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We Can't Ignore the Detrimental Effects of Involuntary Mental Health Treatment

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Sometimes the news isn’t as straightforward as it’s made to seem. Here’s what to keep in mind if you see this topic or similar stories in your newsfeed. This is The Mighty Takeaway.

It’s a statement that probably sounds familiar if you’ve sought mental health treatment before: Your privacy is protected unless your therapist or doctor believes you’re a threat to yourself or another person. You may think it could never happen to you — involuntary treatment only happens to people are “worse off.” In reality, this isn’t always the case. Despite growing mental health awareness, this aspect of mental health treatment — the fact that in some circumstances, it’s legal to give someone treatment against their will — is still hush-hush, even within the mental health community. 

While there are times forced treatment may be needed to protect someone, involuntary treatment can be traumatic and has shown to be less effective than voluntary treatment.

In a recent study, researchers found that patients who received coerced treatment for mental illness were less likely to view the help as beneficial compared to those who sought treatment on their own. The researchers looked at two forms of coerced treatment.

How People Are Coerced Into Treatment

“Formal” coerced treatment includes anyone who is ordered by a court to receive treatment. If a person commits a crime — and this happens often with crimes related to substance abuse — a judge may mandate a person to receive substance abuse treatment or other mental health treatment instead of going to jail. Because there is technically a threat of jail time if the person refuses, it’s still considered coerced treatment.

Another type of formal coerced treatment is an emergency hold, which is typically 72 hours. Psychiatric wards can hold someone for up to three days if the doctors believe the person is a threat to themselves or others. If a doctor believes the patient needs to be held longer, they can advise a 14-day hold and the patient is entitled to a hearing about their involuntary commitment. Laws can vary by state, so it’s a good idea to talk to a lawyer or research the laws in your state.

Even if a patient enters treatment voluntarily, it can still take days for the patient to be discharged after they express a desire to leave, effectively rendering the “voluntary commitment” useless. According to Illinois law, a mental health facility has five business days from when a patient requests discharge (in writing) to when they legally have to let the patient go. The facility can also petition a court to keep the patient longer, even if they were voluntarily admitted. An Illinois facility can keep “voluntary” admissions for over two weeks from the discharge request. Other states have similar situations where it can take up to 72 hours for a discharge to be processed. People in the hospital for non-mental health reasons are usually discharged in a matter of hours. In non-mental health cases, if a patient wishes to leave, but the doctor does not recommend it, they are still allowed to leave against medical advice.

“Informal” coerced treatment is when someone feels pressure from their loved ones to seek help. This may include inpatient treatment, but people can be pressured into going to therapy or taking medication.

According to the study, people can be “informally coerced or manipulated into care using social benefits that are dependent on engaging in treatment.” This includes ultimatums from loved ones if the person doesn’t receive help. They may restrict money, housing or other necessities unless the person agrees to get help. It’s important to note, however, that encouraging or suggesting a loved one seek help isn’t forcing them into treatment.

Why Coerced Treatment Is a Problem

The researchers found that people with severe mental illnesses, who are already more likely to be forced into treatment, were less likely to perceive forced treatment as effective. Patients forced into inpatient treatment are also at risk of experiencing potential trauma associated with being forced into treatment. Involuntary commitment to psychiatric hospitals means a loss of agency and control. The choice to be there wasn’t the individual’s in the first place, and then they’re stuck there for at least 72 hours against their will.

A particularly traumatic part of “treatment” is the use of physical restraints. Mighty Contributor Victoria Murphy detailed an experience when she was restrained by nurses and staff at a hospital, which she considered a “nicer” restraint. Murphy said of restraints for psychiatric patients:

Restraints are awful situations to be in, for both the people initiating it and the person being restrained. They’ve come under a lot of speculation lately, some of which I can understand. I’ve been in restraints that have left nasty bruises and twisted limbs, people yelling at me and holding me incorrectly, and even restrained for no reason at all, simply because “they could.” So, while I agree that sometimes a restraint is needed to ensure someone’s immediate safety, there needs to be much tighter guidelines on them. A restraint should always be a last resort, not a show of power from ignorant nursing staff or a way to control a “problematic patient.” A restraint should be a way to save someone’s life.

The American Psychiatric Nurse Association (APNA) stands against restraint and seclusion of patients, though it happens routinely. The association said its committed to the reduction and eventual elimination of these practices. The APNA also advocates for more research to find the best practices for the prevention and better management of behavioral emergencies.

The APNA said reports of patient injuries and deaths, as well as the emotional effect of restraint and seclusion, are a serious ethical conflict, which comes from the “nurse’s responsibility to prevent harm and the patient’s right to autonomy.”

Restraints are even used outside of the hospital. It’s common for police to handcuff patients when they’re transporting them to hospitals, which is not necessary in many cases. The general excuse is that it’s “protocol” to handcuff patients, though you’d be hard-pressed to find any other patient handcuffed or transported by police in the first place. While an ambulance may not be needed, there are services that offer non-emergency medical transport.

We may be protecting someone in the short-term when treatment is forced, but the long-term effect could be detrimental. According to a 2014 study, “self-stigma, associated stress and a reduced empowerment from coerced treatment predicted a poorer quality of life and lowered people’s self-esteem.” The study also found that cognitive and emotional reactions to coerced treatment impacted a person’s quality of life more than the number of coerced treatments received over time.

Involuntary commitment happens more often than needed because determining if someone is a harm to themselves or others isn’t a perfect science. Studies have shown that predicting someone’s risk is fairly inaccurate. It makes sense for doctors and therapists to err on the side of caution, but there’s a strong chance for a breakdown of trust between the mental health professional and client if they’re forced into an inpatient treatment facility. In a blog post for Psychology Today, Dr. Lloyd Sederer recounted three separate patients who fired him as their doctor following an involuntary commitment. He wrote: 

It’s hard to share suicidal thoughts, especially if a client is worried opening up will send them to the hospital. Most mental health professionals aren’t going to hospitalize someone for just having suicidal thoughts, unless there’s intent to act on a plan. Figuring out intent, though, is subjective unless a patient explicitly states they’re going to do it. A mental health professional has to weigh the probability of the client quitting treatment and getting worse after a forced hospitalization and the probability of the client acting on suicidal thoughts. It’s a tough decision, and clearly keeping a patient alive is the most important, but we can’t ignore the detrimental effects of forced hospitalization.

If a patient is safe and doesn’t need inpatient, forced outpatient has its issues, too. Motivation is important for making substantial change. When it comes to therapy, you have to put in work for it to be effective. If someone’s forced to go to therapy or group therapy, the motivation to follow through on their work isn’t there, though that doesn’t mean they won’t benefit somewhat. If an individual is unmotivated, they’re more likely to drop out of treatment prematurely or they may stop taking their medications. Since there are a limited number of beds in inpatient facilities and long wait times for outpatient services, we should be making sure the people using these services are getting the most out of it. We also need to expand these services so we aren’t turning people seeking voluntary treatment away.

What We Can Do to Lessen the Use of Coercion

Some people who were forced into treatment say it did save their lives or help them. This piece is not to discount those stories. Everyone experiences mental health and treatment differently, so it’d be wrong to say that no one has ever benefited from coerced or involuntary treatment. There are tough decisions to be made when someone who’s experiencing psychosis, for example, is acting in a way that seems to suggest they could be a danger to themselves or others — even though violence towards others is rare and likely due to a numbers of factors. 

What needs to change, though, is how we treat people who were coerced into treatment and find ways to maximize benefit from treatment. This could mean changing the way we transport patients instead of handcuffing them like criminals. Involuntary or coerced treatment should be handled in a way that minimizes harm, both physical and psychological. Involuntary treatment tends to happen when a person has already reached a crisis level or nearly there. Better preventive and early mental health care could reduce the overall need for involuntary treatment, and therefore give people a chance to get the most out of treatment.

Coerced treatment inherently takes a person’s autonomy way. A great way to prevent this, even if involuntary treatment is needed, is to give the patient a voice ahead of time. A joint crisis plan is a negotiation between a patient and their care providers about the patient’s future treatment for psychiatric emergencies. It gives the patient a chance to have input into what can or should happen in a time of crisis, especially if the patient is too unwell to express their desires at the time of crisis. Research has shown that joint crisis plans may also reduce the need for coerced treatment overall because it can help people identify relapses earlier or clear up any confusion about treatment plans ahead of time.

No one wants to feel like control has been taken away from them or like they’re a prisoner, especially when they need help. People with mental illnesses need to be treated with compassion and more so when they’re at crisis points. We can’t expect threats of treatment, restraints and other possibly traumatic situations to aid in someone’s recovery.

Photo via Getty Images/paolo81

Originally published: February 12, 2019
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