Refusing Care: Forced Treatment and the Rights of the Mentally Ill

Vol. 15 No.11 (November 2005), pp.1019-1021

REFUSING CARE: FORCED TREATMENT AND THE RIGHTS OF THE MENTALLY ILL, by Elyn R. Saks. Chicago: The University of Chicago Press, 2002. 314pp. Cloth $39.00. ISBN: 0-226-73397.

Reviewed by Katherine M. Nagle, Department of Special Education, University of Maryland. Email: knagle [at] umd.edu .

Elyn Saks is to be congratulated. In writing REFUSING CARE: FORCED TREATMENT AND THE RIGHTS OF THE MENTALLY ILL she has woven a tapestry rich with detail and powerful in the clarity and starkness of its message. This is a book that is long overdue, as it uncovers the sad truth behind society’s equivocal acceptance of people with mental health issues, which is at best conditional and patronizing and at worst fearful, demeaning, and profoundly damaging to some of society’s most vulnerable members. One of the most refreshing aspects of the book is her implicit argument that the humanity and dignity of people with mental health issues should be at the center of the mental health system, and should dictate our structures of decision-making about care and treatment. In the introduction Saks provides the reader with an important principle: “Throughout—so as to not contribute to marginalization and stigmatization—I ask whether the mentally ill should be treated differently in these matters than the non-mentally ill, and if so, why. I recommend standards that should apply, when relevant conditions are met, to the non-ill as much as the ill” (p.3).

Saks brings satisfying clarity to very complex philosophical and historical issues by challenging the reader to consider intriguing “what if” scenarios, and exposing him or her to intentionally ambiguous case exemplars. She delights in analyzing the complex implications of conceptual definitions and many of her arguments rest on precise meanings of such things as “emergency,” “incompetence,” “impairment,” “capacity,” “health,” and “normalcy.” By deftly justifying one position and then jumping over the fence and supporting the opposite argument, she shows how the current status quo does not really hold up. Saks uses an appropriate and engaging mixed methods design as she intertwines information from actual legal cases with empirical evidence from the fields of law, medicine, and psychology to reveal society’s problematic and at times contradictory approaches to meeting the needs of this population. Society will at times intervene in ways that are more damaging to individuals than the condition itself and at times will ignore genuine cries for help by treating the individual as a criminal or citing lack of resources to meet individual needs. Saks states clearly that the subject of the unmet needs of people with mental health issues is a serious problem, but takes as her focus the dilemmas of forced treatment on such individuals.

The heart of the book, then, is the systematic consideration of three special cases of forced care: involuntary commitment, forced medication, and the use of seclusion and restraints. [*1020] Discussing commitment, Saks argues that the legal standard should require serious impairment, the patient’s “transformation into a different person,” serious danger or grave disability, and in many cases, a likelihood of treatment benefit before an individual should be confined against his or her will. Likewise, she argues for a “robust” right to refuse medication that may substantially alter the individual’s state of mind and, indeed, sense of personhood. In both cases, however, she also argues for what she calls the “one-shot-rule,” that gives doctors much more leeway to intervene during the first psychotic break. After that the patient should develop a set of advanced directives that dictate what should occur in the future, should she or he become incompetent again. By allowing individuals to choose what will happen to them when they are in the middle of a psychotic episode, Saks postulates that a more trusting relationship will develop between physician and patient and that individuals will have higher self esteem and be more likely to follow through on treatment options if they feel that they are in control.

The organization of the book facilitates the transmission of the overall message. In the opening chapters, Saks presents the reader with two personas: that of the physician and that of the lawyer. Each individual is placed at either end of a treatment continuum. The physician wishes above all things to cure the patient and is more likely to enforce treatment against the wishes of an individual with mental health issues, while the lawyer wishes to protect individual autonomy and is more likely to respect the wishes of the individual even if the individual rejects medical advice. Saks then moves swiftly to challenge the very concept of mental illness by providing numerous examples of behaviors that initially appear to signify a mental illness, but on further reflection are open to dispute. The point is well made that, if the definition of mental illness is subjective and contextual and the consequences of identification so potentially damaging, we must be very sure that in labeling an individual as mentally ill and treating them differently we are making a thoughtful and benign decision. As Saks points out, the stigma of mental illness brings with it such negative connotations that individuals are subjected to questionable treatments when they have committed no crime nor exhibited any behaviors that are dangerous to themselves or others. This message is repeated throughout each subsequent chapter, as Saks ranges from civil commitment sentences that last for years, the right of individuals to refuse mind altering medications (some of which have proven negative side effects) to the seclusion of individuals in empty rooms as a treatment option, or even as a punishment, and the use mechanical restraints, including the extreme measure of tying someone to a bed.

One of the great strengths of this book is that Saks does not shirk the difficult task of proposing another approach to the treatment of individuals with mental health issues. Saks’ firm commitment to people with mental disabilities does not allow her to ignore the fact that in some instances an individual will need to be treated against his or her will. Indeed, Saks states: “I am persuaded that a concept of mental illness is useful and necessary” (p.42). However, even when behavior crosses into dangerousness for [*1021] individuals or those around them, Saks makes it very clear that the least restrictive and least intrusive interventions should be implemented first and that they should never be used to punish individuals who cannot be held responsible for their own actions. Saks provides disturbing evidence of inmates of mental facilities left alone in small, bare rooms for long periods of time for what appear to be minor infractions of ward rules.

As I discussed earlier, Saks adopts what I would describe as a mixed-methods design. She uses traditional legal research, citing case law and judicial decisions with imaginative scenarios to illustrate discriminatory treatment experienced by this population. Although the evidence she presents would be convincing on its own, I would have preferred more qualitative data, perhaps from interviews to make more real the experiences of individuals with mental illness. For example, this approach was used to great effect by Stefan (2001) and made for harrowing and compelling reading. Saks’ approach does not enable the voices of individuals with mental health issues to be heard directly and thus misses a valuable opportunity to include these stories from individuals directly affected by discrimination. For the reader, the inclusion of routinely excluded voices would have provided a deeper dimension to their understanding of how forced treatment may be perceived by people with mental health issues.

In FORCED TREATMENT, Elyn Saks addresses the treatment of mental health issues in a unique way that should force her intended audience of mental health professionals, lawyers, physicians, and disability rights activists to pause and reconsider how individuals with mental health issues are treated and how they ought to be treated. Forced treatment of individuals with mental health issues not only discriminates against them, but robs them of their dignity, their personhood and possibly even their lives.

REFERENCES:

Stefan, Susan. 2001. UNEQUAL RIGHTS: DISCRIMINATION AGAINST PEOPLE WITH MENTAL DISABILITIES AND THE AMERICANS WITH DISABILITIES ACT by Susan Stefan. Washington: American Psychological Association.

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