The ethical dilemma of involuntary mental health treatment – WBUR News

Several states have changed their policies in recent years to make involuntary commitment easier for people with severe mental illnesses.

But forced treatment still raises civil rights questions, with some saying it can harm, not help patients.

Today, On Point: The ethical dilemma of involuntary mental health treatment.

Will James, host of KUOW and The Seattle Times Lost Patients podcast.

Dominic Sisti, associate professor of medical ethics and health policy at the University of Pennsylvania. Director of the Scattergood Program for the Applied Ethics of Behavioral Health Care.

Laura Craciun, a mother who struggles with bipolar I disorder with psychotic features and anosognosia.

Stefanie Lyn Kaufman-Mthimkhulu, founder and executive director of Project LETS.

Part I

DEBORAH BECKER: This is On Point. Im Deborah Becker in for Meghna Chakrabarti.

Understanding mental illness of a loved one often means looking back.

JON CHANG: Tell me about Nick as a child. I mean, what was he like growing up? What kind of son was he?

LAURA CRACIUN: Adorable. He looked like a little Ewok in a Star Wars film. And when he was younger, he would excel at any sport we introduced to him, including gymnastics and hip-hop dance, and was the best charades player I'd ever seen, and just so creative.

BECKER: Thats Laura Craciun, an artist on Cape Cod, speaking with On Point producer Jonathan Chang about her son Nick.

We should note this story contains descriptions of violence.

Nick was an athlete with a big heart, Laura says. But there was something else that clouded over his childhood.

CRACIUN: The thing that plagued him most of his life, really, was that he could hear and see things that weren't real. And that started very early on in diapers. We would see him sometimes leave the house, saying there was something in it, and he didn't feel safe. And he also had anxiety that we were going to die.

BECKER: Laura visited three different neurologists, who prescribed ADHD medications but not much more. Laura says she trusted their expertise. But years later, Nick got a different diagnosis.

After graduating from high school in 2020, Nick Craciun was living with his father in Cambridge, Massachusetts and struggling to keep a job.

In 2022, his father lost his job as a caretaker and was at the risk of losing his home.

That April, Nick ran away from home without notice.

CRACIUN: We had a large search going on, not just through the police, but through social media, all his friends, no one was finding him.

BECKER: Laura feared the worst. Months passed by without any word about Nick.

CRACIUN: Eventually, I bothered his friends in Boston so much with a guilt trip that one of them did feel bad. And she said, I've heard from the guys that he's around and that he's just hiding in south of Boston. So that was my first indication of hope that he was alive, but still, she wouldn't reveal her name to police. They couldn't follow up. It was difficult.

BECKER: It took three months before Nick finally returned home that July. He had no explanation for his disappearance, other than saying he came back because he remembered their yearly Fourth of July celebrations.

And the Nick who returned was a different person.

CRACIUN: His hair was wild. His eyes were wild and overly opened. He had awkward social cues and he had lost 20, 30 pounds and had no possessions except the jeans and t-shirt he had on. And a few days after, we all sat down as a family. And in a living room setting with eight people present, Nick told us what happened while he was gone.

As if everything was normal. But we were hearing a story that made no sense. It was that he was living in a car in his friend's driveway, hiding between the seats at night. And then during the day, he would travel into the woods, climb trees and hills without clothes on to get closer to the voices in his head.

We tried to figure out what to do next. We asked his lawyer that we had hired when he went missing, what we should do, and he said have him go to the Cape Cod Hospital, and we were able to get him there. He wasn't happy, and when he got to the ER, because he was over 18, the clinicians wanted to speak to him alone, and when I was able to get through to them, they said they were concerned. But if he's not a danger to himself or others, we aren't allowed to hospitalize him against his will.

BECKER: For Laura, Nicks refusal to receive treatment is personal.

CRACIUN: I myself had experienced mixed mania. Bipolar runs in my side of the family. The first time I realized I was bipolar was when I was medicated and actually felt relief from the pain that was in me.

BECKER: Laura has benefited from treatment for 30 years now. And she became increasingly desperate as she watched her own son deteriorate.

Today: were going to explore this idea of involuntary mental health treatment. The experience of families like Lauras. What some of the research shows, and the ethical dilemmas surrounding committing someone to treatment.

By November of 2022, Nick started to pose legitimate safety concerns.

CRACIUN: His father and he had an argument that got violent, where he was chopping vegetables. His father was using a very sharp butcher knife. And in the middle of the argument, his son grabbed the butcher blade, not the handle, and wrapped his fingers around it. While he was arguing. So of course, his father stopped chopping and he stayed very still. And it was shortly after that, that Nick went up to him very close to his face and said, do you want to die three times in a row?

BECKER: After that, Nick was committed to McLean Hospital, a psychiatric hospital in Belmont, Massachusetts. There, Nick received the diagnosis: bipolar I with psychotic features. Nick also had anosognosia, a condition where a patient is unaware of their neurological deficit or psychiatric issue. Laura was told that he refused medication.

CRACIUN: He believed that medication was going to make him worse. He had no faith that he had any sort of illness. So when we got in front of professionals, he did his best to pull it together and not repeat what we were seeing and what we were hearing. And he was able to speak coherently and almost reign, he almost learned the language of how to speak in front of a professional so that they wouldn't be able to commit him without his permission.

BECKER: In Massachusetts, as in most states, there are laws that allow emergency restraint and hospitalization of someone, if they pose risk of serious harm to self or others because of mental illness.

But advocates like Laura say that the bar to prove this potential harm is too high, and often its difficult to receive help when you need it.

CRACIUN: We had many moments where all these crisis helplines trying to get the story, right? And when they finally arrived, it was too late. That episode had passed. And so it was a very frustrating process when we tried to get him help.

BECKER: Without treatment, Laura says Nick became a shell of his former self though there were times that she saw the son she remembered.

CRACIUN: There were moments where he was very kind and thoughtful, but they were almost exaggeratedly so. And he would give us generous gifts from each of one of his paychecks. And this is the loving child that we knew, but it was also accompanied by belief that He was unclean and that there was a big conspiracy against him and the FBI, you know, so there was a lot of tensions.

CHANG: The fact that there were still those moments of kindness, did they give you hope? Or did that make it even more difficult to process what Nick was going through?

CRACIUN: That was more of a sadness, because here there's this beautiful person who is so loving, sweet, and kind, totally out of control. His moods were out of control. This was not the son we knew.

BECKER: Last December, Nick had his fifth and most recent psychotic break at his fathers home.

CRACIUN: He asked his father if he could sleep in the same room with him because he was afraid to sleep alone in that living room on the couch. So his father dragged his mattress off of the bed and instead of sleeping on the couch, Nick walked around the coffee table and laid down with his father on that mattress. His father was extremely uncomfortable and said, I'm sorry, I need more personal space. And instead of replying, he elbowed his, you know, father so hard and yelled, shut up.

So his father stood up. But was almost dizzy and falling down. So he couldn't quite get away from Nick, yelling to the neighbors for help as he was leaving his apartment. And when he got to the doorway, his neighbors were alerted, they were coming out of the doors.

BECKER: As they continued to struggle, neighbors called 911.

CRACIUN: Meanwhile, Nick continued punching and putting his father in a headlock with multiple punches. And then his father wanted to pin the arms so that he wouldn't get punched anymore. So he backed his son up to a wall, and that's when Nick started to bite him.

And he was biting so hard. He did get through layers of clothing and drew blood. The police report said that when they arrived, his father was on the ground. Nick was on top of him. pinning his lower half with his knees and had both arms on either side of his head, headbutting him forehead to forehead and also smashing the back of his head down to the pavement.

BECKER: Nick and his father were taken to separate hospitals for care.

Nick Craciun is now 22 and has been incarcerated since December 27, 2023, at Bridgewater State Hospital, that's state facility for those deemed criminally insane. And those whose mental health is being evaluated for the criminal justice system. In March, Nick was moved to a county jail, still without medication.

Laura Craciun believes Nick is not a criminal. Hes a person in need of help, she says. And in need of policies that would allow people with severe mental illness to receive involuntary treatment sometimes called Assisted Outpatient Treatment or AOT.

CRACIUN: I'm at a loss as to how it got to be so bad, except if there were an AOT law, we're going to see a huge difference in getting those criminal populations down from the mentally ill population or the tragedies that have occurred. So I have a lot of hope and I hope that more conversations come out.

BECKER: Massachusetts is one of only three states that does not permit involuntary outpatient mental health treatment.

Across the country, families like Laura's have been pushing to make it easier to mandate treatment to people with severe mental illness.

In cities such as New York and San Diego, officials have taken steps to allow more involuntary treatment. Especially for those who are unhoused. Heres New York City Mayor Eric Adams in November of 2022:

ERIC ADAMS: That is just so irresponsible, that we know that this person is about to probably go off the edge and harm someone, but were going to wait until it happens. Not in this administration.

BECKER: In California, Governor Gavin Newsom overhauled the states mental health policies last October the changes which included loosening long-standing rules about whos eligible for involuntary treatment.

But opponents say forced treatment is not effective. And can sometimes harm patients and compound trauma. They argue that forcing a treatment protocol takes away a person's right and their agency to deal with their mental health. Coming up, well talk about some of the changing policies around the country and the ethical challenges of involuntary treatment. Im Deborah Becker. This is On Point.

Part II

BECKER: Today, we're talking about mandating mental health treatment. Several states and cities have been considering changing policies to make it easier to Involuntarily treat people with mental illness. We'll talk about some of these efforts and some of the ethical dilemmas surrounding them.

Joining us is Will James. He's host of the "Lost Patients" podcast. That's a collaboration between KUOW and the Seattle Times. The six-part series examines the difficulties of treating serious mental illness through the lens of Seattle. Will James, welcome to On Point.

WILL JAMES: Thanks, Deborah. Really glad to be here.

BECKER: We just heard Laura Craciun's story in Massachusetts about her son, Nick, who is now incarcerated with untreated mental illness. Is her story, does it sound familiar to you? Do you think you heard that from a lot of the families that you spoke with for the podcast?

JAMES: So familiar. It is an absolutely very common story among families across the country right now.

In fact, when we see these pushes to expand involuntary treatment, to open up laws to make it easier to involuntarily commit people, a lot of that push is coming from families like Laura's. Families who are trapped in these terrible situations where they are watching a loved one decline.

They're watching their loved one's mental health deteriorate. Their behavior grow more erratic. Sometimes the loved one becomes homeless, gets into increasingly dangerous situations. And the family is left just feeling utterly helpless and powerless. And I, in the course of reporting this podcast, sat with a family that was in a situation much like Laura's. And just the sense of helplessness and fear and stress was absolutely palpable.

BECKER: And that's basically because what makes it so difficult, is the laws are pretty strict in terms of who meets the criteria for involuntary commitment. Is that right?

JAMES: That's right. For a lot of our country's history, we had a need to treatment, a need for treatment model for involuntary mental health care.

So what that looked like was, in a lot of the last century, for instance, a doctor or two would look at a patient and say, "Yeah, they need care, they need treatment. So we are going to treat them whether they want to or not." And then at some point in the middle of the last century, we started to switch.

There were all these revolutions in psychiatric care in this country, and it switched to a dangerousness criteria. So what that meant is in order to treat someone against their will, they have to essentially be a danger to themselves, at risk of dying, essentially. Or, at risk of really harming other people.

And there are good reasons for that. Before that, involuntary treatment was overused and led to all sorts of abuses and a terrible era in our history. But when we see it switched to this dangerousness criteria, almost immediately, for instance, here in the state archives in Washington state, we see families writing to the governor, saying, telling stories almost exactly like Laura's, struggling with often grown-up children who are declining.

Acting more radically, and the family feels absolutely helpless.

BECKER: So is it a case of the pendulum swinging back because it went too far? Do you think? Or are there just, obviously, this is a complicated issue. There are so many factors, but is that a big part of it?

JAMES: There is a argument right now that, exactly as you said, we swung the pendulum too far in the direction of patients' rights.

But it is very complicated, that is a very common argument that the public has internalized lately due to mostly the sight of seriously mentally ill people who are homeless on the streets of cities like Seattle. Like New York, like Boston, all over the country, here in the West Coast, we started seeing that phenomenon really grow in the public consciousness about a decade ago. In other parts of the country, it really became more prominent during the pandemic. But It's really a reaction to the sights of seriously mentally ill people out in public on the streets.

BECKER: And so a lot of this effort to change what's happened with our system right now is coming from families who have loved ones with serious mental illness.

I wonder, what do patients say, who've been civilly committed to treatment? What typically is the experience like for them?

JAMES: Yeah, there are really two, kind of, there are many views on this issue, but you could split them into two camps. And one is led by, essentially, by patients, families, and some psychiatrists.

And as you said, they want these laws, they want it to be easier to involuntarily commit people, but there's also a patience rights movement. And this is a movement saying involuntary care is a really blunt and flawed and risky instrument of psychiatric care.

The experience of being strapped to a gurney and taken, usually first to an emergency room for evaluation, a chaotic emergency room that is loud and full of people, while the patient is in psychosis can be deeply traumatizing. It can deepen distrust in psychiatric care. It can worsen symptoms. It's almost like you couldn't design a worse scenario to put someone who's feeling paranoid and terrified into, than a chaotic emergency room hallway.

And also, a really powerful part of that argument is that some of the public's desire to get people off the streets who are seriously mentally ill, I think is rooted in a misunderstanding of what actually happens when someone is involuntarily committed. I think there's a view that these serious mental illnesses are physical, purely physical brain diseases that can be cured by the right medication.

And while there is some truth to that, that there is a physical element to these illnesses, and that medication is a powerful tool. It often does not work like that. These illnesses blur the lines between someone's personality and wishes and a diagnosable illness, and it's hard to tell where one ends, and one begins.

And the medications we have are essentially unchanged from when antipsychotics first emerged in the 1950s. I mean there have been some tweaks, but they work basically the same. And they can lessen symptoms, but for most people, they won't be a cure. They often come with really brutal side effects that some people find intolerable.

So the result of involuntary treatment, I think, often fall short of the public's imagination and sometimes the family's imagination of what their loved one is getting.

BECKER: I want to bring someone else into the conversation here. Dominic Sisti. He's an associate professor of medical ethics and health policy at the university of Pennsylvania.

He's also director of the scatter good program for the applied ethics of behavioral health care. Hello, professor Sisti. Thanks for being On Point.

DOMINIC SISTI: Hey, Deb. Thanks for having me.

BECKER: So tell us a little bit about what we know about whether involuntary treatment is effective. I know that research on this is mixed and it's hard to find because the population can be so different.

And as Will told us, there are so many complex issues involved here. But what do we know about the effectiveness of this form of treatment?

SISTI: Yeah, I think you nailed it. It's mixed. There are folks who do well and get better. And after a certain amount of time, it might be weeks, months, or even years, are able to reintegrate into society and build and recover and have happy lives with support. There's other folks who don't do as well. And it is the case, I think, that medication and medical interventions are just one thing that these folks need. They need wraparound services, they need support, they need transitional care, moving from a hospital back into the community.

If these pieces are not in place, inpatient hospitalization won't be as effective. So the outcomes really will depend on the quality of all the other services that may wrap around the patient. So it is absolutely true that hospitals themselves are not a cure all. They're a necessary component, I'd say, to a comprehensive mental health care system.

But they're not sufficient.

BECKER: And yet we hear that many states and cities around the country are trying to increase the use of hospitalization or involuntary treatment, California, New York City. I just wonder if we could just touch on those and explain those a little bit. In California, it's my understanding, Professor Sisti, that this effort basically expands the legal definition of when someone can be treated against their will. Is that right?

SISTI: Yeah. So it expands out the notion of grave disability to include things like substance use disorders, and being unhoused with a substance use disorder. So the idea there is to try to get folks into treatment.

And off the streets. And there are evidence-based treatments for substance use disorders, of course, that folks have trouble accessing. So the idea is to get folks access to those treatments. The problem is rounding up folks for mental health treatment, substance use disorder treatment, et cetera, is not going to work unless you have the capacity to deliver high quality,

ethically administered treatment to folks and settings for that. And currently there just aren't the right, there isn't the capacity to do this. And, in California, there is this huge investment in building new psychiatric spaces, hospitals, recovery centers and those are definitely necessary.

BECKER: And a funding mechanism, right? Using some of the millionaire's tax to help pay for some of these things. So there could be money too, right?

SISTI: Yes. Yes. There's, I think, $6.5 billionalso slated to be used for this. So I think that the idea is good and right.

It's just I think the idea of rounding folks up now before the system is built is the problem. I don't know that we want to begin the process of involuntarily committing people to nowhere, in other words.

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