June 27, 2007

Damned If You Do... No, That's All. Damned If You Do.

In case there was any doubt that psychiatry is on the march (from Psychiatric Times June 2007):

The mass murders at Virginia Tech [sic: there was only one mass murder] could lead to harsher laws restricting [mentally ill people's] rights... Perlin, professor of law at NYU, predicted that several states will try to change the basis for involuntary commitment from danger of harm to self and/or others to the need for psychiatric treatment. [emphasis mine, but really, does it need emphasis?]

Mr. Perlin said he expects the U.S. Supreme Court will be asked to rule on such a statute's constitutionality within 10 years.  "I am already counting the votes."

Me, too: Scalia, Thomas, Roberts, Alito, Ginsburg-- strange bedfellows, indeed, but Scalia and Ginsburg spend every New Year's Eve together-- against; Souter, Kennedy for; the rest is anyone's guess (Stevens may not even be there.)

The second article, from the same issue, accidentally describes the crux of the psychiatry/violence dichotomy.  In "Mental Health Staff Can't Sue If Injured By Patient," the writer explains how it is rare, and generally discouraged, for staff to sue or press charges against a patient who is violent and injures them.

Patients who attack mental health professionals in hospital settings are rarely prosecuted and usually cannot be sued for civil damages [said] Ralph Slovenko, Ph.D. at the annual meeting of the American College of Forensic  Psychiatry.

...Authorities usually take the position that it would be inconsistent to prosecute a person who has already been hospitalized for reason of mental illness...

... a New Jersey Court ruled [that] to convict a mentally ill person for displaying symptoms of mental illness... could not be justified constitutionally or morally.

Anyone disagree?  Choose carefully.  Here's the problem: the exemption from prosecution isn't for the insane behaving insanely, or the schizophrenic exhibiting psychosis; the exemption is for any patient. "Patient" in this context, is defined as anyone who is in the psychiatric hospital.  In other words, it's not a label based on pathology; it's a label based on geography.

This may surprise many people, but psychiatrists hospitalize non-mentally ill people all the time.  Any resident will lament how often they are confronted with the malingering drug user who fakes suicidality to gain admission.  Well, if you admit him-- strike that, if he has ever been admitted-- then he is a de facto patient.  If he kills you, he is automatically in a different legal status than if he murdered you in a supermarket.  For example: no death penalty.

It goes without saying, of course, that even the presence of mental illness shouldn't free one from prosecution.  That's why we have the legal construct of insanity.

Here's the clincher:

The situation is analogous to the "Fireman's Rule" in tort law, he said. A firefighter... cannot sue the owner of a burning building for injuries sustained in firefighting.

... I assume because a firefighter must have a reasonable expectation of fire-related danger.  Fine.  But if the firefighter, while fighting the fire, gets shot in the face by one of the meth-lab workers inside that the owner of the building is employing to make methamphetamine, is there no basis for a suit?  Does reasonable expectation of a certain level of danger extend to, well, to volitional acts of violence that have nothing to do with the physical structure that the violence happens in?

The reason I mention these two articles together is because they are the same. "Mental illness" is a term so vague and empty that it is dangerously useless.  Reducing one's responsibility, or restricting their freedom, based on such an arbitrary term is, well, insane.  Doing both at the same time is a tacit acceptance of classism; that some have the responsibility to rule, and some have the responsibility to be ruled.

Oh, I know:  everyone hates George Bush because he has no respect for civil liberties.  Ok.


"[It is] predicted that sev... (Below threshold)

June 28, 2007 7:40 AM | Posted by Obdulantist: | Reply

"[It is] predicted that several states will try to change the basis for involuntary commitment from danger of harm to self and/or others to the need for psychiatric treatment."

Psychiatry is in serious danger of forfeiting whatever credibility it has left if it supports this control lust nonsense.

"'Mental illness' is a term so vague and empty that it is dangerously useless."


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It would be great if the bi... (Below threshold)

June 28, 2007 11:05 AM | Posted by Crawford: | Reply

It would be great if the biggest problem facing us was that of staff being physically injured by patients.

Alone's response: oh, you miss my point completely. It is very rare that staff are injured by patients. My point, however, is that labeling someone as a patient does not define them (right?) and so should neither exempt them from responsibility for their actions. Walking into the box that is University Hospital should have force in defining you.

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Hmmmm, I was with you until... (Below threshold)

June 29, 2007 5:03 AM | Posted by Andy: | Reply

Hmmmm, I was with you until the phrase "volitional act of violence" occurred. How do you determine if someone acted with volition?

Alone's response: so that's the exact issue. How do you know it was volitional? You don't-- it has to be determined on a case by case basis. Certainly, I can't say all acts of violence in a hospital are volitional. But, equally, one can't say that all acts of violence in a hospital _aren't_. Therefore, they don't deserve a categorical exemption. Hence my point about making a judgment exclusively on geography (e.g. in a hospital vs. out of a hospital.

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I think looking at the pat... (Below threshold)

July 1, 2007 1:56 PM | Posted by Its_me: | Reply

I think looking at the patient as ".. a label based on geography" misses the point. I'm sure there's huge variety amongst patients in terms of severity of illness (or presence of illness), but still: once they're forced into the "patient" role or allowed to assume the "patient" role, they are a mental patient, and this will define them and their actions for a while to come, if not forever. This has to be the case for psychiatry to continue- if some patients were "really" sick and therefore exempted from some responsibilities and absolved of responsibility for their actions, while others were not "really" sick, the whole role would lose meaning, and the "mental patient" role must continue to have meaning in order for society as a whole to continue to be able to control deviant, but not necessarily criminal, behavior.
As for the new scary laws that may make commitment easier: the only way to prevent that is to get rid of involuntary commitment, right? As long as the option exists to focibly detain people for acts that may be disturbing (but aren't necessarily illegal), the conditions upon which that can be done will vary. Sometimes they will be more liberal, other times they will be more demanding. Either way, some people will be upset--its too easy to lock up people and call them "crazy," or its not easy enough to lock up these disturbing "crazies."

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I work in Italy where, sinc... (Below threshold)

July 1, 2007 4:05 PM | Posted by WillingPsych: | Reply

I work in Italy where, since 1978, you can't commit anyone because "dangerous to self or others", but just because "needs psychiatric treatment". Quite a broad definition, it's true. But I think I would be more embarrassed to decide, from a psychiatric point of view, whether a patient will be dangerous or not. Do we really have specific clues? I mean: previous violence, drug abuse, being young males, being paranoid, don't sound very specific, nor very "psychiatric"; just good common sense, right?
I feel more comfortable in a system which allows me not to consider violence a specific psychiatric issue, at least when involuntary treatment is needed. It's critical that our patients (I mean true,severe psychotic patients, not the "DSM 25%"...) retain their responsibilities. I think it's easier for the patients too, to understand the psychiatrist's role. If you are sick I'll treat you, if you are violent the police will take care of you! Perhaps you get more violent when you are sick? Well, treatment will help you avoid worse consequences, but no way will cancel your responsibility as a citizen.
I mean, advocacy for a "treatment-based" instead of "danger based" commitment can be "left oriented"
I don't think that in our system over-hospitalization is a problem, maybe because commitment is allowed only in small general hospital units and not in long term facilities. It's much more common the opposite complaint: abandonment of people who would require treatment. The same as in US!Ironically here many people advocate just the opposite solution: reintroduce the criterion of danger to self and others.
Clearly it's not a matter of laws. All over the world the question seems to be: how much time, and money, and thought and critical attitude are we ready to spend for the so called mentally ill?

Alone's response: this is a good point. But my problem with this is who decides if the process is being abused? If I get committed, what are my rights to appeal? Additionally, there is the heavy question of the role of society as surrogate parent, the benefit being that society takes care of those who cannot for themselves, and the downside being that now society is obligated to do this. I don't have the answers to that. But my main concern is not so much psychiatrists abusing this power, but the government abusing this power-- using psychiatrist powers to handle societal problems.

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i am a psychiatry resident ... (Below threshold)

July 11, 2007 9:45 PM | Posted by andy geddes: | Reply

i am a psychiatry resident working in australia. the involuntary commitment (what we term 'detention') laws here require 3 features present before we can act. 1, that the patient is a risk to themselves or others, 2 that this is due to a mental illness and 3 that there is treatment that is available and going to be given while they are detained. there are also measures to prevent its misuse. the process is transparent, there are avenues to appeal that are simple to access, legal representation is provided free to the detained person, the orders must be reviewed regularly by 2 independent psychiatrists.
generally this works well, in my experience. it means one cannot be detained for being violent, you must be violent due to being psychotic and detention is for the purpose of treating this. it means you cannot be detained for simply being weird, if your weirdness is causing no harm.
there was recently a case here where the laws were misused, due to pressure from the police and political lobbies. an HIV positive man with a habit of deliberately infecting people was detained under the mental health act. he was not psychotic, just a prick who liked to make other people suffer. this is exactly the sort of misuse that the conditions above are meant to prevent but in this instance there was sufficient pressure from political places and sufficiently pliable doctors to get a detention order. why he was not just put in prison is beyond me.
this sort of involuntary detention for social reasons is not our brief as doctors. however, it is also very rare and it was in the face of a lot of public opposition from psychiatrists as it was clearly social engineering. i don't think this is the beginning of a decline into feudalism, i think it is more indicative of a legal system (not a mental health system) that moves too slowly to keep up with social changes, like HIV.
of course, that does not excuse those who were complicit in misusing their medical authority.
on a side note, there are several cases of psychaitric patients in Australia being charged after assaulting psychiatric staff. this has happened even if the patient is at the time detained.

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I've been a visitor inside ... (Below threshold)

August 22, 2007 11:58 AM | Posted by Stephany: | Reply

I've been a visitor inside some hardcore psych wards and fist fights generally break out when smoke breaks are delayed or canceled. I witnessed state hospital nurses get attacked while I was placed in a nurses station; locking people up in close quarters can create a hostile environment regardless of mental health diagnoses. I can also verify that most of the aggression was in the evening, long after the doctors and psychiatrist left the building. It's the basic staff getting injured, as well as patient to patient violence. I'm not creating commentary here, I am writing based on first-hand accounts within 4 psych wards. Give the patients a little more fresh air and space and dignity and violence might decrease. I have a family member who attacked staff and no one pressed charges; they just gave her seclusion room and Haldol injections instead.

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I have been locked in a psy... (Below threshold)

September 3, 2007 10:55 AM | Posted by Jen: | Reply

I have been locked in a psych ward 11 times, 4 times in the state hospital. Most of the time i believe i needed to be there, however, my most recent (last week) was totally unnecessary. I had injured myself, however, i did not intend to do it again. The fact is, psychiatrists can keep you locked up quite easily: all they have to do is 'prove' you are a danger. In my state, they can keep you for quite a while before you even get a hearing. This seems very unamerican.
Essentially, they have the right to detain you without you having broken a law or even being accused.
Furthermore, they also have the right to force antipsychotic and other drugs on you, just for being 'difficult'. We were often told that if we refused to take our meds i would not be allowed to smoke or visit the vending machine. According to 'official' policy and rules, one has the write to refuse medication. But i digress...

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