Legalized Coercion

This is part [part not set] of 10 in the series Deconstructing Antipsychiatry

PBM, and antipsychiatry in general, chooses to focus most of its energy on involuntary (“forced”) inpatient psychiatric commitment and treatment, and how psychiatry is empowered by the state to lock up those who are “different.”

What they omit, however, is situating that mode of psychiatric care within the context of psychiatric care in general. Given the goal of discrediting psychiatry as a whole, it seems a curious oversight if they were trying to provide an accurate portrayal.

Acknowledging that this omission is actually being used for persuasive purposes, I assume that PBM is trying to leave the impression that most psychiatric care is (or will necessarily become, after you’ve been diagnosed) involuntary. The argument is made that everything associated with involuntary commitment and treatment is bad, though as we’ve seen elsewhere, what is actually backed up by evidence is the existence of multiple negative examples.

Even if it were true (which it isn’t), does that mean that psychiatry as a whole bears the sins of involuntary treatment? Logically it does not; that would be an example of the fallacy of composition.

Involuntary Admission

How about in practice? For how many people today will involuntary commitment be an issue at all? It’s hard to find good data here, but let’s try to break things down a bit. We know that the vast majority of psychiatric care (in the neighbourhood of 80%) is provided by family physicians, with somewhere between 30–70% of people never seeing anyone except their family doctor. So clearly, admission of any kind isn’t an issue for them.

Similarly, most people who go to an ER for mental health reasons aren’t admitted. And for a good proportion of people who see a psychiatrist at all, it will be for a one-time consult or a few short visits. Most psychiatric care is provided on a (voluntary) outpatient basis, rather than inpatient. And in terms of inpatient admissions, somewhere between 25-40% are involuntary.

In terms of involuntary admissions, they’re most prevalent for people with psychotic disorders (e.g. schizophrenia) or bipolar disorder (during either an acute manic or acute suicidal phase), much less so for unipolar depression (acute suicidality), and fairly rare for anxiety, personality disorders, etc.

Keep in mind also that the number of inpatient psychiatric beds continues to shrink (starting with the whole deinstitutionalization movement, but still continuing). We know that its more difficult for a patient to arrange a voluntary admission due to bed shortage; they typically need to be acutely suicidal. Similarly, people are discharged earlier than they have been previously (hence the “revolving door”).

For any given person then who seeks mental health care, what are the odds they will ever in their lifetime be involuntarily admitted and mistreated? Without the data, it’s hard to say, but based on the above rough analysis, for the vast majority of people who tend to be primarily diagnosed with a form of depression or anxiety, not very high.

Having said all that, one person who has their rights violated is one too many. But to imply that it’s almost a virtual certainty is plainly ridiculous.

Pathologizing the Atypical

Is the real goal of “inventing” mental illness, as PBM and antipsychiatrists often claim, to identify and punish societally unacceptable behaviour, to discourage the dissident or free-thinker?

It is certainly true that in the past, asylums were a convenient place for wealthy and powerful families to permanently relocate their more “embarrassing” relatives. Those days are, along with most of the asylums, long gone.

As just noted, involuntary treatment is one relatively small (but important) piece of psychiatry today. Being “different” or just having a psychiatric diagnosis, does not meet the threshold.

For the majority of people who are seen or treated, it is on a voluntary basis. As we’ve already discussed, to receive a diagnosis in the first place, it is not enough to be “different,” but that the symptoms demonstrate “clinically significant distress or impairment.”

And even if a diagnosis is given, the decision to agree to treatment (often choosing among several offered) is a matter of individual choice. As is the decision to later terminate treatment. Many people receive a diagnosis, yet decide the likely negative consequences of the treatment outweighs the likely benefits. Yet others will choose to look for non-pharmacological treatments, both those that might be recommended by psychiatrists (e.g. therapy, exercise, nutrition, meditation) and those that would not be (e.g. homeopathy). These are all rational decisions that most individuals are free to pursue.

For others, some perhaps who have tried some alternatives, realize the terrible cost that their symptoms are putting on their life, and feel that this outweighs the potential negative consequences of treatment. These are rational decisions, freely made.

Part of Deconstructing Antipsychiatry