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
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
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.
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.
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.
- Senior Associate, National Empowerment Center, Lawrence, Massachusetts
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.
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
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
1. Lewis, C.S. "The Humanitarian Theory of Punishment," God in the Dock. William B. Berdmans Publishing Company, Grand Rapids, MI, 1994.