Involuntary treatment

Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without a person's consent. In almost all circumstances, involuntary treatment refers to psychiatric treatment administered despite an individual's objections. These are typically individuals who have been diagnosed with a mental illness and are deemed by a court to be a danger to themselves or others.

Limitations on forcible treatment
In 1975, the U.S. Supreme Court ruled in O'Connor v. Donaldson that involuntary hospitalization and/or treatment violates an individual's civil rights. The individual must be exhibiting behavior that is a danger to himself or others and a court order must be received for more than a 72 hour hold. The treatment must take place in the least restrictive setting possible. This ruling has severely limited involuntary treatment and hospitalization in the United States. The statutes vary somewhat from state to state.

In 1979, the United States Court of Appeals for the First Circuit established in Rogers v. Okin that a competent patient committed to a psychiatric hospital has the right to refuse treatment in non-emergency situations. The case of Rennie v. Klein established that an involuntarily committed individual has a constitutional right to refuse psychotropic medication without a court order. Rogers v. Okin established the patient's right to make treatment decisions.

Additional U.S. Supreme Court decisions have added more restraints to involuntary commitment and treatment. Foucha v. Louisiana established the unconstitutionality of the continued commitment of an insanity acquittee who was not suffering from a mental illness. In Jackson v. Indiana the court ruled that a person adjudicated incompetent could not be indefinitely committed. In Perry v. Louisiana the court struck down the forcible medication of a prisoner for the purposes of rendering him competent to be executed. In Riggins v. Nevada the court ruled that a defendant had the right to refuse psychiatric medication while he was on trial, given to mitigate his psychiatric symptoms. Sell v. United States severely limited the ability of a psychiatric hospital to forcibly medicate a patient. In Washington v. Harper the Supreme Court upheld the involuntary medication of correctional facility inmates only under certain conditions as determined by established policy and procedures.

Justifications and criticisms
Justification for involuntary treatment is often attempted by emphasizing the potential for severe consequences that may result from lack of treatment, such as homelessness, victimization, suicide, violence. However, critics argue that psychiatric treatment can also have severe consequences such as misdiagnosis, psychiatric assault and disabling drug side effects.

Involuntary treatment is generally undertaken at the behest of family members. Supporters of involuntary treatment include mainstream organizations such as the National Alliance on Mental Illness (NAMI) and the American Psychiatric Association. Involuntary treatment's biggest supporter in the United States is the Treatment Advocacy Center.

Anti-psychiatry groups, loosely allied with members of the psychiatric survivors movement, vigorously oppose involuntary treatment on civil rights grounds. Also, critics oppose involuntary treatment because of the significant potential for side effects, ranging from mild to severe structural brain damage, and because of its emphasis upon enforcing compliance via chemical restraints over practices aimed at achieving mental health. Critics, such as the New York Civil Liberties Union, have denounced the strong racial and socioeconomic biases in forced treatment orders.

The Church of Scientology is also aggressively opposed to involuntary treatment. In the United States case law rulings have almost eliminated the legal right to involuntarily treat a patient or incarcerated inmate in non-emergency situations, starting in 1975 with O'Connor v. Donaldson, Rennie v. Klein in 1978 and Rogers v. Okin in 1979, and continuing with Washington v. Harper (1990), to name a few.

Methods
Psychiatric treatment primarily involves psychotropic medications, such as antidepressants, mood stabilizers, sedatives and "anti-psychotic" or neuroleptic medication. These medications are generally considered effective by the medical community in treating severe and persistent mental illness although they have common adverse side effects. Opponents of treatment point to other studies that suggest that long-range outcomes are much worse with treatment. Involuntary treatment can also include commitment to a psychiatric ward and electroconvulsive therapy (also known as electroshock).

Mental health law
All but four states in the U.S. allow for some form of involuntary treatment for short periods of time under emergency conditions, although criteria vary. Since the late 1990s, a growing number of states have adopted Assisted Outpatient Commitment (AOC) laws.

Under "assisted" outpatient commitment, people committed involuntarily can live outside the psychiatric hospital, sometimes under strict conditions including reporting to mandatory psychiatric appointments, taking psychiatric drugs in the presence of a nursing team, and proving medication blood levels. Forty-two states presently allow for outpatient commitment.

Effects of involuntary medication
In some studies, the majority of people retrospectively agreed that involuntary medication had been in their best interest, with little or no consideration given to those who disagreed with their treatment. Anecdotal reports from opponents of involuntary medication, indicating that involuntary treatment has widespread, devastating, and lasting effects, are downplayed by studies cited by supporters, including TAC. However, other studies cast doubt on the efficacy of involuntary treatment.

Selected bibliography

 * Appel, JM. The Forcible Treatment of Criminal Defendants.  Med & Health, RI.  Nov. 2003.