Letter

To the Editor: Bill Anthony has been a wonderful pioneer in psychiatric rehabilitation and in promoting dignity, respect, and the recovery orientation in the treatment of mental illness. His multiple sclerosis (MS) is painful news to all of us who admire him ( 1 ). But as he notes, MS is not mental illness. Anthony's family does not have to contend with his denial of illness. He does not accuse them of having MS rather than himself. He does not vehemently reject medical treatment for this disease that he denies having. He does not have frightening delusions or hallucinations, refuse food because it is poisoned, waste away and decompensate in front of their eyes while family members stand helplessly by unable to make him accept treatment. Nor does he threaten or attempt suicide. On the contrary, he cooperates with his doctors, takes medications, and is a rational, willing participant in his own recovery.

Of course, Anthony is right in saying that force should have no place in a helping profession and that people really cannot recover from mental illness without free will. But there are stages of illness, levels of disability, and cognitive impairments that impede even the recognition of the concept and need for recovery and that preclude the exercise of judgment that is the basis of free will. Opposition to forced treatment as a championing of human rights is admirable if one does not have to cope with the realities of a severe psychotic episode or with the rights of others.

It seems to me that sometimes a mystifying dishonesty pervades this discussion. A noble ideological principle too often is coupled with an unconscionable indifference even to acknowledging the conditions that typically generate forced treatment. Psychotic and self-destructive behaviors can lead to terrible social consequences and may affect many people other than those who are ill. Children, siblings, spouses, and aging parents are among those deeply affected and psychologically harmed by untreated psychosis—not to mention the damaging effects to the persons themselves.

Are there alternatives to involuntary hospitalization? The United Kingdom has early-intervention teams that deal with people in their first episode of psychosis and that even attempt early detection. There are also high-risk and prodromal teams, subdivided into early intervention and prodromal intervention, as well as continuing care teams with specific criteria for "ultra high-risk subjects" and modes of intervention ( 2 ).With community outreach teams, skilled mental health workers can usually convince a frightened person to accept treatment. Services can be offered in the home before the need arises for forced treatment in a hospital setting.

I recognize and fully sympathize with the desire of consumers to end this profound insult to their integrity as human beings. We need viable alternatives, with high consumer participation, that are not ancillary but embedded in the system of care. But if all else fails, involuntary treatment in hospitals is preferable, any time, to the perils and indignities of jail, homelessness, or death on the streets. And in our current system, unfortunately it is often the only available prelude to the ultimate exercise of free choice.

Dr. Lefley is professor in the Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami.