The Involuntary Commitment Debate

Readers of this blog know that I have long suggested that we would do well to commit dangerous schizophrenics involuntarily. This means, we should be able to provide psychiatric treatment to severely ill patients, even if they refuse it.

Intuitively, it feels easier to institutionalize a few dangerous psychotics than to remove nearly 300,000,000 guns from the hands of American citizens.

Other problems exist. Beyond the civil liberties concerns, Dr. E. Fuller Torrey points out that even if we decide on more lax standards for involuntary commitment, we do not have enough psychiatric beds to treat all the patients. After all, we, as a nation decided on a policy of deinstitutionalization several decades ago. We are now, as the Bible says, reaping the whirlwind.

For my part, I would like to know how many other civilized nations allow schizophrenics to wander around at will. How many nations refuse to treat psychotics until they commit a horrific act of violence, against themselves and others. Even if these patients do not commit violent actions, do we have a moral responsibility to offer them treatment when they are incapable of deciding what is best for themselves.

This morning Dr. Richard Friedman offered a cogent argument against involuntary commitment in The New York Times.

It is worth examining in detail.

Friedman explains:

While it is true that most mass killers have a psychiatric illness, the vast majority of violent people are not mentally ill and most mentally ill people are not violent. Indeed, only about 4 percent of overall violence in the United States can be attributed to those with mental illness. Most homicides in the United States are committed by people without mental illness who use guns.

These are good points. And yet, the issue is not gun violence, but the treatment of psychosis. Besides, psychosis is not an ordinary mental illness. Research suggests that it is a brain disease.

No one is suggesting that all people who suffer from mental illness—the latest version of the DSM defines so many varieties that just about everyone qualifies—should be subjected to involuntary hospitalization.

While it is true that most homicides are committed by people who are not mentally ill, the fact that we cannot stop all of the violence does not mean that we should not stop some of it.

One must note that most gun homicides are committed by gang members in large American cities. How many of these cities have strict gun control laws? Anyone who believes that stricter gun control will solve anything should explain how well it’s working in New York, Chicago, Philadelphia and Washington, DC.

Then, Dr. Friedman suggests that the link between violence and major mental illness is real:

Large epidemiologic studies show that psychiatric illness is a risk factor for violent behavior, but the risk is small and linked only to a few serious mental disorders. People with schizophrenia, major depression or bipolar disorder were two to three times as likely as those without these disorders to be violent. The actual lifetime prevalence of violence among people with serious mental illness is about 16 percent compared with 7 percent among people who are not mentally ill. 

Again, the issue is not so much who will or will not commit violent acts, though those who suffer from severe mental illness are far more likely to do so. The issue is whether it is good or bad policy to treat schizophrenics against their will.

If we are talking only about violence, Dr. Friedman notes, people suffering from drug or alcohol addiction are very likely to commit violent acts:

What most people don’t know is that drug and alcohol abuse are far more powerful risk factors for violence than other psychiatric illnesses. Individuals who abuse drugs or alcohol but have no other psychiatric disorder are almost seven times more likely than those without substance abuse to act violently.

It is worth asking how many of these addicts are self-medicating, that is, treating a severe psychiatric illness with their own kind of medication.

He continues:

Would lowering the threshold for involuntary psychiatric treatment, as some argue, be effective in preventing mass killings or homicide in general? It’s doubtful.

The current guideline for psychiatric treatment over the objection of the patient is, in most states, imminent risk of harm to self or others. Short of issuing a direct threat of violence or appearing grossly disturbed, you will not receive involuntary treatment. When Mr. Rodger was interviewed by the police after his mother expressed alarm about videos he had posted, several weeks ago, he appeared calm and in control and was thus not apprehended. In other words, a normal-appearing killer who is quietly planning a massacre can easily evade detection.

It is surely possible to evade detection in a single interview, but people who spent time with Elliot Rodger and Adam Lanza knew perfectly well that they looked crazy.

Dr. Torrey offers a different take on the issue:

Many individuals who are psychiatrically disturbed are able to “hang it together” for a few minutes when confronted by a police officer, judge, etc. I have had very psychotic patients appear quite rational for 10 minutes in a courtroom by focusing their mind. Patients with Parkinson’s disease can similarly suppress their tremor briefly by focusing their mind on it. Thus, it is unrealistic to expect a police officer to make a clinical evaluation, and such evaluations should include a mental health professional.

Here, Dr. Torrey raises the issue of the competence of mental health professionals. If no psychiatrist understood how ill Adam Lanza was, that can mean that he hid his illness very well or else that the psychiatrists were not doing a very good job.

Keep in mind, Elliot Rodger availed himself fully of the resources provided by the mental health system. He saw multiple therapists for many, many years.

Ought we not to question their competence and the effectiveness of the treatments they were offering.

Finally, Dr. Friedman explains that if we made it easier to commit patients involuntarily, other patients might be discouraged from availing themselves of treatment.

In his words:

In the wake of these horrific killings, it would be understandable if the public wanted to make it easier to force treatment on patients before a threat is issued. But that might simply discourage other mentally ill people from being candid and drive some of the sickest patients away from the mental health care system.

The point might have some validity in some cases. And yet, the notion of involuntary commitment assumes that the sickest patients systematically refuse all dealings with the mental health system.

We cannot, Dr. Friedman correctly notes, predict violent behavior, but we can see when someone is severely ill and incapable of making a rational decision about care.

He writes:

We have always had — and always will have — Adam Lanzas and Elliot Rodgers. The sobering fact is that there is little we can do to predict or change human behavior, particularly violence; it is a lot easier to control its expression, and to limit deadly means of self-expression. In every state, we should prevent individuals with a known history of serious psychiatric illness or substance abuse, both of which predict increased risk of violence, from owning or purchasing guns.

Let’s imagine that states do not hand out gun permits to people who suffer severe psychiatric illness. If a schizophrenic wants to commit gun violence would he not be likely to avoid mental health treatment. If he cannot be committed involuntarily, how are the authorities to know about his illness?

As for substance abuse, how can state employees know whether someone is an addict without, for example, some kind of test? And, what about people who are abusing medication that has been duly prescribed by a physician? Aren’t more and more people are becoming addicted to prescription painkillers?

Of course, the campaign for gun control will have no effect on those who, like Rodger kill with knives, or on those who, like Lanza use someone else’s guns.