Balancing Patient Freedom With Safety And Well Being

I have always hated involuntary psychiatric treatment. It is demeaning to human dignity, subject to abuse, and extremely unpleasant both to experience and to recommend. But there are rare times when pressuring someone into treatment becomes the lesser evil, preferable to the risks of suicide, violence, jail or homelessness.

My first experiences in psychiatry occurred fifty years ago, at a time when 650,000 patients were warehoused in psychiatric hospitals, accurately described as ‘snake pits’. I very much admired Tom Szasz for calling this out and fighting to free patients from their bondage. Some of my own earliest writings were directed against psychiatric paternalism- emphasizing instead the great value of eliciting patient preferences and of negotiating, rather than dictating, their treatment plans. And, in many years of emergency room work, my instinct was almost always on the side of taking reasonable risks- letting most people go when they insisted, rather than playing it safe by forcing them into a hospital stay.

But there are exceptions- people with severe and chronic mental illness who are an ongoing, clear, and present danger to self, family, and/or the public, but who lack the insight or volition to get the help needed to reduce what is otherwise an unacceptable risk.

How do we achieve an equitable balance between the sometimes competing values of freedom and safety?

Involuntary commitment to inpatient psychiatric hospitals has become very uncommon in the US because almost all psychiatric hospitals have been closed (90%, comprising 600,000 beds in the last 50 years). Completely not coincidentally, the concomitant failure to provide adequate community treatment and housing has resulted in an equivalent 600,000 people with severe mental illness being housed in jails or left homeless on the street. This neglect has made the United States for many people the worst place in the —> Read More