Mental illness is fairly unique in that laws allow for treatment to be imposed involuntarily. I’m not against involuntary psychiatric treatment entirely, and it can play an important role, but there are some things that can and should be done better.
When involuntary treatment is necessary
Working as a nurse in community mental health, there were plenty of times when I was involved in sending people to hospital involuntarily. They were just too ill to keep in the community, whether that be because of suicidality or severe psychosis or what have you. I had a pretty high threshold for what I considered too ill to manage in the community, and the doctors I worked with were the same, so I don’t think we were overdoing that.
Three of my four hospitalizations were involuntary. For the first and fourth, I don’t dispute that I needed to be involuntary, although I certainly wasn’t happy about it. For my third hospital stay, my doctor and I had agreed that I would go in voluntarily. When I got there, they committed me and locked me in seclusion. Immediately, I requested a review panel to contest it, and the whole time I was there, it was really adversarial. I came out not doing any better than when I went in. I’m very independent, and my reaction when my autonomy is taken away is to fight back however I can.
There’s somewhat of a philosophical debate within the mental health care world about having open vs. locked units. The inpatient unit I worked on for the first five years of my career was an open, unlocked unit. That’s all well and good in theory, but when you’re forcing people to be there involuntarily but at the same time making it easy to walk away, that’s a bit of a contradiction. And sending police to haul people back into hospital seemed all very unnecessary and traumatizing, especially when it involved the same patient repeatedly. The police sometimes got pretty annoyed with us, understandably so.
My first hospital stay, other than my time in psych ICU, was on an open unit. The other three were locked units. Whether or not the door was locked really didn’t make that much of a difference in how I felt about being there, other than it would have been easier to AWOL, and therefore more likely that I would have, had the units not been locked.
What I found far more frustrating and dehumanizing than locked doors while in hospital was the many arbitrary rules and restrictions. Sure, some are necessary for safety. But within the confines of what’s necessary for safety, I firmly believe that the treatment team should be going out of their way to promote as much autonomy as possible. Treating people like children and refusing reasonable requests simply because they’re against the unreasonable rules is not helpful. What’s worse is when staff get annoyed at patients for daring to ask for something that doesn’t fit within the arbitrary rules, and give no thought to how they themselves might feel to be treated with scorn for making a reasonable request.
I’ve seen this as both nurse and patient, and I can’t stand it. Restrictions should be for safety or otherwise somehow therapeutic. They should not be put in place to establish a power hierarchy and force conformity to whatever “proper patient” stereotype the staff have constructed.
Community treatment orders
Exactly what involuntary treatment in the community looks like will vary depending on local laws. Where I am, it’s called “extended leave” under the Mental Health Act, meaning someone is released from hospital under extended leave with conditions to follow. Typically, that’s seeing the treatment team and taking meds. If people don’t follow the conditions, or if they start to get really sick, they can be “recalled” back to hospital.
Often, people on extended leave were on long-acting injectable antipsychotics. If someone missed an injection, they could be recalled to hospital. That often meant the police (or the police/nurse mental health car) would track the person down, haul them into ER to get their injection, and then they’d be released. The team I worked at was pretty proactive about doing outreach to track people down rather than recalling them, but I don’t think that was the case at other teams.
I don’t have a problem with making sure someone gets their meds, but the whole police-hospital shebang seems unnecessarily traumatizing. There’s got to be a better way.
Concurrent disorders, co-occurring disorders, dual diagnosis… whatever you want to call it, this is people who have a substance use disorder as well as some other form of mental illness. My job, although I haven’t worked in a year, is at a concurrent disorders transitional program. Clients arrive there from one of two concurrent disorders treatment programs.
The treatment facility is a designated facility under the Mental Health Act, which means they’re able to provide treatment involuntarily as a designated hospital would. Often, clients would end up being sent there involuntarily because their concurrent disorders made them very difficult to manage in the community.
The hope with involuntary treatment, in that case, is that if you force some clean time on people and get whatever else is going on treated and under control, they’ll develop some desire to stay clean, and recovery can progress from there. They may be kept involuntary during their nine months or so at the treatment centre, and then they may be discharged on extended leave to the transitional program.
All of this involuntariness is one thing if it helps. But that “if” is pretty iffy. And the longer it’s drawn out, the iffier it is. It’s awfully hard to treat an addiction without a decent level of buy-in from the patient and even a smidge of intrinsic motivation. I can absolutely see it taking a few months to get people well enough to be in a position to actually make a decision about what they want. Beyond that, though, I’m not convinced, especially when clients are expressing that they have no interest in being clean.
I’m not sure how this would compare to court-mandated treatment, but I would guess that mental health legislation isn’t as compelling a motivator as the courts.
Can the system do better?
I do think there’s a role for involuntary psychiatric treatment. What I would really like to see, though, is mental health care providers seriously considering how they might feel if they, or a loved one, were in the position of an involuntary patient. That us vs. them gulf is often a wide one, and I think everyone would benefit by narrowing it.
If inpatient care was better and more respectful, then it would be easier for people to make the decision to seek out treatment voluntarily, making involuntary care less necessary.
What are your thoughts on involuntary treatment? Is it something you’ve experienced?
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