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.