US Letter: Treatment of mental illness moves towards involuntary committals

In the 1980s when I was starting out as a young health correspondent, one of the big areas of medical reform was in psychiatry.

The large old psychiatric hospitals were being closed down. There was a shift in thinking, not just in Ireland but internationally, away from the detention and segregation of those experiencing mental illness.

The fashionable term at the time was care in the community.

The idea was that, if at all possible, patients should live in their own homes or in small group accommodation. Those with serious illness would receive care in units in general hospitals rather than in standalone psychiatric institutions.

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The message appeared to be that detaining someone against their will for psychiatric care should be the exception; to be used only where absolutely unavoidable. And even then, safeguards were put in place such as independent reviews and appeals processes.

The concept behind these reforms was sound. However there was always the danger that once in the community, of some patients falling through the cracks and essentially receiving little or no treatment at all – a risk that is very real in this part of the world.

The health service in the United States is undoubtedly one of the best anywhere, as long as you have good health insurance or a lot of money to pay for it.

Without sufficient resources, access to healthcare is rather more uncertain.

Looking at people living in tents on roundabouts in Washington – not too far from the very centres of power – as well as the large numbers dwelling on the streets in west coast cities, I wonder about the level of healthcare available to them, despite the best efforts of dedicated outreach professionals, volunteers and charities.

Studies suggest there is an interconnection between mental illness and homelessness as well as with poverty and social disadvantage.

And research in the United States also indicates untreated mental illness is a very significant issue.

Organisations promoting better care, such as Mental Health United States, maintain that over half of adults with a mental illness are receiving no treatment.

Earlier this week authorities in New York announced a strategy that would see police and medics working for the city adopting a more robust policy to get people with mental illness off the streets and the subway system and into treatment – even if this means involuntarily placing in hospitals those who refused care.

Broadly similar measures are being proposed elsewhere.

In California in September, governor Gavin Newsom signed legislation known as the Community Assistance, Recovery and Empowerment Act which would let family members, first responders and others ask a judge to draw up a treatment plan for someone diagnosed with certain illnesses, including schizophrenia. Those who refuse could be placed under a conservatorship and ordered to comply.

New York mayor Eric Adams said there would be “no more walking by or looking away”. He said there was a “moral obligation to act”.

“These New Yorkers and hundreds of others like them are in urgent need of treatment, yet often refuse it when offered. The very nature of their illnesses keeps them from realising they need intervention and support. Without that intervention, they remain lost and isolated from society, tormented by delusions and disordered thinking. They cycle in and out of hospitals and jails.”

The mayor said it was a “myth” that the law in New York required a person to be behaving in an “outrageously dangerous” or suicidal way before a police officer or medical worker could take action.

“The common misunderstanding persists that we cannot provide involuntary assistance unless the person is violent, suicidal or presents an imminent risk to the public”, he said.

It did not take long for critics to attack the plan.

The New York Civil Liberties Union said forcing people into treatment was a “failed strategy” for connecting people to long-term care.

“The mayor is playing fast and loose with the legal rights of New Yorkers and is not dedicating the resources necessary to address the mental health crises that affect our communities. The federal and state constitutions impose strict limits on the government’s ability to detain people experiencing mental illness – limits that the mayor’s proposed expansion is likely to violate.”

The Coalition for the Homeless also denounced the mayor’s plan, saying the city should focus on expanding access to voluntary psychiatric treatment.

Arguments will undoubtedly continue between supporters and opponents of the new initiatives in the United States. But 40 years on from the shift towards care in the community, an era of more involuntary committals may be returning.