Multiple stakeholders
Many have a stake in how this plays out. There are the patients, who may be suffering and unable to recognize that they are ill, who may have valid reasons for not wanting the treatments, and who ideally should have the right to refuse care.
There are the families who watch their loved ones suffer, deteriorate, and miss the opportunities that life has to offer; who do not want their children to be homeless or incarcerated; and who may be at risk from violent behavior.
There are the mental health professionals who want to do what’s in the best interest of their patients while following legal and ethical mandates, who worry about being sued for tragic outcomes, and who can’t meet the current demand for services.
There is the taxpayer who foots the bill for disability payments, lost productivity, and institutionalization. There is our society that worries that people with psychiatric disorders will commit random acts of violence.
Finally, there are the insurers, who want to pay for as little care as possible and throw up constant hurdles in the treatment process. We must acknowledge that resources used for involuntary treatment are diverted away from those who want care.
Eleanor had many advantages that unhoused people don’t have: a supportive family, health insurance, and the financial means to pay a psychiatrist who respected her wishes to wean off her medications. She returned to a comfortable home and to personal and occupational success.
It is tragic that we have people living on the streets because of a psychiatric disorder, addiction, poverty, or some combination of these. No one should be unhoused. If the rationale of hospitalization is to decrease violence, I am not hopeful. The Epidemiologic Catchment Area study shows that people with psychiatric disorders are responsible for only 4% of all violence.
The logistics of determining which people living on the streets have psychiatric disorders, transporting them safely to medical facilities, and then finding the resources to provide for compassionate and thoughtful care in meaningful and sustained ways are very challenging.
If we don’t want people living on the streets, we need to create supports, including infrastructure to facilitate housing, access to mental health care, and addiction treatment before we resort to involuntary hospitalization.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.