Welcome to From Insults to Respect.

Many people have come to feel that the psychiatric profession has failed to treat them respectfully. Several issues have inflamed them, arguably the most emotional being involuntary drug treatment which, to them, is often viewed as torture.

Among the groups that agree with this torture notion is the National Association for Rights Protection and Advocacy (NARPA). Its mission statement reads:

NARPA’s mission is to promote policies and pursue strategies that result in individuals with psychiatric diagnoses making their own choices regarding treatment. We educate and mentor those individuals to enable them to exercise their legal and human rights with a goal of abolition of all forced treatment.

Several psychiatrists, such as Thomas Szasz and Peter Breggin, have, over the years, fully supported NARPA’s mission.

As Dr. Szasz explained:

Dr. Thomas Szasz

“Benjamin Franklin warned us, ‘They that can give up essential liberty to obtain a little temporary safety, deserves neither liberty nor safety.’ Yet today Americans seem ready to sacrifice liberty to obtain a little temporary ‘mental health.’ To complicate matters, ‘mental health’ is a vague, almost meaningless term…. Franklin was right. Regardless of how we define ‘mental health,’ if we sacrifice essential liberty for it, we shall deserve–and in fact have–neither liberty nor ‘mental health.'”

Dr. Breggin explained his position as follows:

“Since finishing my training, I have never treated or incarcerated anyone against his or her will.  During this period in private practice extending back to 1968, no patients in treatment with me have committed suicide or perpetrated a serious act of violence.  Any good psychiatrist or therapist could have a patient commit suicide or perpetrate violence; but coercion, drug treatment, and hospitalization increases the likelihood. I believe that my refusal to coerce patients, my efforts to prevent hospitalization, and my practice of not starting patients on psychiatric drugs have contributed to the good fortune that my patients have not committed suicide or extreme violence. People in deep distress do not need incarceration or the inevitable drugs that follow; they need caring help from friends, family, and professionals.”

Recently, a United Nations report also condemned involuntary psychiatric interventions, including drug treatment, which it viewed as a form of torture (see HERE). It concluded that for persons with psychosocial disabilities all States should:

“(a) Review the anti-torture framework in relation to persons with disabilities in line with the Convention on the Rights of Persons with Disabilities as authoritative guidance regarding their rights in the context of health-care;

“(b) Impose an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs such as neuroleptics, the use of restraint and solitary confinement, for both long-and short-term application. The obligation to end forced psychiatric interventions based solely on grounds of disability is of immediate application and scarce financial resources cannot justify postponement of its implementation;

“(c) Replace forced treatment and commitment by services in the community. Such services must meet needs expressed by persons with disabilities and respect the autonomy, choices, dignity and privacy of the person concerned, with an emphasis on alternatives to the medical model of mental health, including peer support, awareness-raising and training of mental health-care and law enforcement personnel and others;”

Involuntary psychiatric interventions are legitimized under national laws, and may enjoy wide public support as being in the alleged “best interest” of the person concerned, or because it protects people in the community from the violence that some people labelled mentally ill will carry out. Nevertheless, according to the UN report, “…to the extent that they inflict severe pain and suffering, they violate the absolute prohibition of torture and cruel, inhuman and degrading treatment.

Is It Really Torture?

When people are forced to take psychiatric drugs, it often feels like torture because of a number of their side effects. For example, akathisia makes it hard to stay still. It causes an urge to move that you can’t control. You might need to fidget all the time, walk in place, or cross and uncross your legs. Akathisia is often hard to describe, and it can take over a person’s life and feel awful.

Other torturous effects come from the patient knowing that upon being forced to take these types of drugs it can lead to a number of very serious disabling and embarrassing results. Tardive dyskinesia, a largely irreversible movement disorder, can be very severe and disabling. In one case that led to a two-million-dollar settlement, a woman developed muscle spasms and abnormal movements that afflicts her face, neck, shoulders and extremities, as well as her speech and breathing.

Tardive dyskinesia occurs at a cumulative rate of 4-7% per year in otherwise healthy, relatively young patients treated with many of the so-called antipsychotic drugs. After only a few years, 20% or more of those treated will be afflicted with tardive dyskinesia. Older patients have an even higher risk.

These types of drugs are also associated with enormous weight gain leading to diabetes and other serious health risks, along with the added consequences of being humiliated from people who call you disgustingly fat. Knowing that the drug you are being forced to take can lead to all of these types of consequences understandably can be extremely disturbing. When added to the fact that psychiatric patients are typically already in very highly stressful situations, the negative side effects of these drugs, along with fear of getting some of the permanent health problems related to using these drugs, which I have only touched upon, it becomes understandable that many experience forced drug treatment as torture.

Is It Fair To Drug People Who Will Never Commit a Violent Act Simply Because They Fall Into Some Category That Is Predictive Of Violence?

According to the United States Department of Justice men commit violent crimes more than three times as often as women, although most men do not commit a violent crime. Since men are more likely to commit violence, should all men be involuntarily placed on psychiatric drugs?

Because men, as a group, are pretty powerful, it is not likely that any laws will be passed that will force all men to be placed in such a degrading and torturous situation. Nevertheless, we see on TV media reports numerous incidences of violent acts, most of them by far are committed by men.

Individuals who are male teenagers or young adults are also more at risk of violence than the average person in a given population. Thankfully, for my two sons, our society does not require that all of these at risk individuals be placed on psychiatric drugs.

When the media depict a violent person who is described as schizophrenic or psychotic, the public cries out for involuntary treatment. This is a politically disempowered group. So, it is relatively easy for the public to ignore the fact that this policy would require numerous individuals who are not violent to suffer the horrendous consequences of such a policy.

It’s important to keep in mind that most commitment laws do not require a judicial determination of incompetence, nor do they require a criminal charge or a criminal conviction (see HERE). Rather, a psychiatrist must make a prediction that the person is dangerous to self or others. These types of predictions tend to be more wrong than right. Moreover, there are numerous examples of patients who are forced to be on these drugs who end up committing a violent act anyway.

The best scientific analysis that looks at whether or not the drugs significantly reduce violence when involuntarily administered has been provided by the nonprofit group called Cochrane (see HERE). It turns out that there is no reliable evidence that these types of drugs do decrease violence with involuntary patients.

A few studies have provided some evidence that suggests that the drugs can moderately reduce violence for involuntary patients who have a history of engaging in substance abuse. However, the relevant evidence is based on relatively small trials, with high or unclear risk of blinding bias, a significant number of subjects who are lost to the researchers during the study, or the study’s design did not use random assignment of subjects.

It is important to point out that the vast majority of individuals who are said to have committed a violent act in such studies don’t actually physically hurt anyone. They typically have engaged in an angry exchange and ended up breaking something, smashing a window, or, in the heat of the exchange, threatened someone with a violent act. Some studies suggest that the drugs used can actually increase the likelihood of violence.

The best predictors of future violence are a history of past violent crime, victimization, involvement with illegal drugs and drug markets, poverty, life trauma exposure, and ambient neighborhood crime. When these factors are not present for an individual, being classified as mentally ill is not related to violence. Rather than the vague notion of mental illness, it appears that these are the real factors that lead to the statistically modest increased risk of violence among those labelled as mentally ill because such labelled individuals are more likely to be exposed to these risk factors (see HERE).

Even if we were to take the evidence that suggests that the drugs might reduce violence as absolutely true, then, once again, we must face the moral dilemma: Is it morally acceptable to involuntarily place on these types of drugs all people deemed as possibly likely to commit violence even though most will never hurt anyone? To say yes means that the policy will expose numerous people who would not hurt anyone to torture and physically harmful consequences.

Is There A Better Alternative To Involuntary Treatment?

Clearly, people in our communities have justification to want to keep people from harming themselves or others. I know I don’t want violent people running around my neighborhood. However, the use of psychiatric drugs too often lead people to think that the mental health professionals did what was needed, and thus reduces the necessary motivation to advocate for more helpful action. In my view, there are far better ways to address these concerns without any need for involuntary treatment or torturing anyone.

First of all, we already have laws for someone who commits a violent crime. I support these laws because without them many people who might otherwise act violently find that to avoid prison time they can choose a nonviolent alternative, thus making our communities safer. For those who fail to choose nonviolent ways to deal with life challenges, the law requires that they serve time in prison. Removing them from our communities for a period of time leads to our communities being safer, and gives the person who committed the crime an opportunity to consider better alternatives to deal with the type of situation that led to their incarceration. Moreover, as they serve time in prison, they become older, thus they enter an age range that leads to more thoughtful considerations and a much lower likelihood of choosing violent options.

Now, I hasten to point out that many prison officials believe that when people serve time they should be punished in degrading ways. But most people placed in prison, whether they are displaying behavior that often leads one to receive a mental illness label or not, are best treated with respect and dignity. The vast majority will eventually return to our neighborhoods and to traumatize them with abusive actions while they are in prison increases the risk that they will become less than ideal citizens. There are a number of countries that have been trying out more humanistic approaches to treating prisoners and the results have been very promising.

So the current laws, especially if carried out humanistically, already offer people in communities a good deal of safety. Yes, people who are imprisoned have typically been placed there against their will, and therefore, this can be viewed as an involuntary treatment. But, in such cases, they are first entitled to present their case in front of a jury of their peers, be represented by a lawyer, and, if treated humanistically, are not involuntarily drugged or tortured in some other manner. The constitution prohibits cruel and inhumane punishment.

In addition to providing safety within communities via laws that lead to people convicted of a violent act being imprisoned, what else can be done? In an article that I wrote and had published in the peer reviewed journal Professional Psychology: Research and Practice, I describe a promising approach that goes well beyond simply locking people up. For those people who are at risk of violence, we can incentivize them to learn nonviolent ways to deal with the kinds of anger arousing situations that they may potentially face. For example, people who have been convicted of a violent crime and are serving out their sentence can be incentivized to learn prosocial skills by reducing their sentence a month if they demonstrate mastery of the skills. People at risk who are not incarcerated may be offered some other incentives such as access to better housing, or even be provided a monetary incentive that is about the same amount as the combined cost of a drug management program. Drug management typically includes the cost for the drugs plus the time for professionals to assess, prescribe, and monitor the patient. Monitoring the patient includes regular meetings to assess drug side-effects, readjust the medication dose, prescribe a different or additional drug, and sending out a social worker or nurse to remind patients to take their prescriptions. These costs are significant and if redirected to incentivizing people at risk, it would lead to a significant level of voluntary participation.

Some Details Regarding a Prevention Program

What would a program that teaches nonviolent ways to deal with anger arousing situations look like? Teachers would identify their student’s pattern of anger expression and the situations in which the student typically experiences anger. Responding to criticism and providing criticism are particularly hot spots, so they would be the focus of early lessons (see HERE to begin the process of learning incompetent versus competent behaviors for dealing with these types of situations). Viewing audiovisual recordings depicting alternative nonviolent behavior would provide effective modeling of prosocial skills.

Students would be informed that when they are learning alternative behaviors, attempts at suppressing old behaviors are not necessary unless it would lead to someone really getting hurt. No one expects perfect learning, and some recorded behaviors may not be right for a given student. By viewing many recordings depicting alternative behaviors, students find that they adopt some of the skills in an effortless manner. It’s kind of like hearing a song several times. You might not decide by an act of will to learn the lyrics, but you may find that you are singing the words anyway.

For the dangerous student who is locked up because of being convicted of a crime, safety during this part of the training is maximized by eliminating from the environment potential weapons and making certain that an adequate, well trained security staff is readily available. At the first sign of violence, the staff isolates the combatant until anger is diminished and an alternative style for dealing with the arousing event has been identified by the student. Note that with this type of structure, it is not necessary to encourage students to control their behavior by an act of will. Instead, they are challenged to process the information provided at their own pace.

In the next part of the training, students begin to make their own audiovisual conflict recordings. Concrete examples are thus affectively, cognitively, and behaviorally rehearsed while clear audiovisual feedback is provided by observing the created recordings. From my own experience working with these types of students, this is enormously fun for them and is experienced as making their own TV shows.

As in the previous training period, some of the practitioner’s suggestions may begin to feel uncomfortable to the client. This can seriously interfere with the learning period if poorly handled. I have found it useful from time to time to preface my recommendations with the same gentle admonishment that the famous physics professor Niels Bohr used to give his students: “Every sentence that I utter should be regarded by you not as an assertion but as a question.” This tends to disarm the student, sets the stage for a positive collaboration, and fosters interest from the satisfaction derived from fulfilling one’s own internal standards.

Stubborn anger problems require the setting of gradual goals and the accompaniment of the student into the community setting for participant modeling. Careful selection of encounters of increasing difficulty would permit students to bolster their self-confidence. As learning progresses, guided participation would be reduced and students would then be assigned to progressively more challenging tasks to perform on their own.

Anger management interventions have not advanced so far as to completely eliminate anger from an individual’s repertoire. In order to prepare students for these recurrences, it is recommended that such interventions be designed to encourage students to view lapses in training not as a sign of their helplessness, but as a challenge to improve.

In a study that cited my anger article, an intervention with physically aggressive children using several of my ideas were put into practice. Compared to a randomly assigned control group, the program developed was “efficacious in reducing children’s physically aggressive behaviors, improving the parent-child relationship, and enhancing parental behaviors and skills in dealing with childhood aggression.”

In a second study that cited my anger article, a social skills and anger management program was provided to adult criminal offenders with a history of violence. Results of the study support the hypotheses that social-skills training can reduce anger among high-risk offenders.

Well, there you have it, my thoughts on involuntary psychiatric drugging and a promising alternative. I conclude with a quote from John Perceval who had provided his own account of his extreme state that was labelled “psychosis”:

“I wish to stir up an intelligent and active sympathy, on behalf of the most wretched and the most oppressed, by proving how much needless tyranny they are treated–and this in mockery–by men who pretend indeed their cure, but who are, in reality, their tormentors and destroyers.”

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.

Alternatives to involuntary psychiatric treatmentinvoluntary psychiatric drug treatmentPeter BregginPredicting violencepsychiatryThomas Szasz