As psychiatrists, my colleagues and I sadly see some of the most ill members of our society on a disturbingly frequent basis. The majority of these troubled individuals recognize their need for treatment; or if they do not willingly acknowledge it, many are at least open to accepting help for their difficulties. Yet sometimes as professionals our hands are tied, relegated to the heart-wrenching position of observers of a pending disaster, put in this position by laws established to protect the civil liberties of our patients.
In many states the laws regulating commitment to a psychiatric hospital requires that the individual is at a strong, fairly imminent risk of harming himself or others or to use a more popular phrase, is "a clear and present danger" to one's self or others. Perhaps to be even more direct, there has to be a very high suspicion that not placing a person in the hospital would result in suicidal or homicidal actions in the very near future. Consistent with our core beliefs as Americans, the law protects the rights of the individual, as it should be.
Involuntary hospitalization deprives a person of his or her liberty and freedom of choice to receive medical/mental intervention. Only when the danger level is too high, can this basic right be challenged.
Unique to the United States, our legal system is structured to oppose possible actions that would strip away a person's basic inalienable rights. Someone can't be put in an institution and the key thrown away, just for protesting against the governing administration for example; whereas in some countries such actions would be cause for incarceration in either a political or mental asylum. Generally in America, you have the right to appeal any restriction you feel has been unfairly placed upon you.
Occasionally in the process of trying to protect individuals in our society, we do just the opposite. Put another way, we need to recognize that there can be collateral damage as a result from the basic freedoms we hold so dear.
Though a bold, and some may even say offensive statement, it is perhaps best elucidated by the daily outlandish personal actions displayed by former pop princess Britney Spears. Whether you think her problem is biological (which I suspect plays a significant role), is related to substance abuse or environmental issues such as her divorce and continuing custody issues, or her behaviors are the actions of a spoiled successful young woman who has easy access to excess; few would question her dire need for professional help. Most agree that a train wreck is inevitable if Britney continues to be left to her own devices as unfortunately, she appears to see no major problem with her actions. Although she currently seems to be in need of professional help that may best be provided in a hospital-type setting, she does not meet the criteria of imminent danger outlined earlier. She appears to be destroying her own life and wreaking havoc on those she loves. If she continues on her present path, suicide becomes a serious possibility, leaving additional residual collateral damage to the mental health of her children as well.
One need not be a psychiatrist to feel sad and somewhat helpless watching Britney's daily escapades. But she is hardly alone in this downward spiral. Her story is true for a significant number of mentally ill persons in our country. There are many whose lives are dangerously falling apart, but who deny their problems and refuse treatment. Being an impotent bystander, be it doctor, family member or friend, and having to witness the life of someone you care about implode, is a sad, frightening and potentially devastating experience.
I would never promote taking away anyone's individual rights, but what do we do when we see someone who is very clearly self-destructing in front of our eyes? I don't know what the right answer is, but I have certainly grappled with the question professionally and find it interesting to hear the media hinting at it now that one of the headline princesses raises the issue. In the process of preserving one's basic rights, how far can we intervene to help preserve his or her very life?