Treating Someone Who Doesn't Want Treatment
It’s a familiar situation: a family member or friend is very depressed, maybe even psychotic, but doesn’t want to get any treatment. What do you do?
It’s easier to explain what you are allowed to do. The specifics in each state vary, but in general if someone has attempted, is threatening to attempt, or you have reason to believe they are going to attempt, suicide, you can involuntarily commit them to a hospital.
“You” in this case means any person who directly observed the dangerous behaviors; or a police officer; or a doctor.
Once the person is brought to the hospital and evaluated, and the doctor agrees with the commitment, the patient can be held against his or her will for three-five days, after which there is a court review for further commitment or immediate discharge.
Depending on your stance on individual freedom/civil liberties, it is either good or bad that pretty much nothing else is permissible by law.
For example: a doctor absolutely cannot give a person antidepressant medication without them knowing; i.e. no slipping meds into food or drink. There are very specific circumstances when a psychiatrist can give meds against a person’s will, but never without that individual’s knowledge (unless they are incapacitated.) Otherwise, this is considered battery as in “assault and battery.”
So without any immediate risk of death, no psychiatric treatment can be initiated without the person’s consent. Notice I said “person,” not “patient.” That is because in the absence of a consent to treatment (or court order), the person in question isn’t considered a patient.
So what can a parent do when their 19-year old son is depressed and/or abusing heroin? In this case, in the absence of any direct suicide tendencies, you can’t commit the person to a hospital, even though everyone knows that this behavior could ultimately result in their death. But because it isn’t suicidal, or immediately dangerous, there are no grounds for commitment.
This is by far the most frustrating part of psychiatry for most laypeople. On the one hand, psychiatrists are proclaiming new awareness of and treatments for disorders; but on the other hand, when you need them most, they are almost useless. And psychiatrists feel this frustration, too. On the one hand they are looked to for help, expected to help, and sometimes even responsible for the consequences but they’re still powerless.
There’s no good way out of this situation. I’ve tried a lot of different techniques, with few good results. In my experience, the only way that has had any success is a large scale intervention: get as many friends and family into the room simultaneously, and have them unanimously declare that the their loved one needs to get help. I am not being facetious; you need at least ten people to make this work. The room has to be crowded. Very crowded.
In the face of this overwhelming brigade of concerned people, the person being confronted will sometimes give (reluctant) consent to initiate treatment.
Neutral third parties (i.e. doctors) are not going to be able to convince the person to get help. Family and friends must get involved. Additionally, the family/friends have to be extremely motivated and invested in getting their loved one to consent to treatment. Take the whole day off, because it won’t be a quick process. And everyone has to be prepared to perform similar large scale interventions multiple times, as dropout from treatment is generally high.
We can argue the social policy implications of psychiatry’s paralysis (or its excess of power again, depends on your perspective) all we want, but it doesn’t change the reality. Much of our current laws were brought about by the courts in reaction to the “gross” (depending on the perspective) disregard for personal freedoms of the earlier days of psychiatry, and the current principle that having a mental illness does not therefore negate one’s freedoms or their own personal responsibility for their behavior.
It’s a tricky balance, and one that is also very difficult to formalize. But here we deal with the practical:
If your loved one is in danger, drag him or her to an ER or call the police. If he/she is not in immediate danger, and are refusing to get treatment, call as many people as you know to come over.
Paul Ballas, D.O., wrote about mental health for HealthCentral. He is a member of the American Psychiatric Association and has been a presenter at the American Psychiatric Association and American Academy of Psychosomatic Medicine meetings.