One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part IV

David Laing DawsonBy Dr David Laing Dawson

It is difficult, if not impossible, to fully understand the forces altering, changing, insidiously impacting our attitudes, laws, institutions, and behaviour in our own time. It takes distance and serious historians to dissect these things, and even then we are probably viewing them from a clouded contemporary prism. But something happened between 1990 and 2015 I would not have expected in 1970. Many of our mentally ill fellow citizens today are worse off than they would have been had they been born 50 years earlier. There are parts of the United States where one could make the case that they are worse off than they would have been had they been born in 1850. How could this have happened during a period of increasing knowledge, advanced medical tools, relative peace and prosperity?

This is one part of the puzzle:

The mental health laws were tightened, restricted during those years (1970 to 1990), and safeguards put in place, all toward the righteous goal of preventing anyone, ever, from being unnecessarily stripped of freedom and independence without “due process”. On paper it looks fine. Now one could not be held for a psychiatric assessment unless he or she was judged to present an imminent threat of harm to self or others. Within 72 hours if a psychiatrist came to the same conclusion about imminent threat to self or others, that person could be kept for another two weeks. Further safeguards were put in place – appeal processes, Review Board Hearings, lawyers made available, patient advocates. The wording, the processes are all a little different in each North American jurisdiction, but with similar intent and outcome.

And then the act of treating was separated from the act of detaining. A second process is required for involuntary treatment: a determination of not being competent to consent to treatment, and then the treatment authority would be conferred on a nearest relative, or, failing that, a public official. And this determination could also be appealed, taken to a Review Board, and ultimately to court.

This distinction between the right to detain and the right to treat has led to some paradoxical situations in which everybody loses. A person can be deemed too imminently dangerous to self or others to set free, to be allowed to leave, yet competent to refuse treatment. The patient suffers physically, mentally, left in a state of psychosis for a long period of time; families watch this suffering; unhappy doctors and nurses watch someone deteriorate to a state of chronic psychosis, to a state of true madness and unpredictability not seen in our mental hospitals since the introduction of effective medication.

Apart from this paradox all the new rules sounded commendable, and guaranteed to reduce or eliminate type I errors. Type I errors being the unnecessary detention of someone eccentric, a nuisance, but not dangerous, and the forced treatment of someone who should (within our current view of individual rights) be allowed to decide for himself. They prevent the abuse of a Nurse Rached, or a Dr. Donald Cameron. And these new rules were informed, to some extent I am sure, by our increasing awareness of the use of Psychiatry in the Soviet Union to deal with people deemed to be enemies of the state.

We need strong safe guards in all our systems and institutions, for humans in positions of power are always capable of abusing or misusing that power, of convincing themselves on some philosophical basis or other, that they are doing the right thing.

But when we completely eradicate the possibility of type I errors we open the door for type II errors. In this case not detaining someone who, in hindsight, should have been detained, not protecting and treating people who need treatment and protection. The most dramatic form of Type II error brings about the headline that we have read with horror and disbelief about twice per year the past twenty years. A patient is released from hospital, gets on a Greyhound bus, and decapitates a fellow passenger. A young man stops taking his pills and butchers his mother;  another shoots a journalist with a crossbow; yet another shoots an Arizona politician in the head.

But a less dramatic and more insidious type II error has been the increasing numbers of mentally ill (not deemed imminently dangerous to self or others) left to fend for themselves on the street, in shelters, and in jails and prisons. For a significant number of mentally ill people (and their families) we have, over the past 30 years, reversed the reforms provoked by Dorothea Dix in 1843.


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