5 Reflections on Involuntary Mental Hospitalization
Schizophrenia is a mental illness and “one of the top 15 leading causes of disability around the world”, according to the National Institute of Mental Health. Some people affected by this disorder could face involuntary hospitalization.
Psychosis is one of many symptoms that around 0.64% of the population with schizophrenia in the U.S. could possibly experience. During a psychotic event people lose contact with reality. What does a psychotic episode feel like? Professor Elyn Saks, a law professor at the University of Southern California, who suffers from schizophrenia, describes psychosis as having a waking nightmare, in which people have bizarre and confusing thoughts, that ultimately can make them feel “utter terror”.
Thus, when someone experiences psychosis, they may behave in a way that is difficult to understand for people who have never lived in such a situation. Therefore, sometimes people having a psychotic event are involuntarily placed in mental hospitals.
Understanding the legal and ethical struggles of people with schizophrenia help to reduce stigma and discrimination, as well as upholding their human and legal rights.
Let’s discuss whether such involuntary hospitalization is legal, what the benefits are, and the ethical issues related to it.
1. Is Involuntary Hospitalization Legal?
Involuntary commitment can happen to anyone suffering schizophrenia, such as John Nash, the Nobel Prize winner in Economic Science 1994, who suffered from schizophrenia and was involuntarily hospitalized several times.
People with schizophrenia may experience hallucinations and delusions (abnormal beliefs) leading to harm themselves or others. Thus, it is crucial to get treatment for their own and others safety as well. However, people with schizophrenia might not be conscious of their treatment’s need and refuse it.
Thus, in order to provide people with schizophrenia with adequate treatment, care takers can then put them in an involuntary hospitalization, according to the inpatient civil commitment prevision. These laws ask for evidence of mental illness and dangerousness to self and others. Thus, patients can benefit from this reclusion. However, this intervention remains controversial.
Other times, although people with schizophrenia do not need to be committed, they still need treatment to avoid psychiatric deterioration.
With the purpose of avoiding involuntary hospitalization, if possible, the preventive outpatient involuntary treatment law has been developed. This law allows the court to intervene and order people with mental illnesses to comply with treatment without being committed. This law is preventive, so it does not require evidence of mental illness or dangerousness.
Preventive outpatient involuntary treatment could grant involuntary hospitalization in a timely manner in case of psychiatric deterioration. It also results in a reduction of people with mental illness committing crimes and their consequently arrest. Thus, it seems to be working as a preventive intervention.
2. Is involuntary hospitalization a good idea?
Involuntary hospitalization is something that Professor Saks experienced on her own. In the words of Saks:
“If someone has a mental illness and is suicidal or a danger to others, there’s no question that intervention is necessary. But there are often times that people are put away simply because they are acting oddly.”
It is possible that people with a diagnosis of mental illness who are not dangerous, are hospitalized against their will.
What is more, how can we be sure that a person with mental illness could harm themselves or others before nothing wrong has occurred?
Furthermore, how could you objectively evaluate the capacity of people with mental disease to make their own decisions regarding their treatments? Thus, sometimes it is not obvious when people fill the criteria to be involuntarily hospitalized.
Moreover, outpatient involuntary treatment laws were developed to avoid unnecessary cases of involuntary detainment. However, experts believe that there are still some points to watch respecting these regulations. For instance, in the case of preventive outpatient involuntary treatment,experts wonder to what extent they can restraint individual liberty because “they think” a person “could harm” himself or others before nothing wrong has happened.
Development of legislation in order to assist people with mental illness while their rights are observed is fundamental to properly take care of people with schizophrenia.
3. Human rights and legal provisions regarding involuntary hospitalization
In both cases, involuntary hospitalization (inpatient civil commitment) and preventive outpatient involuntary treatment, there are still ethical issues to resolve.
For instance, autonomy is understood as the ability of an individual to govern themself according to their own reasons and motives. On the one hand, medical practitioners are used to following the ethical principle to “do no harm”. Thus to observe the “do no harm” principle, autonomy should be respected.
On the other hand, schizophrenic patients sometimes lose capacity in making decisions in their best interest, so that their autonomy is diminished. Moreover, medical doctors are alienated from the ethical principle of “beneficence”, which leads them to provide patients the necessary service they need to benefit.
Thus, weighing those values and principles is challenging when people have to decide to hospitalize patients or give them treatment against their will. These decisions are made based on medical considerations, as well as based on laws that establish standards for involuntary treatment.
However, such laws have room for interpretation. For instance, in the case of involuntary hospitalization, the criteria of dangerousness must be proven regarding the patient. But, how should “dangerousness” be interpreted? Most of the time it means that “physical harm to self (suicide) or physical harm to others (homicide)” is likely to occur, and that it could occur in the near future. And still interpretation of dangerousness changes from one state to another in the U.S.
Additionally, if dangerousness criteria prevails in order to get access to psychiatric treatment, then other patients who are not dangerous but really need a cure would see their access to psychiatric care dilapidated.
4. A personal experience of mechanical restraint
In the case of Professor Saks, she was not only hospitalized against her will, but she was mechanically restrained. Mechanical restraint means to restrict a person free movement by using devices such as leather straps.
How did she feel being restrained? In her own words:
“It is frightening to be put and kept in restraints, causes feelings of degradation and helplessness, and over, say, ten hours is extremely painful… This was the worst trauma I have ever been subjected to. I had nightmares about it for years and years.”
Saks was restrained for almost one month for about four, fifteen or twenty hours a day. Although she never harmed anyone, she was restrained.
Professor Saks believes that by investing more in research and treatment better care can be offered to people with schizophrenia to prevent the use of force.
5. Options beyond involuntary hospitalization for patients with schizophrenia
Without a doubt it is challenging for people with schizophrenia to get timely treatment. It is also difficult for caretakers to decide which treatment would be best for them when patients are not able to make their own decisions.
Sometimes people with schizophrenia are grateful for having been forced to have treatment. Thus, Professor Saks thinks that a first-time forced treatment could be beneficial. After this first experience, patients should be asked in advance to put in writing how they would prefer to be treated during another psychotic episode.
Without question, mechanical restraint should be better regulated to protect the integrity and autonomy of patients. Indeed, there is literature reporting deaths due to inadequate procedures.
In summary, knowing and sharing the legal and ethical struggles of people with schizophrenia is necessary in order to educate society, patients and their families about when involuntary treatment or hospitalization would be beneficial. It can also prevent undermining their human rights. Finally, it can help the patient’s caretakers to face the hard decision of involuntarily hospitalizing their loved ones.
Allow me a final word. Why should we have an open discussion about schizophrenia? Well, to paraphrase Professor Saks, in the end…
what people with schizophrenia want is what everyone of us wants: “…in the words of Sigmund Freud ‘to work and to love’”.
You can find below fragments of the Spanish transcript of a Ted talk on schizophrenia by Professor Elyn Saks.
Fragment 1
Soy una mujer que sufre de esquizofrenia crónica. He pasado cientos de días en hospitales psiquiátricos. Podría haber pasado gran parte de mi vida en el último pabellón de un hospital. pero no fue así. De hecho, me las arreglé para mantenerme alejada de los hospitales por lo menos tres décadas, este es quizá, mi mayor logro. Esto no significa que me haya alejado de todas las dificultades psiquiátricas.
De joven, estuve en un hospital psiquiátrico en tres ocasiones durante periodos prolongados. Los médicos me diagnosticaron esquizofrenia crónica, y me dieron un pronóstico “grave”. Es decir que, en el mejor de los casos, se esperaba que viviera en una residencia y trabajara en puestos sin importancia. Afortunadamente, el caso fue que no desarrollé ese pronóstico. En cambio, soy catedrática titular en abogacía, psicología y psiquiatría, en la facultad de derecho de USC Gould. Tengo muchos amigos cercanos un esposo amado, Will, que nos acompaña aquí hoy.
Hace varios años, decidí escribir mis propias experiencias y mi crónica personal, y quisiera compartir un poco más esta historia con Uds., para transmitirles el punto de vista desde adentro.
El siguiente episodio ocurrió la séptima semana del primer semestre de mi primer año en la facultad de derecho de Yale. Cito de mis notas: “Concerté una cita con mis dos compañeras de clase, Rebel y Val para encontrarnos en la biblioteca el viernes noche para trabajar en un ejercicio de clase. Pero no pasó mucho tiempo antes de que yo hablara de una manera que no tenía ningún sentido.
Fragment 2
“Los memos son visitas”, les dije. “Determinan ciertos puntos. El punto está en sus cabezas. Pat solía decirlo. ¿Han matado a alguien?” Rebel y Val me miraron como si a ellas o a mí les hubiese caído un balde de agua fría. “¿De qué estás hablando, Elyn?” “Oh, ya saben, lo de siempre. Quién es qué y qué es quién, del cielo y el infierno. Subamos al techo. Es una superficie plana. Es seguro.” Rebel y Val me siguieron la corriente y me preguntaron qué me pasaba. “Este es mi verdadero yo”, anuncié, sacudiendo mis brazos por encima de mi cabeza. Y así fue como, tarde un viernes noche en el techo de la facultad de derecho de Yale, comencé a cantar, y no disimuladamente.
“Vengan al arbusto resplandeciente de Florida. ¿Quieren bailar?” Una de ellas preguntó “¿Estás drogada?” “¿Drogada? ¿Yo? Para nada, sin drogas. Vengan al arbusto resplandeciente de Florida, donde hay limones, donde se forman demonios.” “Me asustas”, dijo una de ellas, y Rebel y Val se dirigieron nuevamente hacia la biblioteca. Me encongí de hombros y las seguí.
Una vez adentro, le pregunté a mis compañeras si ellas también tenían la misma experiencia que yo, de palabras saltando de un lado a otro. “Creo que alguien se infiltró en las copias de mis casos,” dije. “Tenemos que vigilar el caso. No creo en las articulaciones, pero evitan que el cuerpo se desarme.”” Es un ejemplo de asociaciones por asonancia:
“Finalmente logré regresar a mi dormitorio, y una vez allí, no pude tranquilizarme. Mi cabeza estaba llena de ruidos, de naranjos, y memos legales que no podía escribir y asesinatos en masa de los que sabía sería responsable. Sentada en mi cama, me mecía adelante y atrás, gimiendo por miedo y aislamiento.” Este episodio llevó a mi primera hospitalización en los EE.UU. Tuve dos episodios anteriores en Inglaterra.
Fragment 3
Continúo con mis escritos: “A la mañana siguiente, fui a la oficina de mi profesor para pedir una prórroga en el trabajo de clase, y comencé a balbucear incomprensiblemente tal como lo había hecho la noche anterior, hasta que finalmente me llevó a la sala de emergencias. Una vez allí, alguien, a quien solo llamaré ‘El Doctor’ y todo su equipo de matones, se abalanzaron, me levantaron en el aire y me tiraron a una cama de metal con tanta fuerza, que vi las estrellas. Me ataron las piernas y brazos a la cama de metal con gruesas correas de cuero.
Salió un sonido de mi boca que nunca antes había oído: mitad gruñido, mitad grito, apenas humano y de terror puro. Luego este sonido volvió a salir forzado desde algún lugar profundo de mi estómago y carraspeando salvajemente mi garganta.” Este episodio derivó en mi hospitalización involuntaria. Una de las razones dadas por los médicos por haberme hospitalizado contra mi voluntad fue que yo estaba “gravemente discapacitada.” Para respaldar este punto, escribieron en mi historia clínica que no podía hacer mi tarea de la facultad de derecho de Yale. Me preguntaba qué significaba eso respecto a los demás en New Haven (Risas)
Durante el año siguiente, pasé cinco meses en un hospital psiquiátrico. A veces pasaba hasta 20 horas en contención mecánica con los brazos atados, los brazos y piernas atadas, brazos y piernas atadas con una red con fuerza sobre mi pecho. Nunca golpeé a nadie. Jamás le hice daño a nadie. Nunca amenacé directamente. Si nunca han sido atados, seguramente tengan una imagen benévola de la experiencia. No tiene nada de benévolo.
