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PRO
E. Fuller Torrey, MD
- President, Treatment
Advocacy Center, Arlington, Virginia
- Professor of Psychiatry,
Uniformed Services, University of Health Sciences, Bethesda, Maryland
- Executive Director, Stanley
Foundation Research Programs, Bethesda, Maryland
There
are scientific, humane, public protection, and practical reasons why the
involuntary treatment of individuals with severe mental illness (SMI) is
sometimes necessary. Scientifically, it has been shown in many recent
studies that 40% to 50% of individuals with schizophrenia and bipolar
disorder have an impaired awareness of their illness (also called impaired
insight).1 Their illness has impaired the function of the prefrontal
cortex, which is the part of the brain that is used for self-reflection and
to appreciate one's own needs. Thus, many people with SMI are similar to
individuals who have suffered strokes that have impaired their
self-awareness (e.g., denial that one leg is paralyzed) or individuals in
the early stages of Alzheimer's disease.
On
humane grounds, the failure to treat such individuals often leads to
homelessness or incarceration on misdemeanor charges. The streets, public
shelters, and jails are overflowing with such individuals. On humane grounds
alone, is it fair to leave those who are not aware of their own illness
living in the streets and eating out of garbage cans, as over 25% of the
population with severe mental illness do?2
The
issue of public protection arises because a small number of individuals with
SMI who are not being treated become dangerous, usually because of their
delusions. There have been at least 25 studies in the past 15 years that
have reported that untreated individuals with SMI are significantly more
dangerous than the general population. A 1994 Department of Justice study
reported that 4.3% of all homicides (approximately 1,000 per year) are
committed by individuals with a history of mental illness;3 most of
these homicides would not happen if these individuals were being treated. In
terms of public safety, an individual with schizophrenic or bipolar disorder
who is not being treated is similar to a person with untreated epilepsy who
is driving a car, or a person with untreated active tuberculosis who is
sitting next to you in a movie theater; in both cases, we require that these
individuals receive treatment.
Finally,
involuntary treatment should be used when necessary because-on practical
grounds-it works. In New Hampshire, for example, the use of conditional
release was found to improve medication compliance by a factor of three and
to reduce episodes of violence to one-third their previous
level.4 Outpatient commitment has similarly been shown to markedly
reduce the readmission rates in studies in Ohio, Iowa, North Carolina,
Arizona, and the District of Columbia.
Objections
to involuntary treatment are ill-founded. It is claimed, for example, that
if the mental health services are attractive enough, the patients will seek
them out. Individuals with no awareness of their illness will never seek out
services, because they do not believe they are sick.
Others
claim that involuntary treatment drives patients away. in fact, studies have
shown quite the opposite. In one study of patients who had been
involuntarily medicated, 71% later agreed with the following statement:
"If I become ill again and require medication, I believe it should be
given to me even if I don't want it at the time."5 In another
study, 60% of patients who had been forcibly medicated agreed
retrospectively that it was a good idea.6
Others
oppose involuntary treatment because of its potential for abuse, evoking
memories of Nazi Germany or Stalinist Russia. Of course, treatment can be
abused; however, it need not be if a proper system of checks and balances
are [sic] put in place. Given that the United States has over 900,000
lawyers, there is no reason that these precautions cannot be taken.
Finally,
civil libertarians decry involuntary treatment as an infringement of the
person's fundamental rights. One must ask, however, whether a person with
schizophrenia or bipolar disorder who is living on the streets is truly free
in any meaningful sense.
The
final word on this belongs to Herschel Hardin, who for 9 years was a
director of the British Columbia Civil Liberties Association:
"The
opposition to involuntary committal and treatment betrays a profound
understanding of the principle of civil liberties. Medication can free
victims from their illness-free them from the Bastille of their
psychoses-and restore their dignity, their free will, and the meaningful
exercise of their liberties."7
References
1.
Amador X.F., David A.S., eds. Insight
and Psychosis. Oxford, New York, NY, 1998.
2.
Gelberg, L., and Linn, L.S. Hosp.
Community Psychiatry, 1988;39:510-516.
3.
Dawson, J.M. Langan, PA. "Murder in Families," Bureau of Justice Statistics Special Report.
Office of Justice Programs, U.S. Department of Justice, Washington, DC,
1988.
4.
O'Keefe, C., et. al. J Nerv Ment Dis 1997;185:409-411.
5.
Schwartz, H., et. al. Bull Am Acad
Psychiatry Law. 1996;24:513-524.
7.
Hardin, H. "Uncivil Liberties." Vancouver
Sun, July 22, 1993.
Rebuttal to the Article by Ms. Chamberlin
By E. Fuller Torrey, MD
Ms.
Chamberlin's contribution suggests that she may be woefully out of touch
with scientific literature in this field.
1)
"Schizophrenia" is more than a "clinical impression." It
is a clearly established, biologically based brain dysfunction. There are
literally hundreds of studies that have shown that individuals with
schizophrenia differ from normal controls in both brain structure (e.g.,
ventricular enlargement, loss of hippocampal volume, decreased gray matter)
and brain function (e.g., neurochemically, neurologically, neurophysically).
Schizophrenia is no more a "clinical impression" than is
Parkinson's disease.
2) She
is also incorrect in stating that antipsychotic drugs may cause the brain
changes cited. There are studies showing, for example, that ventricular
enlargement,1 loss of hippocampal volume2 and decreased gray
matter occur in individuals with schizophrenia who have never been treated.
3) She
cites one non-peer-reviewed study alleging that "more than half"
of patients "avoided voluntary treatment...because of a fear of being
subjected to involuntary treatment." Almost every peer-reviewed article
on this question has reported that the majority of involuntarily treated
patients retrospectively acknowledge its necessity.
4)
While ignoring multiple studies that have proven the efficacy of outpatient
commitment, she cites the New York City Bellevue Hospital study as having
found "no difference between the group that received enhanced
outpatient services without compulsion, and the group that received the
services under court order." In fact, the group under court order was
hospitalized for a median of 43 days in the following 11 months compared
with 101 days for the group not under court order. This difference just
missed being statistically significant at the P=0.05 level of significance
but certainly supports the other studies that have proven the efficacy of
outpatient commitment.
5) She
alleges that episodes of violence by seriously mentally ill individuals are
"rare." If the person is being treated, that is true. For those
individuals who are not being treated, multiple studies have shown that this
is not true. For example, the families of mentally ill individuals who
reported that 11% of their seriously ill relatives had harmed another person
in the preceding year do not consider this "rare."4 And the
relatives of 133 outpatients of which "13% of the study group were
characteristically violent" do not consider this
"rare."5 I would suggest that Ms. Chamberlin spend some time
in a public shelter filled with untreated seriously mentally ill individuals
to establish for herself just how "rare" violent episodes are.
References
1.Knable,
M.B., Kleinman, J.E., and Weinberger, D.R. Textbook of Psychopharmacology,
2nd edition. Schatzberg A.F., and Nemroff, C.B., eds. APA Press, Washington,
DC, 1998.
2.Velskoulis,
D., et. al. Arch Gen Psychiatry 1999;56:133-141.
3.Zipursky,
R.D., et. al. Arch Gen Psychiatry 1998;55:540-546.
4.Steinwachs,
D.M., Kasper, J.D., and Skinner, E.A. Family Perspectives on Meeting the
Needs for Care of Severely Mentally Ill Relatives: A National Survey.
National Alliance for the Mentally Ill, Arlington, VA, 1992:25-30.
5.Bartels,
J., et. al. Schizophr Bull 1991;17:163-171.
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CON
Judi Chamberlin
- Senior Associate, National
Empowerment Center, Lawrence, Massachusetts
The
question posed in this debate is not purely a medical one; therefore, it is
appropriate that one of the discussants is not a doctor, but a legal rights
advocate. The issue here is not the use of psychiatric medications per se,
but whether doctors should be permitted to force medications on unwilling
recipients. Although the question refers to "patients," it is
clear that the people under discussion have chose not to be patients. The
question might better be framed as, "Should psychiatrists be able to
define people as 'patients' against their will?" making it clearer that
the issues under discussion are more about legal rights and ethics than
about medicine.
There
are no medical tests that clearly separate those with the diagnosis from
those without it. Sarbin, in an analysis of 30 years of psychological
research, concluded that it "has produced no marker that would
establish the validity of the schizophrenia
disorder."1 "Schizophrenia" remains a clinical
impression, and one that is heavily influenced by such non-medical factors
as race and social class.2 Again, these facts point to the necessity
for enlarging this debate beyond purely medical considerations.
The
question also contains certain assumptions that must be carefully
scrutinized, specifically (1) that medication improves outcome, and (2) that
force is an efficacious way of medicating objecting individuals.
With
regard to outcome, there is little objective evidence that it is improved by
neuroleptic drugs. In fact, there has been little change in outcomes of
people diagnosed with serious mental illness over the past 100 years,
despite claims that neuroleptic drugs are specific
treatments.3 Further, there is growing evidence that neuroleptics
themselves are responsible for brain changes that are often pointed to as
evidence of schizophrenic deterioration.4,5
With
regard to efficacy, the largest single study of out-patient commitment, the
New York City Involuntary Out-Patient Commitment Program, found that there
was no difference between groups that received enhanced out-patient services
without compulsion, and the group that received such services under court
order.6 Both groups were equal in terms of rehospitalization, drop-out
rates, and outcome measures. What this study indicates is that the key
variable is enhanced services, not compulsion. Services like one-to-one
counseling, support groups, and help in finding housing and jobs have been
shown repeatedly7 to benefit people diagnosed with serious mental
illness. the irony is that every dollar spent on surveillance and control is
a dollar that is not available to fund services that research shows really
make a difference.
Campbell
and Shraiber8 found that slightly more than half of a group of
Californians diagnosed with serious mental illness avoided voluntary
treatment at times when they believed it might benefit them because of a
fear of being subjected to involuntary treatment. Kasper, Hoge,
Feucht-Haviar, Cortina, and Cohen9 studied treatment refusers in
Virginia and concluded that "these patients suffered more morbidity
than compliant patients. This study suggests that the negative sequelae of
of an in-hospital treatment refusal cannot be eliminated by rapid
treatment." Further, "refusers were prescribed higher doses of
anti-psychotic medications than were compliant patients," and were
found to have "negative attitudes toward past, present, and future
treatment at the time of admission," Coercive treatment thus creates a
negative cycle, calling for the use of ever more coercion.
The
usual justification for forced treatment is violence on the part of people
with serious mental illness. However, not only is violence rare, but
according to the American Psychiatric Association, "Psychiatrists have
no special knowledge or ability with which to predict dangerous
behavior." Studies have shown that "even with patients in which
there is a history of violent acts, predictions of future violence will be
wrong for two out of every three patients."10 Further, although
the usual justification for forced treatment is lack of insight and the
unwillingness of subjects to seek treatment voluntarily, it is instructive
to note that several of the individuals involved in recent highly publicized
incidents of violence committed by former patients had been engaged in
fruitless efforts to get treatment in the weeks preceding their criminal
acts, visiting emergency rooms and clinics, and being repeatedly turned
away. Rather than lacking insight, these individuals sensed their own
emotional deterioration, which was apparently invisible to those clinicians
that came into contact with.
Under
all of these circumstances, it is clear that calls for expanded involuntary
treatment benefit neither those who might be subjected to it, those who are
traumatized and driven away from voluntary help, nor the public at large,
whose safety is not improved, and whose tax dollars will go toward making
the mental health system even less able to offer the kinds of voluntary
programs that enhance community integration.
References
1.
Sarbin, T.R. J Mind Behavior.
1990:259-283.
2.
Hollingshead, A.B., and Redlich, F.C. Social
Class and Mental Illness. John Wiley: New York, NY, 1958.
3.
Hegarty, J., et. al. Am J Psychiatry 1994;151:1409-1416.
4.
Chakos, M.H., et. al. Am J Psychiatry 1994;151:1430-1436
5.
Gur, R.E. et. al. Am J Psychiatry 1998;155:1711.
6.
"Final Report: Research Study of the New York City Involuntary
Outpatient Commitment Pilot Program." Policy Research Associates,
Delmar, NY, 1998.
7.
Anthony, W.A., Cohen, and M., Parkas, M. Psychiatric
Rehabilitation. Boston University Center for Psychiatric
Rehabilitation, Boston, MA, 1991.
8.
Campbell, J. and Schraiber, R. In
Pursuit of Wellness: The Well-Being Project. California Department of
Mental Health, Sacramento, CA, 1989.
9.
Kasper, J.A., et. al. Am J Psychiatry 1997;154:483-489.
10.
American Psychiatric Association. "Statement on the Prediction of
Dangerousness." Washington, DC, 1983.
Rebuttal to the Article by Dr. Torrey
By Judi Chamberlin
The
arguments raised by Dr. Torrey are primarily ethical and moral ones, in
which he proposes that involuntary outpatient commitment (IOC) is humane to
the individual and beneficial to society. In contrast, I believe that IOC
would make society less humane and more unjust.
First,
as I argued earlier, there is no reliable way to diagnose severe mental
illness (SMI); therefore, people would lose their right to choose or refuse
treatment based on vague diagnostic criteria. This would create a loosely
defined group of citizens who have fewer rights than others. We know from
both history and current public policy that little money or attention is
given to people diagnosed as mentally ill. The deinstitutionalization
decried by Dr. Torrey was fueled, in part, by repeated revelations of
horrific conditions inside state mental institutions; there is no reason to
believe that wide-scale IOC would be any less horrific.
Dr.
Torrey also makes the logical mistake of generalizing from the minority of
individuals with SMI who are lawbreakers, and extending his draconian
prescriptions to the much larger number of law-abiding, productive citizens
who, despite their diagnoses, function well in society with the treatments
and/or supports of their choice. By his logic, all members of racial
minority groups, for example, should be subjected to restrictions on their
freedom because some members of the group are lawbreakers. Such a policy
would result in less freedom for all.
Another
logical flaw in Dr. Torrey's argument is the claim that most murders
committed by individuals with SMI would not happen if these individuals were
receiving treatment, which is an unprovable assertion. Further, even the
elimination of the 1,000 murders a year cited by Dr. Torrey would make
barely a blip in crime statistics. The reasons why the United States has one
of the highest murder rates in the world has far more to do with the easy
availability of guns and other social factors than with mental illness.
I,
too, will close with a quote and invite readers to reflect on society and
morality:
"Of
all tyrannies a tyranny sincerely exercised for the good of its victims may
be the most oppressive. It may be better to live under robber barons than
under omnipotent, moral busybodies. The robber baron's cruelty may sometimes
sleep, his cupidity may at some point be satiated; but those who torment us
for our own good will torment us without end for they do so with the
approval of their own conscience.... To be "cured" against one's
will and cured of states which we may not regard as disease is to be put on
a level with those who have not yet reached the age of reason."1
References
1.
Lewis, C.S. "The Humanitarian Theory of Punishment," God in the Dock. William B. Berdmans
Publishing Company, Grand Rapids, MI, 1994.
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