This may seem to be a bit of a digression but has important relevance to the topics I have been addressing in this series.
(Earlier posts in the series can be found at Part I, Part II, Part III)
The New York Times has a story on the front page of their web site on the misuse of Psychiatry to punish dissidents in China. Joseph Kahn reports in Sane Chinese Put in Asylum, Doctors Find that the Chinese have taken the old Soviet practice of pathologizing dissent to a significantly higher level:
Dutch psychiatrists have determined that a prominent Chinese dissident who spent 13 years in a police-run psychiatric institution in Beijing did not have mental problems that would justify his incarceration, two human rights groups said Thursday.
And:
The authorities determined that he had "delusions of grandeur, litigation mania and conspicuously enhanced pathological will," which Western human rights groups say are diagnoses that officials have used to lock up troublesome dissidents who have not broken any laws.
After his release in 2005, Mr. Wang described widespread abuses in the mental asylum, known as the Beijing Ankang. He said he had lived in cells with psychotically disturbed inmates convicted of murder and was forced to swallow drugs to blunt his will. He also said the staff members had used electrified acupuncture needles to punish patients while other inmates were made to watch.
The politicization of Medicine and Psychiatry have an unfortunate pedigree. The Nazis were famous for co-opting Doctors to their ideological purposes and did experiments on concentration camp prisoners that were indistinguishable from torture. The ethical dilemma of using some of their research data to save lives has never really been resolved, though one could argue that it is a fitting tribute to the victims that their pain and suffering has saved the lives of many innocent people.
There are many complaints one can make about the activist philosophy of the Supreme Court, but some of their decisions in the 1970's have served to insulate and protect American Psychiatry from involvement and subversion by politics. In 1975, the Supreme Court made the first of several rulings that had the effect of making involuntary confinement and treatment of the mentally ill much more difficult:
... the first significant Supreme Court case involving the civil rights of a person who was involuntarily hospitalized for mental illness was in 1975. In O'Connor v. Donaldson,(2) the Court made a fairly simple ruling that a person may not be involuntarily treated for mental illness, if he or she can survive safely in freedom singly or with the help of family or friends. Just as a person may not be involuntarily treated for cancer or other physical illnesses, the Court reasoned that mental illness should be treated no differently if it poses no danger or threat to anyone, as long as the person with mental illness competently understands and accepts his or her condition.
Although the Supreme Court has since 1975 addressed other rights of persons with mental illness, recently it has issued two very significant rulings involving the treatment of mental illness which will be analyzed in this article. The first, Washington v. Harper,(3) is the long-awaited decision on the requirements of due process needed for involuntary treatment with psychotropic medications. The second decision, Zinermon v. Burch,(4) deals with a rather technical point of law, but one which is nevertheless very significant because the context of it is the issue of informed consent for psychiatric treatment.
In effect the Supreme Court ruled that even in those cases where the patient's judgment is compromised by their mental illness, there is no a priori justification for treatment against the person's will. The effect of these decisions has been that in order for a Psychiatrist to take on the arduous legal process of obtaining involuntary confinement and treatment, he must first be convinced that it is absolutely required in order to prevent the patient from harming himself or others, and must be prepared to convince a judge of the same thing. In New York, the negative consequences have been apparent for a long time, with the number of psychiatrically disturbed persons living on the streets waxing and waning but never completely dissipating. The positive effects of the outcome are harder to see. However, the protection it offers me as a Psychiatrist is considerable.
In the local Mental Health Clinic where I work part time, I see a number of patients who have severe psychiatric disorders and refuse to take medication. I know that their judgment is significantly impaired by their illness and the temptation to treat them, in their best interest, would be considerable if I had the legal authority to do so. Furthermore there would be considerable pressure from the clinic administration and staff to treat such people. Psychiatric treatment via medications in a clinic setting generally makes money for the clinic; treating as many patients as possible increases our statistics; and after all, people who go into Social Work, Psychology, and Psychiatry want to help people feel better and function better.
Here are the two main problems that the Supreme Court has allowed me and my colleagues to minimize:
1) How is anyone to determine whether their judgment for what is best for another person should overrule that person's judgment about what is best for themselves?
I would agree with the courts that, even with all the problems that arise from their decisions, it is the person who has to live with the consequences of their illness and of their treatment or lack of treatment.
Here is how this might work in the real world: A pleasant middle aged man comes into a clinic; he has been delusional for many years. His supportive housing program insists that he be under the care of a Psychiatrist or he will lose his apartment. He has no objection to keeping his appointments but consistently refuses medicine because the voices tell him not to take it and he has no particular complaints about how his life is progressing. Under the most optimistic scenario, I could treat this men with aggressive anti-psychotic medications, perhaps resolve some or even all of his delusions, and be left with a man who is alone, with no relationships outside of the clinic professionals, no ability to work for a living, and nothing to make him feel special to anyone. On top of that he would have to deal with the side effects that almost all medications have. Would the judgment that this is worth it be better coming from him or from me?
2) The second point concerns the inevitable results of determining that someone else, in this case acting as an agent for the greater society, can be in a position to determine whether or not your behavior is acceptable and appropriate. Obviously, we do have a consensus of the limits of acceptable behavior, and when people transgress such limits, we rightly consider it a legal issue and I have no problem with that. In the legal system there are multiple levels of oversight and checks and balances; allowing Psychiatrists to determine treatment against a patient's will was seriously lacking in such oversight until some of the cases I linked to above.
In Soviet Russia, and now in China, people who objected to the government were considered, a priori, to be psychiatrically disturbed. After all, if your system is based on a Utopian ideal of equality, anyone who objects must be mentally ill. How far is this from those who would silence people for being insufficiently politically correct? Once you leave it up to Psychiatrists to determine when someone who doesn't fit in requires psychiatric treatment, as opposed to leaving it up to the patient, you are treading on thin ice.
If you have read this entire series, you may recall that it was triggered by Dr. Helen's use of the term client to refer to those who I refer to as patients. Further, in her post she was addressing a political position that the American Psychological Association took in relation to homosexuality. The APA determined that they would not approve of a course of therapy that was designed to change the orientation of homosexuals to heterosexual. This is not the time or place to discuss the wisdom of such treatment, or the efficacy (most of the time, discussions of homosexuality degenerate into political discussions rather than scientific or psychiatric) but the decision by the APA was clearly a political decision. Once a professional organization takes it upon itself to determine what is pathology or appropriate treatment based on political considerations, they have crossed a dangerous line. It is almost inevitable that those who push such politicization will make further efforts to have such things as Homophobia or Islamophobia pathologized. Actually, as I wrote about in Psychiatric Nonsense, such efforts are already underway and threaten to endanger all of the mental health professions. Luckily for all concerned, even if they succeed and such diagnoses enter the next DSM, the Supreme Court has determined that we can not treat such people against their will. (The bonanza for the legal profession and the professional victims organizations of such a change is another topic altogether.)
It is difficult for many people to resist exercising authority over other people, especially when it is in the best interests of the "victims" but this is a very dangerous position to take and easily abused. In my last post jw commented:
This is something I've long had a big problem with. In going to a therapist I want advice. I already know the cause of the emotional pain: I've written and published about it: I've blogged about it. I want advice on what works to reduce emotional pain.
jw's appeal to my authority is common and is worth addressing further in my next post in this series. I would suggest that it indicates a subtle and very common misunderstanding of what therapy can and cannot do, has relevance for the discussion of involuntary treatment, and raises a number of important questions for further dissection.
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