by Daisy Kielty
May is Mental Health Awareness Month. For resources, including information on common mental illnesses and help hotlines, visit the National Alliance on Mental Illness’ website.
The United States prides itself on its commitment to individual liberty, which has historically been held up in the court of law and defended by our societal values. Our judicial system is complicated, mixed with varying constitutional interpretations, ideas, and values that are all deeply entrenched in our institutions and in our identities. Like the judiciary, the mental healthcare system in the United States is equally convoluted. Often, mental health policy and case law impacting its implementation lack a human element. Both federal and state courts have addressed America’s mental healthcare policy but demonstrated a great lack of understanding in the process.
Some embrace a flexible reading of liberty through application of substantive due process. This interpretation can act as a constraint upon the way proper mental health treatment is carried out. Deciding cases surrounding mental illness purely on an expansive view of liberty does not create laws that benefit the nation's citizens. Although a non-originalist approach interprets the Constitution in ways that sometimes give more freedom and liberty to individuals, this interpretation can preclude people with serious mental illness from getting the treatment they need to live safe, fulfilling lives. How do we balance an individual’s liberty with providing competent mental healthcare? Can we be stripped of our liberty while involuntarily incarcerated and treated, or should we have complete freedom to not be treated?
The lack of treatment and mental health education perpetuates the prevalence of mental illness, which affects nearly one in five adults.[1] In a given year, only 43 percent of adults with mental illnesses are properly treated through therapy or medication.[2] Comparatively, one in 25 adults experience a more severe mental illness, such as schizophrenia or bipolar disorder, and only 64 percent of them are treated for it.[3] On average, the delay between the onset of symptoms and treatment is 11 years, risking worsening symptoms that could unfortunately lead to suicide or incarceration.[4] Data from the Healthcare Cost and Utilization Project show that hospital stays among children for mood disorders increased 80 percent during 1997-2010, from 10 to 17 stays per 10,000 people.[5] The prevalence of mental health conditions is increasing in the country, so—appropriately—the government has made laws to assist with treatment.
Civil commitment laws outline when the condition of an individual with psychiatric symptoms warrants a court order to mandate mental health treatment in a hospital or facility against the patient’s will.[6] States ground their laws on two required elements for commitment: a diagnosis of a mental illness and a need for treatment or potential danger the individual presents to themselves or others.[7] Every state has civil commitment laws, but the quality of the laws and their implementation are not always consistent. In a majority of states, the quality of the laws are below what is necessary to provide accessible treatment and recovery for individuals unable to seek care for themselves.[8] The Treatment Advocacy Center examined each state’s civil commitment laws by assessing the adequacy of their statutes to facilitate short-term emergency hospitalization, long-term commitment to a psychiatric hospital, treatment in a mental health facility, and the laws’ applications. Less than one-third of states received the highest grade: a “B.”[9]
People in need of psychiatric treatment can either be voluntary or involuntary committed to a mental health facility or hospital.[10] Voluntary commitment is straightforward—any individual can seek help from a hospital for their own mental health on their own.[11] Involuntary commitment involves a third party’s decision that an individual is a danger to themselves or others and requires institutionalization.[12] Unfortunately, the “danger” standard often means imminent danger instead of the long-term dangerous effects that mental illness can have on a person.[13] Many individuals who are not constantly violent do not receive the treatment they need as a result. Only four percent of violent acts can be attributed to mental illness, so assessing whether to involuntarily admit someone purely on potential imminent danger should not be the standard.[14] Civil commitment laws require the individual subject to commitment to be mentally ill as well as an additional ground for commitment. Originally, the additional ground was simply a “need for treatment.”[15] This standard is intentionally broad to allow a wide array of people, dangerous or not, to receive treatment through commitment.[16] In the 1950s, states narrowed the “need for treatment” standard to the “danger” standard, restricting those eligible for commitment.[17] Now, only 18 states recognize a “need for treatment” as a ground for commitment to a hospital.[18] Civil commitment laws should move back to the “need for treatment” standard in order to be inclusive to all who need to be committed in order to get better.[19]
During psychosis, a time when a person is detached from reality, “voluntary” commitments are prohibited.[20] In 1990, Daniel Burch was found bruised, bloodied, and disoriented while wandering along a highway and taken to a private mental health center. After being diagnosed with paranoid schizophrenia, he was taken to the state hospital for further treatment. He signed consent for treatment at the mental health center and hospital but was not aware of what he was doing in his psychosis. After Burch’s release from the hospital, he brought suit against the physicians, administrators, and staff members at the hospital claiming they deprived him of his liberty without due process of law.[21] Justice Blackmun, in the majority opinion, stated that a patient’s right to due process is violated when they agree to be treated while experiencing psychosis and are incapable of giving informed consent.[22] The patient’s procedural due process rights are being taken away from them by not being able to make decisions for themselves.
Mental illness patients’ right to liberty was expanded in Riggins v. Nevada (1992).[23] Prior to Riggins, defendants on trial in Nevada could be involuntarily treated for their mental illness with medication in order to ensure they were competent enough to stand trial.[24] David Riggins wanted to suspend his treatment of an antipsychotic drug, prescribed to him by the jail’s doctor, in order to show the jury his true mental state and offer an insanity defense. The district court denied Riggins’ motion, and he was found guilty of murder and sentenced to death. Justice Sandra Day O’Connor declared in the Court’s majority opinion that such mandatory treatment violated one’s right to liberty guaranteed through the Due Process Clause of the Fourteenth Amendment.[25] Now, defendants have the right to refuse antipsychotic drug treatment unless the state can prove there is a necessity for the medication, such as an individual’s danger to themself or others. Individuals still have the liberty to decide how they appear in a trial even while in the state’s custody. Although it is reasonable to allow individuals control how they want to appear in front of a judge and jury, this decision forgets that when severe mental illnesses are active and untreated, the individual does not have control over themselves. Withholding treatment will only cause more harm to the individual in custody as their condition will only worsen. Only two-thirds of adults with a serious mental illness are treated in a given year, and those hospitalized are much more likely to be readmitted if they do not receive follow-up treatment.[26] According to a study in the United States from the Agency for Healthcare Research and Quality, within 30 days, 22.4 percent of initial inpatient stays for schizophrenia were readmitted.[27] Untreated mental illness is estimated to cost the country up to $300 billion, and $1 trillion globally, every year due to lost productivity.[28]
The expansion of one’s autonomy is somewhat justified by the Constitution, but at a certain point, this expansion of liberty goes too far. In Riese v. St. Mary’s Hospital and Medical Center (1989), the California Supreme Court decided that patients involuntarily committed for short-term crisis care can refuse antipsychotic medications.[29] Patients in the state may be forced to take treatment only if a judge determines they are incapable of making an informed decision about their medical care.[30] This also may appear fair; it’s one’s own right to decide what to do with their body and how to be treated. However, there is no point in having involuntary commitment if patients are not being treated. Serious mental illnesses often require medication to help relieve symptoms, such as psychosis and hallucinations, and improve quality of life.[31] Talk therapy, which requires a great amount of personal work, does not guarantee relief of symptoms in the same way as the correct medication does.
Treatment for mental illnesses are not as simple as treating a physical ailment. Psychosis occurs in about 97 percent of cases of serious mental illnesses.[32] To make matters more difficult, 50 percent of psychosis cases are accompanied with anosognosia, the inability to understand that one has a psychotic illness.[33] In accordance with the nation’s laws and court decisions, American patients decide whether they should be considered dangerous, trumping medical judgment. Judges think they are helping people by giving them full liberty over their lives, but their decisions ultimately hurt the individuals they try to help. Individuals who are not in control of themselves should not be given full liberty to make their medical decisions.
The Supreme Court decided in Washington v. Harper (1990) that the Due Process Clause allows a state to treat an inmate suffering from a serious mental illness with antipsychotic drugs against their will if they are considered dangerous or if the treatment is in their best medical interest.[34] The state has a legitimate governmental interest both in reducing violence in its prisons and in giving prisoners the opportunity for rehabilitation. The Due Process Clause is in the Constitution for a reason, and failures to uphold people’s due process rights in any circumstance risks stripping them of their liberty. But America’s legal system needs to become more competent in the real-life repercussions that occur when such liberties are guaranteed to people who do not have control over their actions.
There is no single item that will completely fix the mental healthcare system. We can start with early education about mental illness and increase access to treatment. We can educate our politicians and judges so they make competent decisions about mental health law that helps affected individuals. We could treat every individual with a mental illness with the standard set out in Washington. Although people’s rights to liberty and autonomy should generally be upheld, one’s health and ability to be treated should overcome this idealization.
[1] National Alliance on Mental Illness, Mental Health by the Numbers, Nᴀᴛɪᴏɴᴀʟ Aʟʟɪᴀɴᴄᴇ ᴏɴ Mᴇɴᴛᴀʟ Iʟʟɴᴇss (Sept. 2019), https://nami.org/mhstats. [2] Id. [3] Id. [4] Id. [5] Ruth Perou et. al., Mental Health Surveillance Among Children - United States, 2005–2011, Cᴇɴᴛᴇʀs ғᴏʀ Dɪsᴇᴀsᴇ Cᴏɴᴛʀᴏʟ ᴀɴᴅ Pʀᴇᴠᴇɴᴛɪᴏɴ 2 (May 17, 2013), https://www.cdc.gov/mmwr/pdf/other/su6202.pdf. [6] Heather Carroll, Mental Health Commitment Laws, Tʀᴇᴀᴛᴍᴇɴᴛ Aᴅᴠᴏᴄᴀᴄʏ Cᴇɴᴛᴇʀ (2014), www.treatmentadvocacycenter.org/mental-health-commitment-laws. [7] Id. [8] Id. [9] Id. [10] Substance Abuse and Mental Health Services Administration, Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice, Sᴜʙsᴛᴀɴᴄᴇ Aʙᴜsᴇ ᴀɴᴅ Mᴇɴᴛᴀʟ Hᴇᴀʟᴛʜ Sᴇʀᴠɪᴄᴇs Aᴅᴍɪɴɪsᴛʀᴀᴛɪᴏɴ 1 (2019), https://www.samhsa.gov/sites/default/files/civil-commitment-continuum-of-care.pdf. [11] Id. [12] Id. [13] Sara Gordon, The Danger Zone: How the Dangerousness Standard in Civil Commitment Proceedings Harms People with Serious Mental Illness, 66 Cᴀsᴇ W. Rᴇs. L. Rᴇᴠ. 657, 669 (2016). [14] Dylan Matthews, Stop blaming mental illness for mass shootings, Vᴏx (Aug. 5, 2019 10:00 AM), https://www.vox.com/policy-and-politics/2017/11/9/16618472/mental-illness-gun-homicide-mass-shootings. [15] Id. [16] Id. [17] Id. [18] Matthews, supra note 14. [19] Id. [20] Zinermon v. Burch, 494 U.S. 113 (1990). [21] Id. at 118–120. [22] Id. at 138, stating that “Burch, according to the allegations of his complaint, was deprived of a substantial liberty interest without either valid consent or an involuntary placement hearing, by the very state officials charged with the power to deprive mental patients of their liberty and the duty to implement procedural safeguards.” [23] Riggins v. Nevada, 504 U.S. 127 (1992). [24] Id. [25] Id. at 135–137, stating that “Nevada certainly would have satisfied due process if the prosecution had demonstrated, and the District Court had found, that treatment with antipsychotic medication was medically appropriate and, considering less intrusive alternatives, essential for the sake of Riggins' own safety or the safety of others … What the testimony of doctors who examined Riggins establishes, and what we will not ignore, is a strong possibility that Riggins' defense was impaired due to the administration of Mellaril.” [26] Kevin C. Heslin & Audrey J. Weiss, Hospital Readmissions Involving Psychiatric Disorders, 2012, Hᴇᴀʟᴛʜᴄᴀʀᴇ Cᴏsᴛ ᴀɴᴅ Uᴛɪʟɪᴢᴀᴛɪᴏɴ Pʀᴏᴊᴇᴄᴛ (May 2015), https://www.hcup-us.ahrq.gov/reports/statbriefs/sb189-Hospital-Readmissions-Psychiatric-Disorders-2012.jsp. [27] Id. [28] Thomas R. Insel, Assessing the Economic Costs of Serious Mental Illness, 165 Aᴍ. J. Psʏᴄʜɪᴀᴛʀʏ 663, 664 (2008). [29] Riese v. St. Mary’s Hospital and Medical Center, 209 Cal.App.3d 1303, 1308 (1989). [30] Id. [31] National Institute of Mental Health, Mental Health Medications, Nᴀᴛɪᴏɴᴀʟ Iɴsᴛɪᴛᴜᴛᴇ ᴏғ Mᴇɴᴛᴀʟ Hᴇᴀʟᴛʜ (Oct. 2016), https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149866. [32] Clara Humpston, Schizophrenia and the Paradoxes of Insight, Psʏᴄʜᴏʟᴏɢʏ Tᴏᴅᴀʏ (Jan. 7, 2020), https://www.psychologytoday.com/us/blog/hallucinating-the-self/202001/schizophrenia-and-the-paradoxes-insight?fbclid=IwAR37FNddoOTyOs6NCNdc7VKUouK-EPjb5G2i-iKQVU2NnXntEL8sJ94nbM8. [33] Id. [34] Washington v. Harper, 494 U.S. 210, 218 (1990).