “jail” where patients were held with “no judge, jury or release date”.
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Frances Elena Farmer (19 September 1913 to 01 August 1970) was an American actress and television hostess. She appeared in over a dozen feature films over the course of her career, though she garnered notoriety for the various sensationalised accounts of her life, especially her involuntary commitment to psychiatric hospitals and subsequent mental health struggles.
A native of Seattle, Washington, Farmer began acting in stage productions while a student at the University of Washington. After graduating, she began performing in stock theatre before signing a film contract with Paramount Pictures on her 22nd birthday in September 1935. She made her film debut in the B film Too Many Parents (1936), followed by another B picture, Border Flight, before being given the lead role opposite Bing Crosby in the musical Western Rhythm on the Range (1936). Unhappy with the opportunities the studio gave her, Farmer returned to stock theatre in 1937 before being cast in the original Broadway production of Clifford Odets’s Golden Boy, staged by New York City’s Group Theatre. She followed this with two Broadway productions directed by Elia Kazan in 1939, but a battle with depression and binge drinking caused her to drop out of a subsequent Ernest Hemingway stage adaptation.
Farmer returned to Los Angeles, earning supporting roles in the comedy World Premiere (1941) and the film noir Among the Living (1941). In 1942, publicity of her reportedly erratic behaviour began to surface and, after several arrests and committals to psychiatric institutions, Farmer was diagnosed with paranoid schizophrenia. At the request of her family, particularly her mother, she was committed to an institution in her home state of Washington, where she remained a patient until 1950. Farmer attempted an acting comeback, mainly appearing as a television host in Indianapolis on her own series, Frances Farmer Presents. Her final film role was in the 1958 drama The Party Crashers, after which she spent the majority of the 1960s occasionally performing in local theatre productions staged by Purdue University. In the spring of 1970, she was diagnosed with oesophageal cancer, from which she died on 01 August 1970, aged 56.
Farmer has been the subject of various works, including two feature films and several books, many of which focus on her time spent institutionalised, during which she claimed to have been subject to various systemic abuses. Her posthumously released, ghostwritten, and widely discredited autobiography, Will There Really Be a Morning? (1972), details these claims, but has been exposed as a largely fictional work by a friend of Farmer’s to clear debts. Another discredited 1978 biography of her life, Shadowland, alleged that Farmer underwent a transorbital lobotomy during her institutionalisation, but the author has since stated in court that he fabricated this incident and several other aspects of the book. A 1982 biographical film based on this book depicted these events as true, resulting in renewed interest in her life and career.
Adam Phillips
Adam Phillips (born 19 September 1954) is a British psychoanalytic psychotherapist and essayist.
Since 2003 he has been the general editor of the new Penguin Modern Classics translations of Sigmund Freud. He is also a regular contributor to the London Review of Books.
Joan Acocella, writing in The New Yorker, described Phillips as “Britain’s foremost psychoanalytic writer”,[2] an opinion echoed by historian Élisabeth Roudinesco in Le Monde.
Thomas Stephen Szasz (15 April 1920 to 08 September 2012) was a Hungarian-American academic and psychiatrist.
Thomas Szasz, Psychiatrist.
He served for most of his career as professor of psychiatry at the State University of New York Upstate Medical University in Syracuse, New York. A distinguished lifetime fellow of the American Psychiatric Association and a life member of the American Psychoanalytic Association, he was best known as a social critic of the moral and scientific foundations of psychiatry, as what he saw as the social control aims of medicine in modern society, as well as scientism. His books The Myth of Mental Illness (1961) and The Manufacture of Madness (1970) set out some of the arguments most associated with him.
Szasz argued throughout his career that mental illness is a metaphor for human problems in living, and that mental illnesses are not “illnesses” in the sense that physical illnesses are, and that except for a few identifiable brain diseases, there are “neither biological or chemical tests nor biopsy or necropsy findings for verifying DSM diagnoses.”
Szasz maintained throughout his career that he was not anti-psychiatry but rather that he opposed coercive psychiatry. He was a staunch opponent of civil commitment and involuntary psychiatric treatment, but he believed in and practiced psychiatry and psychotherapy between consenting adults.
Life
Szasz was born to Jewish parents Gyula and Lily Szász on 15 April 1920, in Budapest, Hungary. In 1938, Szasz moved to the United States, where he attended the University of Cincinnati for his Bachelor of Science in physics, and received his M.D. from the same university in 1944. Szasz completed his residency requirement at the Cincinnati General Hospital, then worked at the Chicago Institute for Psychoanalysis from 1951-1956, and then for the next five years was a member of its staff – taking 24 months out for duty with the US Naval Reserve.
In 1962 Szasz received a tenured position in medicine at the State University of New York. Szasz had first joined SUNY in 1956.
Szasz had two daughters. His wife, Rosine, died in 1971. Szasz’s colleague Jeff Schaler described her death as a suicide.
Szasz’s views of psychiatry were influenced by the writings of Frigyes Karinthy.
Death
Thomas Szasz ended his own life on 08 September 2012. He had previously suffered a fall and would have had to live in chronic pain otherwise. Szasz argued for the right to suicide in his writings.
Rise of Szasz’s Arguments
Szasz first presented his attack on “mental illness” as a legal term in 1958 in the Columbia Law Review. In his article he argued that mental illness was no more a fact bearing on a suspect’s guilt than is possession by the devil.
In 1961 Szasz testified before a United States Senate Committee, arguing that using mental hospitals to incarcerate people defined as insane violated the general assumptions of the patient-doctor relationship, and turned the doctor into a warden and keeper of a prison.
Szasz’s Main Arguments
Szasz was convinced there was a metaphorical character to mental disorders, and its uses in psychiatry were frequently injurious. He set himself a task to delegitimise legitimating agencies and authorities, and what he saw as their vast powers, enforced by psychiatrists and other mental health professionals, mental health laws, mental health courts, and mental health sentences.
Szasz was a critic of the influence of modern medicine on society, which he considered to be the secularization of religion’s hold on humankind. Criticising scientism, he targeted psychiatry in particular, underscoring its campaigns against masturbation at the end of the 19th century, its use of medical imagery and language to describe misbehaviour, its reliance on involuntary mental hospitalisation to protect society, and the use of lobotomy and other interventions to treat psychosis. To sum up his description of the political influence of medicine in modern societies imbued by faith in science, he declared:
Since theocracy is the rule of God or its priests, and democracy the rule of the people or of the majority, pharmacracy is therefore the rule of medicine or of doctors.
Szasz consistently paid attention to the power of language in the establishment and maintenance of the social order, both in small interpersonal and in wider social, economic, and/or political spheres:
The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?… [the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed.
His main arguments can be summarised as follows:
“Myth of Mental Illness”
“Mental illness” is an expression, a metaphor that describes an offending, disturbing, shocking, or vexing conduct, action, or pattern of behavior, such as packaged under the wide-ranging term schizophrenia, as an “illness” or “disease”. Szasz wrote: “If you talk to God, you are praying; If God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; If you talk to the dead, you are a schizophrenic.”[13]: 85 He maintained that, while people behave and think in disturbing ways, and those ways may resemble a disease process (pain, deterioration, response to various interventions), this does not mean they actually have a disease. To Szasz, disease can only mean something people “have”, while behaviour is what people “do”. Diseases are “malfunctions of the human body, of the heart, the liver, the kidney, the brain” while “no behavior or misbehavior is a disease or can be a disease. That’s not what diseases are.” Szasz cited drapetomania as an example of a behaviour that many in society did not approve of, being labelled and widely cited as a disease. Likewise, women who did not bend to a man’s will were said to have hysteria. He thought that psychiatry actively obscures the difference between behaviour and disease in its quest to help or harm parties in conflicts. He maintained that, by calling people diseased, psychiatry attempts to deny them responsibility as moral agents in order to better control them.
In Szasz’s view, people who are said by themselves or others to have a mental illness can only have, at best, “problems in living”. Diagnoses of “mental illness” or “mental disorder” (the latter expression called by Szasz a “weasel term” for mental illness) are passed off as “scientific categories” but they remain merely judgments (judgements of disdain) to support certain uses of power by psychiatric authorities. In that line of thinking, schizophrenia becomes not the name of a disease entity but a judgement of extreme psychiatric and social disapprobation. Szasz called schizophrenia “the sacred symbol of psychiatry” because those so labelled have long provided and continue to provide justification for psychiatric theories, treatments, abuses, and reforms.
The figure of the psychotic or schizophrenic person to psychiatric experts and authorities, according to Szasz, is analogous with the figure of the heretic or blasphemer to theological experts and authorities. According to Szasz, to understand the metaphorical nature of the term “disease” in psychiatry, one must first understand its literal meaning in the rest of medicine. To be a true disease, the entity must first somehow be capable of being approached, measured, or tested in scientific fashion. Second, to be confirmed as a disease, a condition must demonstrate pathology at the cellular or molecular level.
A genuine disease must also be found on the autopsy table (not merely in the living person) and meet pathological definition instead of being voted into existence by members of the American Psychiatric Association. “Mental illnesses” are really problems in living. They are often “like a” disease, argued Szasz, which makes the medical metaphor understandable, but in no way validates it as an accurate description or explanation. Psychiatry is a pseudoscience that parodies medicine by using medical-sounding words invented especially over the last one hundred years. To be clear, heart break and heart attack, or spring fever and typhoid fever belong to two completely different logical categories, and treating one as the other constitutes a category error. Psychiatrists are the successors of “soul doctors”, priests who dealt and deal with the spiritual conundrums, dilemmas, and vexations – the “problems in living” – that have troubled people forever.
Psychiatry’s main methods are assessment, medication, conversation or rhetoric and incarceration. To the extent that psychiatry presents these problems as “medical diseases”, its methods as “medical treatments”, and its clients – especially involuntary – as medically ill patients, it embodies a lie and therefore constitutes a fundamental threat to freedom and dignity. Psychiatry, supported by the state through various Mental Health Acts, has become a modern secular state religion according to Szasz. It is a vastly elaborate social control system, using both brute force and subtle indoctrination, which disguises itself under the claims of being rational, systematic and therefore scientific.
“Patient” as Malingerer
According to Szasz, many people fake their presentation of mental illness, i.e., they are malingering. They do so for gain, for example, in order to escape a burden like evading the draft, or to gain access to drugs or financial support, or for some other personally meaningful reason. By definition, the malingerer is knowingly deceitful (although malingering itself has also been called a mental illness or disorder). Szasz mentions malingering in many of his works, but it is not what he has in mind to explain many other manifestations of so-called “mental illness”. In those cases, so-called “patients” have something personally significant to communicate – their “problems in living” – but unable to express this via conventional means they resort to illness-imitation behaviour, a somatic protolanguage or “body language”, which psychiatrists and psychologists have misguidedly interpreted as the signs/symptoms of real illness. So, for example:
“analyzing the origin of the hysterical protolanguage Szasz states that it has a double origin: – the first root is in the somatic structure of human being. The human body is subject to illnesses and disabilities expressed through somatic signs (like paralysis, convulsions, etc.) and somatic sensations (like pain, tiredness, etc.); – the second root can be found into cultural factors.”
Separation of Psychiatry and the State
Szasz believed that if we accept that “mental illness” is a euphemism for behaviours that are disapproved of, then the state has no right to force psychiatric “treatment” on these individuals. Similarly, the state should not be able to interfere in mental health practices between consenting adults (for example, by legally controlling the supply of psychotropic drugs or psychiatric medication). The medicalisation of government produces a “therapeutic state”, designating someone as, for example, “insane” or as a “drug addict”.
In Ceremonial Chemistry (1973), he argued that the same persecution that targeted witches, Jews, gypsies, and homosexuals now targets “drug addicts” and “insane” people. Szasz argued that all these categories of people were taken as scapegoats of the community in ritual ceremonies. To underscore this continuation of religion through medicine, he even takes as an example obesity: instead of concentrating on junk food (ill-nutrition), physicians denounced hypernutrition. According to Szasz, despite their scientific appearance, the diets imposed were a moral substitute to the former fasts, and the social injunction not to be overweight is to be considered as a moral order, not as a scientific advice as it claims to be. As with those thought bad (insane people), and those who took the wrong drugs (drug addicts), medicine created a category for those who had the wrong weight (obesity).
Szasz argued that psychiatrics were created in the 17th century to study and control those who erred from the medical norms of social behaviour; a new specialisation, drogophobia, was created in the 20th century to study and control those who erred from the medical norms of drug consumption; and then, in the 1960s, another specialisation, bariatrics (from the Greek βάρος baros, for “weight”), was created to deal with those who erred from the medical norms concerning the weight the body should have. Thus, he underscores that in 1970, the American Society of Bariatric Physicians had 30 members, and already 450 two years later.
Presumption of Competence and Death Control
Just as legal systems work on the presumption that a person is innocent until proven guilty, individuals accused of crimes should not be presumed incompetent simply because a doctor or psychiatrist labels them as such. Mental incompetence should be assessed like any other form of incompetence, i.e. by purely legal and judicial means with the right of representation and appeal by the accused.
In an analogy to birth control, Szasz argued that individuals should be able to choose when to die without interference from medicine or the state, just as they are able to choose when to conceive without outside interference. He considered suicide to be among the most fundamental rights, but he opposed state-sanctioned euthanasia.
In his 2006 book about Virginia Woolf he stated that she put an end to her life by a conscious and deliberate act, her suicide being an expression of her freedom of choice.
Abolition of the Insanity Defence and Involuntary Hospitalisation
Szasz believed that testimony about the mental competence of a defendant should not be admissible in trials. Psychiatrists testifying about the mental state of an accused person’s mind have about as much business as a priest testifying about the religious state of a person’s soul in our courts. Insanity (defence) was a legal tactic invented to circumvent the punishments of the Church, which at the time included confiscation of the property of those who committed suicide, often leaving widows and orphans destitute. Only an insane person would do such a thing to his widow and children, it was successfully argued. This is legal mercy masquerading as medicine, according to Szasz.
No one should be deprived of liberty unless he is found guilty of a criminal offense. Depriving a person of liberty for what is said to be his own good is immoral. Just as a person suffering from terminal cancer may refuse treatment, so should a person be able to refuse psychiatric treatment.
The Right to Drugs
Drug addiction is not a “disease” to be cured through legal drugs but a social habit. Szasz also argues in favour of a free market for drugs. He criticised the war on drugs, arguing that using drugs is in fact a victimless crime. Prohibition itself constituted the crime. He argued that the war on drugs leads states to do things that would have never been considered half a century before, such as prohibiting a person from ingesting certain substances or interfering in other countries to impede the production of certain plants, e.g. coca eradication plans, or the campaigns against opium; both are traditional plants opposed by the Western world. Although Szasz was sceptical about the merits of psychotropic medications, he favoured the repeal of drug prohibition.
Szasz also drew analogies between the persecution of the drug-using minority and the persecution of Jewish and homosexual minorities.
The Nazis spoke of having a “Jewish problem”. We now speak of having a drug-abuse problem. Actually, “Jewish problem” was the name the Germans gave to their persecution of the Jews; “drug-abuse problem” is the name we give to the persecution of people who use certain drugs.
Szasz cites former US Representative James M. Hanley’s reference to drug users as “vermin”, using:
“the same metaphor for condemning persons who use or sell illegal drugs that the Nazis used to justify murdering Jews by poison gas – namely, that the persecuted persons are not human beings, but ‘vermin.'”
Therapeutic State
The “Therapeutic State” is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the therapeutic state, a system in which disapproved actions, thoughts, and emotions are repressed (“cured”) through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that “we must guard against charges of nanny statism.” The “nanny state” has turned into the “therapeutic state” where nanny has given way to counsellor. Nanny just told people what to do; counsellors also tell them what to think and what to feel. The “nanny state” was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive – and even more authoritarian.
According to Szasz:
“the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion.”
Faced with the problem of “madness”, Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and non-members of the group from the temptation to worship false gods or goods. A secularization of God and the medicalization of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason – that is, madness.
Civil libertarians warn that the marriage of the state with psychiatry could have catastrophic consequences for civilisation. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the state.
American Association for the Abolition of Involuntary Mental Hospitalisation
Believing that psychiatric hospitals are like prisons not hospitals and that psychiatrists who subject others to coercion function as judges and jailers not physicians, Szasz made efforts to abolish involuntary psychiatric hospitalisation for over two decades, and in 1970 took a part in founding the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH). Its founding was announced by Szasz in 1971 in the American Journal of Psychiatry and American Journal of Public Health. The association provided legal help to psychiatric patients and published a journal, The Abolitionist.
Relationship to Citizens Commission on Human Rights
In 1969, Szasz and the Church of Scientology co-founded the Citizens Commission on Human Rights (CCHR) to oppose involuntary psychiatric treatments. Szasz served on CCHR’s Board of Advisors as Founding Commissioner. In the keynote address at the 25th anniversary of CCHR, Szasz stated:
“We should all honor CCHR because it is really the organization that for the first time in human history has organized a politically, socially, internationally significant voice to combat psychiatry. This has never been done in human history before.”
In a 2009 interview aired by the Australian Broadcasting Corporation, Szasz explained his reason for collaborating with CCHR and lack of involvement with Scientology:
Well I got affiliated with an organisation long after I was established as a critic of psychiatry, called Citizens Commission for Human Rights, because they were then the only organisation and they still are the only organisation who had money and had some access to lawyers and were active in trying to free mental patients who were incarcerated in mental hospitals with whom there was nothing wrong, who had committed no crimes, who wanted to get out of the hospital. And that to me was a very worthwhile cause; it’s still a very worthwhile cause. I no more believe in their religion or their beliefs than I believe in the beliefs of any other religion. I am an atheist, I don’t believe in Christianity, in Judaism, in Islam, in Buddhism and I don’t believe in Scientology. I have nothing to do with Scientology.
Responses and Reactions
Szasz was a strong critic of institutional psychiatry and his publications were very widely read. He argued that so-called mental illnesses had no underlying physiological basis, but were unwanted and unpleasant behaviours. Mental illness, he said, was only a metaphor that described problems that people faced in their daily lives, labelled as if they were medical diseases. Szasz’s ideas had little influence on mainstream psychiatry, but were supported by some behavioural and social scientists. Sociologist Erving Goffman, who wrote Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates, was sceptical about psychiatric practices. He was concerned that the stigma and social rejection associated with psychiatric treatment might harm people. Thomas Scheff, also a sociologist, had similar reservations.
Russell Tribunal
In the summer of 2001, Szasz took a part in a Russell Tribunal on Human rights in Psychiatry held in Berlin between 30 June and 02 July 2001. The tribunal brought in the two following verdicts: the majority verdict claimed that there was “serious abuse of human rights in psychiatry” and that psychiatry was “guilty of the combination of force and unaccountability”; the minority verdict, signed by the Israeli Law Professor Alon Harel and Brazilian novelist Paulo Coelho, called for “public critical examination of the role of psychiatry”.
Awards
Szasz was honoured with over fifty awards including:
American Humanist Association named him Humanist of the Year (1973).
Award for Greatest Public Service Benefiting the Disadvantaged, an award given out annually by Jefferson Awards (1974).
Martin Buber Award (1974).
He was honoured with an honorary doctorate in behavioural science at Universidad Francisco Marroquín (1979).
Humanist Laureate Award (1995).
Great Lake Association of Clinical Medicine Patients’ Rights Advocate Award (1995).
American Psychological Association Rollo May Award (1998).
Kendell’s Views
Robert Evan Kendell presents (in Schaler, 2005[39]) a critique of Szasz’s conception of disease and the contention that mental illness is “mythical” as presented in The Myth of Mental Illness. Kendell’s arguments include the following:
Szasz’s conception of disease exclusively in terms of “lesion”, i.e. morphological abnormality, is arbitrary and his conclusions based on this idea represent special pleading.
There are non-psychiatric conditions that remain defined solely in terms of syndrome, e.g. migraine, torticollis, essential tremor, blepharospasm, torsion dystonia.
Szasz’s scepticism regarding syndromally defined diseases – only in relation to psychiatry – is entirely arbitrary.
Many diseases that are outside the purview of psychiatry are defined purely in terms of the constellation of the symptoms, signs and natural history they present yet Szasz has not expressed any doubt regarding their existence.
Is syndrome-based diagnosis only problematic for psychiatry but without issue for the remaining branches of medicine?
If syndrome-based diagnosis is unsound on account of its absence of objectivity then it must be generally unsound and not only for psychiatry.
Szasz’s ostensibly exclusive criterion of disease as morphological abnormality – i.e. a lesion made evident “by post-mortem examination of organs and tissues” – is unsound because it inadvertently includes many conditions that are not considered to be diseases by virtue of the fact that they do not produce suffering or disability, e.g. functionally inconsequential chromosomal translocations and deletions, fused second and third toes, dextrocardia.
Szasz’s conception of disease does not distinguish between necessary versus sufficient conditions in relation to diagnostic criteria.
In branches of medicine other than psychiatry, morphological abnormality per se is not considered sufficient cause to make a diagnosis of disease; functional abnormality is the necessary condition.
Szasz’s criticism of syndrome-based diagnoses is divorced from a consideration of the history of medicine.
In medicine (in general) diseases are defined in terms of a multitude of criteria, these include: (a) morbid anatomy, e.g. mitral stenosis, cholecystitis; (b) histologically, e.g. most cancers, Alzheimer’s disease; (c) infective organism, e.g. Tuberculosis, Measles; (d) physiologically, e.g. myasthenia gravis; (e) biochemically, e.g. aminoaciduria; (e) chromosomally, e.g. trisomy 21, Turner’s syndrome; (f) molecularly, e.g. thalassemia; (g) genetically, e.g. Huntington’s disease, cystic fibrosis; and (h) syndrome, e.g. migraine, torticollis, essential tremor, blepharospasm, torsion dystonia and most (so-called) mental disorders.
The more objective definitions of disease – specified as (a) through (g) – became possible through the accumulation of scientific knowledge and the development of relevant technology.
Initially the underlying pathology of some diseases was unknown and they were diagnosed only in terms of syndrome – no lesion could be demonstrated “by post-mortem examination of organs and tissues” (as Szasz requires) until later in history, e.g. malaria was diagnosed solely on the basis of syndrome until the advent of microbiology.
A strict application of Szasz’s criterion necessitates the conclusion that diseases such as malaria were “mythical” until medical microbiology arrived, at which point they became “real”.
In this regard Szasz’s criterion of disease is unsound by virtue of its contradictory results.
Szasz’s contention that mental illness is not associated with any morphological abnormality is uninformed by genetics, biochemistry, and current research results on the aetiology of mental illness.
Genes are essentially instructions for the synthesis of proteins.
Hence, any condition that is even partly hereditary necessarily manifests structural abnormality at the molecular level.
Regardless of whether the actual morphological abnormality can be identified, if a condition has a hereditary component then it has a biological basis.
Twin and adoption studies have strongly demonstrated that heredity is a major factor in the aetiology of schizophrenia; thus there must be some biological difference between schizophrenics and non-schizophrenics.
These results in addition to twin and adoption studies provide evidence of an underlying molecular – hence structural – abnormality to depression.
Szasz contends that, “Strictly speaking, disease or illness can affect only the body; hence, there can be no mental illness” and this idea is foundational to Szasz’s position.
In actuality, there are no physical or mental illnesses per se; there are only diseases of organisms, of persons.
The bifurcation of organisms into minds and bodies is the product of the Cartesian dualism that became dominant in the late 18th century and it was at this time that the notion of insanity as something qualitatively different from other illnesses became entrenched.
In actuality, brain and body comprise one integrated and indivisible system and no illness “respects” the abstraction of mind vs. body upon which Szasz’s argument rests.
There are no illnesses that are purely mental or purely physical.
Somatic pain is itself a mental phenomenon as is the subjective distress produced by the acute phase response at the onset of illness or immediately after trauma.
Similarly, conditions such as schizophrenia and major depressive disorder produce somatic symptoms.
Any illness lies somewhere within a continuum between the poles of mind and body; the extrema are purely theoretical abstractions and are unoccupied by any real affliction.
The mind/body division persists purely for pragmatic reasons and forms no real part of modern biomedical science.
Shorter’s Views
Shorter replied to Szasz’s essay “The myth of mental illness: 50 years later”, which was published in the journal The Psychiatrist (and delivered as a plenary address at the International Congress of the Royal College of Psychiatrists in Edinburgh on 24 June 2010) – in recognition of the 50th anniversary of The Myth of Mental Illness – with the following principal criticisms:
Szasz’s critique is implicitly premised on a conception of mind drawn from the psychiatry of the early-mid 20th century – namely psychoanalytic psychiatry – and Szasz has not updated his critique in light of later developments in psychiatry.
The referent of Szasz’s critique – Freud’s mind – is to be found only in the historical record and some isolated islands of psychoanalytic practice.
To this extent, Szasz’s critique does not address contemporary biologically-oriented psychiatry and is irrelevant.
Certainly the phrase mental illness occurs in the contemporary psychiatric lexicon, but that is merely a legacy of the earlier psychoanalytic influence upon psychiatry; the term does not reflect a real belief that psychiatric disease – Shorter’s preferred term – originates in the mind, an abstraction as Szasz rightly explains.
Szasz concedes that some so-called mental illnesses may have a neurological basis – but adds that were such a biological basis discovered for these so-called mental illnesses, they would have to be reclassified from mental illnesses to brain diseases, which would vindicate his position.
Shorter explains that the problem with Szasz’s argument here is that it is the contention of biological psychiatry that so-called mental illnesses are actually brain diseases.
Modern psychiatry has de facto dispensed with the idea of mental illness, i.e. the notion that psychiatric disease is mainly or entirely psychogenic is not a part of biological psychiatry.
There exists at least prima facie evidence that psychiatric illness has a biological basis and Szasz either ignores this evidence or attempts to insulate his argument from such evidence by effectively claiming that “no true mental illness has a biological basis.”
Shorter cites hypothalamic-pituitary-adrenal axis (HPA) dysregulation, a positive dexamethasone suppression test result, and shortened rapid eye movement sleep latency in those with melancholic depression as examples of this evidence.
Further examples cited by Shorter include the responsiveness of catatonia to barbiturates and benzodiazepines.
Outpatient commitment – also termed assisted outpatient treatment (AOT) or community treatment orders (CTO) – refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to an outpatient treatment plan designed to prevent further deterioration or recurrence that is harmful to themselves or others.
This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, and the person’s mental health deteriorates. This generally means taking psychiatric medication as directed and may also include attending appointments with a mental health professional, and sometimes even not to take non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual.
The criteria and process for outpatient commitment are established by law, which vary among nations and, in the US and Canada, among states or provinces. Some jurisdictions require court hearings, where a judge will make a court order, and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted. When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.
Terminology
In the United States the term “assisted outpatient treatment” (AOT) is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well. Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT).
Australia, Canada, England, and New Zealand use the term “community treatment order” (CTO).
Comparison to Inpatient Commitment
The terminology, “outpatient commitment”, and legal construction often equate outpatient commitment with inpatient commitment but providing the patient more freedom. In practice, outpatient commitment may be used in situations where commitment would not be used because it is cheaper than inpatient commitment; seen as less draconian; and protects mental health professionals from moral, civil or criminal liability.
Preventive Use
Outpatient commitment is used in some countries to prevent relapse of mental disorders, as many mental disorders are episodic in natural (for example bipolar disorder or schizophrenia) and it can be difficult to predict whether a mental disorder with reoccur.
Some countries use outpatient commitment for first episode psychosis (FEP).
Implementation
Discussions of “outpatient commitment” began in the psychiatry community in the 1980s following deinstitutionalisation, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community.
Europe
Denmark
Denmark introduced outpatient commitment in 2010 with the Mental Health Act (Danish: Lov om anvendelse af tvang i psykiatrien).
Germany
In Germany, as of 2014, only former forensic psychiatry patients may be placed under community treatment orders. Legislation to allow for wider use of CTOs was considered in 2003-2004, but it was ultimately rejected by the Bundestag.
The Netherlands
As of 2014, Dutch law provides for community treatment orders, and an individual who does not comply with the terms of their CTO may be subject to immediate involuntary commitment.
Norway
When Norway introduced outpatient commitment in the 1961 Mental Health Act, it could only be mandated for individuals who had previously been admitted for inpatient treatment. Revisions in 1999 and 2006 provided for outpatient commitment without previous inpatient treatment, but this provision is seldom used.
Sweden
In Sweden, the Compulsory Psychiatric Care Act (Swedish: Lag om psykiatrisk tvångsvård) provides for an administrative court to mandate psychiatric treatment to prevent harm to the individual or others. The law was created in 1991 and revised in 2008.
England and Wales
Changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. The Mental Health Act 2007 introduced community treatment orders (CTOs). CTOs are legally defined as a form of outpatient leave for individuals detained under section 3 of the Mental Health Act. As such, only members of the medical community are involved in issuing a CTO, though both the section 3 detention underlying the CTO and the CTO itself can be appealed to the Mental Health Tribunal where a panel consisting of medical doctors and a judge will make a decision.
A review of patient data in London found that the average duration of a CTO in the UK was 3 years. Black people in the UK are more than ten times as likely to be under a CTO as white people.
The legislation in the UK specifically allows CTOs to be issued after a single admission to hospital for treatment. However, the Royal College of Psychiatrists suggested limiting CTOs to patients with a history of noncompliance and hospitalization, when it reviewed the current mental health legislation.
John Mayer Chamberlain argues that this legislation was triggered by the Killing of Jonathan Zito by an individual who had interactions with mental health services prior this event, which led the then conservative government to argue for CTOs.
In a 2021 paper reviewing the mental health act, the UK government proposed a new form of indefinite outpatient commitment allowing for deprivation of liberties an continuous supervision termed supervised discharge. This discharge would be reviewed yearly, and only apply to individuals who would not benefit from treatment in a hospital setting and would be based on risk. Further, this legislation would only apply to restricted patients who have been diverted to the mental health care system from courts.
Scotland
Scotland has a different community commitment regime from England and Wales introduced in the 2003 Mental Health Act. There is ongoing debate in the UK on the place of coercion and compulsion in community mental health care.
North America
In the last decade of the 20th century and the first of the 21st, “outpatient commitment” laws were passed in a number of US states and jurisdictions in Canada.
Canada
In the mid-1990s, Saskatchewan became the first Canadian province to implement community treatment orders, and Ontario followed in 2000. As of January 2016, New Brunswick was the only province without legislation that provided for either CTOs or extended leave.
United States
By the end of 2010, 44 US states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicised tragedies, such as the murders of Laura Wilcox and Kendra Webdale.
Oceania
Australia and New Zealand introduced community treatment orders in the 1980s and 1990s.
Australia
In Australia, community treatment orders last for a maximum of twelve months but can be renewed after review by a tribunal.
Evidence
A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomised trials had dramatically varying results and found that no randomised controlled trials showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.
The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.
Cost
Research published in 2013 showed that Kendra’s Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests. About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.
“Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized.”
Arrests, Danger, and Violence
The National Institute of Justice considers assisted outpatient treatment an effective crime prevention programme. Some studies in the US have found that AOT programmes have reduced the chances of arrest. Kendra’s Law has lowered risk of violent behaviours, reduced thoughts about suicide.
Outcomes and hospital admissions
AOT “programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior.”
“The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order…and by over one-third during a subsequent six-month renewal of the order…. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals…. Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.”
74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalisation. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager’s ability. 88% said they and their case manager agreed on what was important to work on.
In Nevada County, CA, AOT (“Laura’s Law“) decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura’s Law implementation saved $1.81-$2.52 for every dollar spent, and receiving services under Laura’s Law caused a “reduction in actual hospital costs of $213,300” and a “reduction in actual incarceration costs of $75,600.”
In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot programme performed “beyond wildest dreams.” AOT reduced hospitalisations, shortened inpatient stays, reduced crime and incarceration, stabilised housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.
Writing in the British Journal of Psychiatry in 2013, Jorun Rugkåsa and John Dawson stated:
“The current evidence from RCTs suggests that CTOs do not reduce readmission rates over 12 months.”
“We find that New York State’s AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients.”
“The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.”
Effect on Mental Illness System
Access to Services
“AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.”
“Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.”
“Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources. There is now an organized process to prioritize and monitor individuals with the greatest need; AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve; There is now increased collaboration between inpatient and community-based providers.”
In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.
“In all three regions, for all three groups, the predicted probability of an MPR ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and ‘neither treatment,’ improving 8–19 points). Some regional differences in MPR trajectories were observed.”
“In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.”
“It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.”
Race
“We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.”
“We found no evidence of racial bias. Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity.”
Service Engagement
“After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.”
Consumers approve. Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.
“When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services.”
In Los Angeles, CA, the AOT pilot programme reduced incarceration 78%, hospitalisation 86%, hospitalisation after discharge from the programme 77%, and cut taxpayer costs 40%.
In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.
In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. “During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment.”
In Arizona, “71% [of AOT patients] … voluntarily maintained treatment contacts six months after their orders expired” compared with “almost no patients” who were not court-ordered to outpatient treatment.
In Iowa, “it appears as though outpatient commitment promotes treatment compliance in about 80% of patients… After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis.”
Controversy
Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, lowers incidence of homelessness, arrest, incarceration and hospitalisation and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, or are applied with racial and socioeconomic biases.
Proponents
While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and “revolving door patients” who experience a cycle of hospitalisation, treatment and stabilisation, release, and decompensation. While the cost of repeated hospitalisations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment. Proponents include: Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Justice, Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices. Crime Solutions: Management Strategies to Reduce Psychiatric Readmissions. The Treatment Advocacy Centre are an advocacy group that campaign for the use of outpatient commitment.
Opponents
Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied.
The opponents claim they are giving medication to the patient, but there are no brain chemical imbalances to correct in “mental illness”. Our ability to control ourselves and reason comes from the mind, and the brain is being reduced in size from the psychiatric medications.
The slippery slope argument of “If government bodies are given power, they will use it in excess.” was proven when 350–450 CTOs were expected to be issued in 2008 and more than five times that number were issued in the first few months. Every year there are increasing numbers of people subject to CTO’s.
The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders. The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.
A psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.
It can inform others about what treatment they want or do not want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of advance health care directive.
Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental health treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney (HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions.
In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents. In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes – expanding the audience for PADs to all 50 states (refer to National Resource Centre on Psychiatric Advance Directives).
In addition, states are beginning to recognise legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and – with certain caveats – that clinicians are obliged to follow these directives.
Finally, the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO) requires behavioural health facilities to ask patients if they have PADs. The Centres for Medicare and Medicaid Services announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare and Medicaid revenue.
Proponents of these directives believe thy of followed by treatment providers, crisis planning using PADs will help involuntary detainees retain control over their decision making – especially during times when they are labelled incompetent. Additionally, advocates argue that health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.
Clinical Benefits
Recent data from a NIH-funded study conducted by researchers at Duke University has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labelled with severe mental illness.
Moreover, PADs provide a transportable document – increasingly accessible through electronic directories – to convey information about a detainee’s treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labelled as psychiatric patients who present or are coercively presented and labelled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making – appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy.
For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy and social welfare for detainees labelled with mental illness. Since PADs are among the first laws that are specifically intended to promote autonomy among people detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.
Barriers
National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD.
Some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, scepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarised, and filing the documents in a medical record or registry may pose a formidable barrier.
Recent studies of practitioners of coercive psychiatry’s attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.
In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care. Further, the more clinicians knew about PAD laws, the more favourable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labelled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.
However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.
Resources
It thus has become clear that the potential significance of PADs is becoming widely recognized among those targeted for coercive psychiatry, survivors of coercive psychiatry, influential policy makers, clinicians, family members, and patient advocacy groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.
As a result, in the United States, a collaboration between the Bazelon Centre for Mental Health Law and Duke University has led to creation of the MacArthur Foundation-funded National Resource Center on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centred crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.
Voluntary commitment is the act or practice of choosing to admit oneself to a psychiatric hospital, or other mental health facility.
Overview
Unlike in involuntary commitment, the person is free to leave the hospital against medical advice, though there may be a requirement of a period of notice or that the leaving take place during daylight hours. In some jurisdictions, a distinction is drawn between formal and informal voluntary commitment, and this may have an effect on how much notice the individual must give before leaving the hospital. This period may be used for the hospital to use involuntary commitment procedures against the patient. People with mental illness can write psychiatric advance directives in which they can, in advance, consent to voluntary admission to a hospital and thus avoid involuntary commitment.
In the UK, people who are admitted to hospital voluntarily are referred to either as voluntary patients or informal patients. These people are free to discharge against medical advice, unless it is felt that they are at immediate risk, then a doctor can use mental health law to hold people in the hospital for up to 72 hours. People who are detained by mental health law are referred to as formal patients.
In Europe, the treatment of mental illness became a health policy priority under the impetus of the World Health Organisation (WHO) Mental Health Plan for Europe elaborated in 2005. This plan promoted a more effective balance between inpatient hospital care and outpatient care through the development of community mental healthcare services. Since the 1970s, the majority of European countries have shifted away from institutionalised care in large mental hospitals to the integration of patients in their living environment through the provision of home and community care services. Germany, England, France and Italy deinstitutionalised psychiatric care in the second half of the 20th century, but the speed and methods by which it was implemented varied, notably due to differences in social and political contexts. In Italy, the reform movement took place a little later. Until the 1968 Mariotti Law introducing voluntary internment, admission into a psychiatric hospital was only by compulsory commitment and was entered in an individual’s criminal records.
Involuntary commitment, civil commitment, or involuntary hospitalisation (also known informally as sectioning or being sectioned in some jurisdictions, such as the UK) is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.
Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalisation, during which an individual with acute psychiatric symptoms is confined for a relatively short duration (e.g. 72 hours) in a treatment facility for evaluation and stabilisation by mental health professionals who may then determine whether further civil commitment is appropriate or necessary. Civil commitment procedures may take place in a court or only involve physicians. If commitment does not involve a court there is normally an appeal process that does involve the judiciary in some capacity, though potentially through a specialist court.
Historically, until the mid-1960s in most jurisdictions in the US, all committals to public psychiatric facilities and most committals to private ones were involuntary. Since then, there have been alternating trends towards the abolition or substantial reduction of involuntary commitment, a trend known as “deinstitutionalisation”. In many currents, individuals can voluntarily admit themselves to a mental health hospital and may have more rights than those who are involuntarily committed. This practice is referred to as voluntary commitment.
In the United States, an indefinite form of commitment is applied to people convicted of some sexual offences.
Purpose
For most jurisdictions, involuntary commitment is applied to individuals believed to be experiencing a mental illness that impairs their ability to reason to such an extent that the agents of the law, state, or courts determine that decisions will be made for the individual under a legal framework. In some jurisdictions, this is a proceeding distinct from being found incompetent. Involuntary commitment is used in some degree for each of the following although different jurisdictions have different criteria. Some jurisdictions limit involuntary treatment to individuals who meet statutory criteria for presenting a danger to self or others. Other jurisdictions have broader criteria. The legal process by which commitment takes place varies between jurisdictions. Some jurisdictions have a formal court hearing where testimony and other evidence may also be submitted where subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. Other jurisdictions have delegated these power to physicians, though may provide an appeal process that involves the judiciary but may also involve physicians. For example in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative.
First Aid
Training is gradually becoming available in mental health first aid to equip community members such as teachers, school administrators, police officers, and medical workers with training in recognising, and authority in managing, situations where involuntary evaluations of behaviour are applicable under law. The extension of first aid training to cover mental health problems and crises is a quite recent development. A mental health first aid training course was developed in Australia in 2001 and has been found to improve assistance provided to persons with an alleged mental illness or mental health crisis. This form of training has now spread to a number of other countries (Canada, Finland, Hong Kong, Ireland, Singapore, Scotland, England, Wales, and the United States). Mental health triage may be used in an emergency room to make a determination about potential risk and apply treatment protocols.
Observation
Observation is sometimes used to determine whether a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person should be committed.
Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, Russia, Taiwan, Ontario (Canada), and the United States have adopted commitment criteria based on the presumed danger of the defendant to self or to others.
People with suicidal thoughts may act on these impulses and harm or kill themselves.
People with psychosis are occasionally driven by their delusions or hallucinations to harm themselves or others. Research has found that those who suffer from schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public. However, because other confounding factors such as childhood adversity and poverty are correlated with both schizophrenia and violence it can be difficult to determine whether this effect is due to schizophrenia or other factors. In an attempt to avoid these confounding factors, researchers have tried comparing the rates of violence amongst people diagnosed with schizophrenia to their siblings in a similar manner to twin studies. In these studies people with schizophrenia are found to be between 1.3 and 1.8 times more likely to engage in violent behaviour.
People with certain types of personality disorders can occasionally present a danger to themselves or others.
This concern has found expression in the standards for involuntary commitment in every US state and in other countries as the danger to self or others standard, sometimes supplemented by the requirement that the danger be imminent. In some jurisdictions, the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as “gravely disabled”.
Starting in the 1960s, there has been a worldwide trend toward moving psychiatric patients from hospital settings to less restricting settings in the community, a shift known as deinstitutionalisation. Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalisation has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. In some jurisdictions, laws authorising court-ordered outpatient treatment have been passed in an effort to compel individuals with chronic, untreated severe mental illness to take psychiatric medication while living outside the hospital (e.g. Laura’s Law and Kendra’s Law).
Before the 1960s deinstitutionalisation there were earlier efforts to free psychiatric patients. Philippe Pinel (1745-1826) ordered the removal of chains from patients.
In a study of 269 patients from Vermont State Hospital done by Courtenay M. Harding and associates, about two-thirds of the ex-patients did well after deinstitutionalisation.
Around the World
France
In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, and, in 1839, he opened the first school for the intellectually disabled. His method of treatment was based on the idea that the intellectually disabled did not suffer from disease.
United Kingdom
In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many ‘pauper lunatics’. Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.
The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents – the Medico-Psychological Association – was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841.
At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalisation was soon disappointed. Psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums kept on growing. Asylums were quickly becoming almost indistinguishable from custodial institutions, and the reputation of psychiatry in the medical world had hit an extreme low.
United States
In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.
In the United States and most other developed societies, severe restrictions have been placed on the circumstances under which a person may be committed or treated against their will as such actions have been ruled by the United States Supreme Court and other national legislative bodies as a violation of civil rights and/or human rights (e.g. O’Connor v. Donaldson). Thus a person is rarely committed against their will and it is illegal for a person to be committed for an indefinite period of time.
United Nations
United Nations General Assembly Resolution 46/119, “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care“, is a non-binding resolution advocating certain broadly drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programmes in some countries to assist in this process.
Criticism
The dangers of institutions were chronicled and criticized by reformers almost since their foundation. Charles Dickens was an outspoken and high-profile early critic, and several of his novels, in particular Oliver Twist and Hard Times demonstrate his insight into the damage that institutions can do to human beings.
Enoch Powell, when Minister for Health in the early 1960s, was a later opponent who was appalled by what he witnessed on his visits to the asylums, and his famous “water tower” speech in 1961 called for the closure of all NHS asylums and their replacement by wards in general hospitals:
“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defenses which we have to storm.”
Scandal after scandal followed, with many high-profile public inquiries. These involved the exposure of abuses such as unscientific surgical techniques such as lobotomy and the widespread neglect and abuse of vulnerable patients in the US and Europe. The growing anti-psychiatry movement in the 1960s and 1970s led in Italy to the first successful legislative challenge to the authority of the mental institutions, culminating in their closure.
During the 1970s and 1990s the hospital population started to fall rapidly, mainly because of the deaths of long-term inmates. Significant efforts were made to re-house large numbers of former residents in a variety of suitable or otherwise alternative accommodation. The first 1,000+ bed hospital to close was Darenth Park Hospital in Kent, swiftly followed by many more across the UK. The haste of these closures, driven by the Conservative governments led by Margaret Thatcher and John Major, led to considerable criticism in the press, as some individuals slipped through the net into homelessness or were discharged to poor quality private sector mini-institutions.
Wrongful Involuntary Commitment
Mental health professionals have, on occasion, wrongfully deemed individuals to have symptoms of a mental disorder, and thereby commit the individual for treatment in a psychiatric hospital. Claims of wrongful commitment are a common theme in the anti-psychiatry movement.
In 1860, the case of Elizabeth Packard, who was wrongfully committed that year and filed a lawsuit and won thereafter, highlighted the issue of wrongful involuntary commitment. In 1887, investigative journalist Nellie Bly went undercover at an asylum in New York City to expose the terrible conditions that mental patients at the time had to deal with. She published her findings and experiences as articles in New York World, and later made the articles into one book called Ten Days in a Mad-House.
In the first half of the twentieth century there were a few high-profile cases of wrongful commitment based on racism or punishment for political dissenters. In the former Soviet Union, psychiatric hospitals were used as prisons to isolate political prisoners from the rest of society. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals. Stoppard was inspired by a meeting with a Russian exile. In 1927, after the execution of Sacco and Vanzetti in the United States, demonstrator Aurora D’Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists. Throughout the 1940s and 1950s in Canada, 20,000 Canadian children, called the Duplessis orphans, were wrongfully certified as being mentally ill and as a result were wrongfully committed to psychiatric institutions where they were forced to take psychiatric medication that they did not need, and were abused. They were named after Maurice Duplessis, the premier of Quebec at the time, who deliberately committed these children to in order to misappropriate additional subsidies from the federal government. Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. In 1958, black pastor and activist Clennon Washington King Jr. tried enrolling at the University of Mississippi, which at the time was white, for summer classes; the local police secretly arrested and involuntarily committed him to a mental hospital for 12 days.
Patients are able to sue if they believe that they have been wrongfully committed. In one instance, Junius Wilson, an African American man, was committed to Cherry Hospital in Goldsboro, North Carolina in 1925 for an alleged crime without a trial or conviction. He was castrated. He continued to be held at Cherry Hospital for the next 67 years of his life. It turned out he was deaf rather than mentally ill.
In many American states sex offenders who have completed a period of incarceration can be civilly committed to a mental institution based on a finding of dangerousness due to a mental disorder. Although the United States Supreme Court determined that this practice does not constitute double jeopardy, organisations such as the American Psychiatric Association (APA) strongly oppose the practice. The Task Force on Sexually Dangerous Offenders, a component of APA’s Council on Psychiatry and Law, reported that “in the opinion of the task force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry, particularly with regard to defining mental illness and the clinical conditions for compulsory treatment. Moreover, by bending civil commitment to serve essentially non-medical purposes, statutes threaten to undermine the legitimacy of the medical model of commitment.”
O’Connor v. Donaldson, 422 U.S. 563 (1975), was a landmark decision of the US Supreme Court in mental health law ruling that a state cannot constitutionally confine a non-dangerous individual who is capable of surviving safely in freedom by themselves or with the help of willing and responsible family members or friends.
Since the trial court jury found, upon ample evidence, that petitioner did so confine respondent, the Supreme Court upheld the trial court’s conclusion that petitioner had violated respondent’s right to liberty.
Kenneth Donaldson (confined patient) had been held for 15 years in Florida State Hospital at Chattahoochee, due to needs of “care, maintenance, and treatment.” He filed a lawsuit against the hospital and staff members claiming they had robbed him of his constitutional rights, by confining him against his will. Donaldson won his case (including monetary damages) in United States District Court, which was affirmed by the United States Court of Appeals for the Fifth Circuit. In 1975, the United States Supreme Court agreed that Donaldson had been improperly confined but vacated the award of damages. On remand, the Fifth Circuit ordered that a new trial on damages be held.
A finding of “mental illness” alone cannot justify a State’s locking a person up against his will and keeping him indefinitely in simple custodial confinement. Assuming that that term can be given a reasonably precise content and that the “mentally ill” can be identified with reasonable accuracy, there is still no constitutional basis for confining such persons involuntarily if they are dangerous to no one and can live safely in freedom.
May the State confine the mentally ill merely to ensure them a living standard superior to that they enjoy in the private community? That the State has a proper interest in providing care and assistance to the unfortunate goes without saying. But the mere presence of mental illness does not disqualify a person from preferring his home to the comforts of an institution. Moreover, while the State may arguably confine a person to save him from harm, incarceration is rarely if ever a necessary condition for raising the living standards of those capable of surviving safely in freedom, on their own or with the help of family or friends. May the State fence in the harmless mentally ill solely to save its citizens from exposure to those whose ways are different? One might as well ask if the State, to avoid public unease, could incarcerate all who are physically unattractive or socially eccentric. Mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty. In short, a State cannot constitutionally confine without more a non-dangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.
Kenneth Donaldson
The origins of Donaldson’s institutionalisation began in 1943, at age 34, when he suffered a traumatic episode. He was hospitalized and received treatment, before resuming life with his family.
In 1956 Donaldson travelled to Florida to visit his elderly parents. While there, Donaldson reported that he believed one of his neighbours in Philadelphia might be poisoning his food. His father, worried that his son suffered from paranoid delusions, petitioned the court for a sanity hearing. Donaldson was evaluated, diagnosed with “paranoid schizophrenia,” and civilly committed to the Florida State mental health system. At his commitment trial, Donaldson did not have legal counsel present to represent his case. Once he entered the Florida hospital, Donaldson was placed with dangerous criminals, even though he had never been proved to be dangerous to himself or others. His ward was understaffed, with only one doctor (who happened to be an obstetrician) for over 1,000 male patients. There were no psychiatrists or counsellors, and the only nurse on site worked in the infirmary.
He spent 15 years as a patient; he did not receive any treatment, actively refusing it, and attempting to secure his release. Throughout his stay he denied he was ever mentally ill, and refused to be put into a halfway house.
Donaldson later wrote a book about his experience as a mental patient titled Insanity Inside Out.
The obligatory dangerousness criterion is a principle present in the mental health law of many developed countries. It mandates evidence of dangerousness to oneself or to others before involuntary treatment for mental illness. The term “dangerousness” refers to one’s ability to hurt oneself or others physically or mentally within an imminent time frame, and the harm caused must have a long-term effect on the person(s).
Psychiatric hospitals and involuntary commitment have been around for hundreds and even thousands of years around the world, but the obligatory dangerousness criterion was created in the United States in the 1900s. The criterion is a controversial topic, with opponents claiming that it is unethical and potentially harmful. Supporters claim that the criterion is necessary to protect the mentally ill and those impacted by their involuntary treatment.
Background
If a court determines that a person may cause long-term harm to themselves or others, then the person can be hospitalised or be required to outpatient treatment and treated involuntarily. In order to be released, the court must determine whether the person is no longer dangerous. The length of time that a person is involuntarily hospitalised varies and is determined by the state.
An obligatory dangerousness criterion has two main parts:
First is the Latin phrase parens patriae, which translates to “parent of his or her nation,” which “assigns to the government a responsibility to intervene on behalf of citizens who cannot act in their own best interest”.
The second part “requires a state to protect the interests of its citizens,” meaning that the government must do what it can to care for greater society, which may involve limiting one individual’s rights to avoid harming the greater society.
Brief History
Psychiatric asylums and guardianship over the mentally ill have been present for centuries. In Greece, individuals, such as Hippocrates, believed that those with mental illnesses should be separated from others and maintained within a safe, healthy environment. Ancient Rome allowed guardianship over mentally ill individuals. In the US, psychiatric hospitals were not established until the late 18th and early 19th centuries. Before their establishment, individuals suffering with mental illnesses were imprisoned or kept from society. After their establishment, anyone could be admitted to a psychiatric hospital if a family member brought them and a physician agreed to provide a treatment. Individuals could be at the hospital indefinitely until a court ruled they could be released.
An obligatory dangerousness criterion was officially established in the United States in 1964 by the Ervin Act in Washington DC. It provided a more lenient interpretation of “dangerousness” as well as alternatives to involuntary hospitalisation. It is meant to protect individuals with mental health disorders on the basis of parens patria. In order to be involuntary hospitalised under the obligatory dangerousness criterion, one must have a mental illness, and most states also require that the individual is in need of medical treatment for the illness.
In 1964, Washington D.C. established that an individual may only be involuntarily hospitalised if the individual has a mental illness, may be threat to others or their self in the near future, or is unable to survive on their own. States followed suit and began implementing a dangerousness criteria, as well. In the 1975 Supreme Court case, O’Connor v. Donaldson, the Supreme Court ruled that the individual must have a mental illness, pose a known threat to the safety of their self or others, be unable to care for themselves, or need psychiatric care. States adjusted their rules so that a patient’s involuntary hospitalisation would be re-evaluated over the span of a short period of time, ranging from two days to two weeks before a patient could have a court hearing to potentially be released.
Controversy
The obligatory dangerousness criterion is controversial. Supporters claim that the criterion is necessary in order to ensure that those who are in vital need of psychiatric care will receive it, and to prevent the mentally ill individual from potentially harming themselves or others. They also note that mental health disorders can impair one’s judgement, for example, if an individual with depression does not think that they need help. They argue that psychiatric care often involves some form of hospitalisation or treatment, and as a result, “involuntary hospitalization, or civil commitment, has been a mainstay of psychiatric care” since the field first began. Some individuals who have been involuntarily hospitalised perceived their experience to be beneficial and fair. Lastly, they also note how many states require that the least invasive measures be taken before involuntary hospitalisation is considered.
Its opponents claim that an obligatory dangerousness criterion is unethical. Some believe it denies the individual of consent, is discriminatory based on mental health, and may increase the patient’s risk of suicide, psychotic symptoms, or other harmful behaviours. They worry an obligatory dangerousness criterion might lead individuals without a serious mental illness to be involuntarily hospitalised, or that individuals without a serious mental illness will be involuntarily hospitalised as a “preventative” means. Those who oppose an obligatory dangerousness criterion also argue that there are less restrictive alternatives to involuntary hospitalisation that can help those with a mental illness.
Emergency psychiatry is the clinical application of psychiatry in emergency settings.
Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behaviour. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work. The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving emergency psychiatry is complex.
Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilisation of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions.
Definition
Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behaviour. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician’s or a nurse’s ability to identify and intervene with these and other medical conditions is critical.
Delivery of Services
The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centres, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine, nursing, psychology, and social work in these settings alongside psychiatrists and emergency physicians. The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week.
Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalisation for the patient, and to treat those patients whose symptoms can be improved within that brief period of time. Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency services are to assess patients’ problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilise teams to carry out interventions at patients’ residences, utilise emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counselling.
Brief History
Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalisation both in Europe and the United States. Deinstitutionalisation, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas.
Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. The individualised care needed for patients utilising psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach.
Scope
Suicide Attempts and Suicidal Thoughts
As of 2000, the World Health Organisation (WHO) estimated one million suicides in the world each year. There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of completed suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.
Violent Behaviour
Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behaviour. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.
Psychosis
Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient suffering from a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan.
An individual could also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention. The lack of identification and treatment can result in suicide, homicide, or other violence.
Substance Dependence, Abuse and Intoxication
Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterised by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short term memory loss which could result in behavioural change causing injury or death, levels of alcohol below 60 milligrams per decilitre of blood are usually considered non-lethal. However, individuals at 200 milligrams per decilitre of blood are considered grossly intoxicated and concentration levels at 400 milligrams per decilitre of blood are lethal, causing complete anaesthesia of the respiratory system.
Beyond the dangerous behavioural changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms.
Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centres, or hospitals. Both the immediate and long term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse.
Hazardous Drug Reactions and Interactions
Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone. Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring.
Personality Disorders
Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and impulse control can be considered personality disorders. Patients suffering from a personality disorder will usually not complain about symptoms resulting from their disorder. Patients suffering an emergency phase of a personality disorder may showcase combative or suspicious behaviour, suffer from brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals suffering from personality disorders in inpatient psychiatric settings is usually 7-25% higher. Clinicians working with such patients attempt to stabilise the individual to their baseline level of function.
Anxiety
Patients suffering from an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalised anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a “safe harbour” for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients suffering from anxiety disorders have a higher risk of premature death.
Disasters
Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria.
Due to the typically disorganised and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may suffer from both chronic or acute post-traumatic stress disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilise the individual.
Abuse
Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable.
Treatment
Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilise life-threatening conditions. Once stabilised, patients suffering chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation. Prescribed treatments within the emergency service setting vary dependent upon the patient’s condition. Different forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency setting. The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilisation of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication.
Medications
With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication. A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. Medication can also be administered through intramuscular injection, or through intravenous injection.
The amount of time required for absorption varies dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood-brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly. Antipsychotics, especially Haloperidol, as well as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation.
Psychotherapy
Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realising psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place their problem in the proper perspective. If the physician determines that deeper psychotherapy sessions are required, they can transition the patient out of the emergency setting and into an appropriate clinic or centre.
ECT
Electroconvulsive therapy (ECT) is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting themselves or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur.
Observation and Collateral Information
There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient’s behaviour is an important aspect of emergency psychiatry inasmuch as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one’s basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behaviour in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed.
Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behaviour can be confirmed or disproven.
Disposition
Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry.
Hospital Admission
The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible.
Involuntary Commitment
Involuntary commitment, or sectioning, refers to situations where police officers, health officers, or health professionals classify an individual as dangerous to themselves, others, gravely disabled, or mentally ill according to the applicable government law for the region. After an individual is transported to a psychiatric emergency service setting, a preliminary professional assessment is completed which may or may not result in involuntary treatment. Some patients may be discharged shortly after being brought to psychiatric emergency services while others will require longer observation and the need for continued involuntary commitment will exist. While some patients may initially come voluntarily, it may be realised that they pose a risk to themselves or others and involuntary commitment may be initiated at that point.
Referrals and Voluntary Hospitalisation
In some locations, such as the United States, voluntary hospitalisations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalisation unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centres. Therefore, patients who are not admitted will be referred to services in the community.
Mental Health Matters 
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