Law Prof Discusses the Ethics of Involuntary Hospitalization

SARA SIDNER, SENIOR CORRESPONDENT: Now, we turn to a woman who has dedicated her career to how people with mental illnesses are cared for. Professor Elyn Saks, focuses on the important ethical issues surrounding their treatment. And here, she is speaking to Michel Martin about her own struggles with schizophrenia, and how to best help others.

(BEGIN VIDEO CLIP)

MICHEL MARTIN, CONTRIBUTOR: Professor Elyn Saks, thank you so much for joining us.

ELYN SAKS, ORRIN B. EVANS PROFESSOR AT USC GOULD SCHOOL OF LAW: I’m really delighted to be here. Thank you so much for inviting me, such an important issue.

MARTIN: It is. And I’m so glad we had a chance to talk with you, because you occupy such a special place in conversations about this issue.

SAKS: Right.

MARTIN: Because you are a distinguished scholar.

SAKS: OK.

MARTIN: You’ve done a very important work, but you have also lived, for many years, with a diagnosis of a serious illness. So, do you mind if I just start with your story? How did the science of mental illness first manifest in your life.

SAKS: When I was a senior in high school, I read Sylvia Plath’s “Bell Jar” and it sort of spoke to me as it does to many teenage girls. So, one day I just got up in the middle school and started walking home, it was about three miles away. And something strange happened, which I started noticing that the shapes and sounds, and so on of everything around me were really different and scary. And I was hearing things, saying, you know, you are special. You are especially bad, you know. Do this. Do that. And I — you know, I was extremely frightened.

MARTIN: You’ve been diagnosed with — living with schizophrenia. Just as briefly as you, because I just think there are so many mythologies around this, like, what is it?

SAKS: So many mythologies. So, a lot of people think because it’s schizophrenia, that it’s a multiple personality disorder. But it decidedly is not personality disorder. It’s a different category of illness. MPD is a dissociative disorder and schizophrenia is a psychotic disorder. So, they’re completely different things that people might have. A lot of confusion about, you know, how dangerous people are and how they’re able to take care of themselves. The stats on dangerousness are very much, don’t show the people of mental health disorders are dangerous. They’re rather victims, more likely, than victimizers.

MARTIN: How does it generally manifest in people?

SAKS: Basically, people have what are called positive symptoms, which means things like hallucinations, delusions, disorganized speech. Negative symptoms are things like apathy and withdrawal and inability to work or connect with people. So, I often have the symptom that I tell hundreds of thousands of people with my thoughts.

MARTIN: Oh, that sounds hard.

SAKS: It’s very hard. It’s very hard.

MARTIN: Yes. Uh-huh.

SAKS: I’ve also had hallucinations, rarely, where I would see a man with a raised knife standing in front of me, or a woman at the foot of my bed at night. So, delusions, hallucinations, disorganized speech. So, people have something called word salad where they put together words that seem like they have a connection, but they don’t really.

MARTIN: And can you cure these illnesses, or is it — at the current moment, is it only that they can be generally controlled?

SAKS: So, we have medications and therapies that can help people put a good life for themselves together. But, you know, it’s very unlikely that anyone would ever — be able to get off medication and do OK.

MARTIN: If you are in the throes of say, a psychotic episode, right?

SAKS: Uh-huh.

MARTIN: Do you know something’s wrong yourself?

SAKS: Yes, it’s not uniform. I think probably about 50 percent of people understand what’s going on and make decisions about treatment and so on. And then another 50 percent say, nothing wrong with me. This is just who I am.

MARTIN: You’ve been hospitalized many times. What happens when your hospitalized?

SAKS: You know, I have been hospitalized many times, but the last time was like in 1986 — ’83. And when I broke down at Yale Law School, I was put in a, you know, Yale New Haven Hospital Psychiatry Department.

MARTIN: You were there in voluntarily?

SAKS: It was very painful and very toxic. I mean, I think they were afraid that I was like a flight risk, so they wouldn’t let me go beyond a certain point on the ward in case I would run. So, that was kind of hard. They restrained made a lot. So, the first two days, 20 hours a day, and the next three weeks, five to 15 hours a day. And my chart had this notation which was, use restraints liberally, which I thought was pretty awful. They restrained me long periods of time, and they even wouldn’t let me go to group therapy because I would upset the other patients. You know, I was really, I think, badly mistreated. I remember when I was in the E.R., they restrained me. There was a woman looking in the E.R. through the glass in the door, and I was like, why is she looking at me? Am I a specimen? You know, a bug impaled on a pin, you know. It’s just really, really awful. And then also, one of my professors at the law school, I told them was going to do my student article on restraints. And I said, it must be very demeaning and painful, but I have — self-disclosing. And he said, oh, Elyn, you don’t understand. These people are psychotic. They’re different from you and me. They experience restraints differently than we would. So, don’t worry about them. And I didn’t have the courage, in that moment, to tell him, no, we’re not that different. And the, you know, the effect of force –mechanical restraint is very painful for people. I used to have nightmares every night about it.

MARTIN: Well, thank you for sharing that. I appreciated. One of the reasons we called you — well, the immediate reason we called you is that there is a new directive in New York to allow people in protective services, you know police, fire, emergency, et cetera, to force hospitalization in certain cases. You know, New York is a big city. It’s an expensive city to live in. It’s got a lot of people who are unhoused. So, people pay attention to the things that people in New York do in a lot of instances. So, I just wanted to ask, you know, what’s your, kind of, top line response to that given your own experience and given your work where you’ve extensively, kind of, studied and written about some of these issues?

SAKS: Yes, actually, the new mayor of L.A. noticed the New York situation and wants to do the same thing here, which I think is kind of a pretty good idea, you know. I think the best idea is to, you know, get people to want care and not use force. It’s a much more sustainable solution if someone buys in themselves than if they’re forced because the force stops, you have no intent of not to go back to the way things were. So, I think that is kind of important.

MARTIN: You said that you are pro-psychiatry but anti-force. What does it mean to be pro-psychiatry but anti-force?

SAKS: What it means is that we should find ways to study how we can get people to want care versus having to use force to get them in care. And I think that is really important and really good. And again, if you buy into the treatment, you’re much likely to stay on it, so that’s another reason.

MARTIN: The New York Mayor, Eric Adams, announcing this new policy, says that he thinks that people misunderstand or have, over the years, taken the wrong approach to this problem. I am quoting here from his announcement.

SAKS: Uh-huh.

MARTIN: He says that, “There is a common misunderstanding that we cannot provide involuntary assistance unless the person is violent, suicidal or presenting a risk of imminent harm”. His argument is that the standard is just too strict. That people who are not necessarily in imminent danger of hurting themselves or others, that if they can’t meet their basic human needs, that that should be the standard.

SAKS: You know —

MARTIN: What is your thinking about that?

SAKS: Yes, my impression is that that is already the standard. That if you’re dangerous to self or others or gravely disabled, meaning you cannot meet essential needs for food, clothing and shelter. Some jurisdictions say, can’t meet requirements for medical care, then you are simply committable. I mean, you know, one question is why can we round up people with mental health challenges, who are homeless, and not just homeless people who don’t have mental health. And I think the answer, you know, if you are homeless mentally ill, you may not be able to live as well as a homeless person who is not mentally ill. It’s also the case that we should be thinking about policing this context. Because a lot of times if police get involved, you know, the easiest thing to do is to bring them to a mental hospital or a jail. And you don’t have to really wait around or anything like that. I think actually the police are doing better than people think that they are. So — when I have my events on mental health and law, we always have a table with police and sheriff. The police also ask me to come down to see them and then separately to see the sheriffs to talk about what I think is the most effective, humane way to deal with someone who has a mental health challenge. So, as an example, in the typical context without mental illness, police use a show of force and that kind of gets people to stand down. But for people with mental health disorders, a show of force is just going to ratchet up the anxiety and make them more dangerous or whatever. So, we have to, you know, be thoughtful about how we approach people with mental health disorders. But I don’t think that it’s a good idea just to hospitalized everybody.

MARTIN: The impression that I get from you is that you don’t object on its phase to requiring some people to involuntarily get psychiatric care and even being hospitalized?

SAKS: I’m not an absolutist that says it’s never permissible, it’s a bad thing to do. I think there are cases where it’s the right thing to do.

MARTIN: I do think that there is a concern that hospitalization will be abused. I mean the fact, is around the world, you know, psychiatric care has been used to punish dissidents, has been used to just sort of kind of get people out of sight, and then nothing happens when they’re out of sight, right?

SAKS: Yes.

MARTIN: And then this becomes this vicious circle. But what are some circumstances in which you think that it could be beneficial?

SAKS: So, I think if someone is seriously mentally ill and unaware of that or doesn’t believe it will and not willing to try treatment, even though trying treatment is the most sensible thing to do. We just have to make a decision as a society of when do we make them get treatment? And I think that’s a, you know, a difficult and a hard, hard decision. And it’s, you know, it’s not just — well, let’s just say, everybody who’s homeless and has mental illness should be rounded up, that’s kind of awful. And if you look at the statistics, there is a lot of discrimination. So, most people who are involuntarily committed to psychiatric hospitals, at least in L.A., are African Americans. And most people who are put in jail or prison are African Americans. So, we’re — you know, we’re not doing this in the right way. I do think, you know — as I said, I think that some forced treatment is necessary and important. It should be the minimal amount of force that you can do. So, you should work really hard to get the person to understand what is going on and, you know, what their options are and what their assets are and stuff like that.

MARTIN: Talk, if you would a bit more, about something you raised earlier which is violence. I mean, you indicated that the number of incidents actually of violence actually committed by people with severe mental illness is relatively low.

SAKS: Correct.

MARTIN: But the ones that do occur are deeply frightening.

SAKS: Right, yes.

MARTIN: They are. I mean, it’s the idea that, you know, you’re just on the subway trying to go to your job and then somebody shoves you in front of a moving train, because they hear — they say they hear voices or somebody — you hear voices telling you to do it. And how should we think about this?

SAKS: I think as a society, we’ve done a disservice to people who have serious, mental illness, suggesting that pushing people in front of a subway or whatever is the norm, and that we really have to worry. And that’s not true. I mean in terms of insanity, only one percent of people have mental illness, and three quarters f that one percent are by agreement of the prosecution. Many people think that psychiatric patients, schizophrenic people are extremely dangerous. They’re going to commit violence, and then they’re going to be put in a hospital for the rest of their lives. So, that’s, kind of, a misconception.

MARTIN: We often think about this in terms of this, kind of, binary conversation about rights.

SAKS: Right.

MARTIN: This person has the right to not accept care.

SAKS: Yes.

MARTIN: Whereas other people say, I have the right to be in a peaceful environment. I’m guessing that maybe this rights conversation is not as productive as it could be. Is there another way we could think about this?

SAKS: You know, the question is what do we do about people who are refusing care but could have a much better life if they accepted care? I mean, rights may not be the right language. Maybe the language should be ability to make reasonable decisions. If they make decisions that we disagree with, that is not a sufficient reason to hospitalize them. If they make decisions that indicate that they don’t really know what’s going on, that’s a different situation. And I guess there is something called anosognosia which is people who don’t have insight that they have a mental illness. And I think with schizophrenia, it’s supposed to be the case of about 50 percent of people have anosognosia. And that is one thing we need to talk about, you know. Is that enough to force you to get care if you don’t know that you need it?

MARTIN: If you could wave a wand and change one thing, what would it be about the way we talk about this issue or address this issue from a matter of policy? What do you think that would be?

SAKS: Wave a wand to help people understand that the stigma is a real scourge, you know. People who have mental health challenges often don’t get help because they don’t want to be identified. I mean, when I used to sit at our admissions committee many years ago, some students would self- disclose in their application. And when I was in the admissions committee, half of the professors were like, and deans and so on, this person has gone through a lot of luck — a lot of stuff in life and they’re — they have come out the other end. How cool. We should give them a chance. And at the other end are people who say, do we really want to borrow trouble if someone with mental illness decompensates (ph). It’s going to affect other students and the morale of the school. And when students who are applying for law school or medical school asked me, should they self- disclose. I always give the pros and cons and let them decide. My real answer is if you don’t have to, don’t explain gaps in your resume, you shouldn’t. But I’m not going to say that because that just sends the wrong message, even if it’s really true, you know.

MARTIN: Do you think these conversations are getting better?

SAKS: I think it’s getting better because people are more willing to come forward and tell their stories, even if it could be risky. Actually, I had a friend, she was a psychiatrist at UCLA. And when I told her I was going to write my memoir, she strongly urge me to do it under a pseudonym. She said, you want to become known as the schizophrenic with a job? And I thought, you know, that’s not how I want to be known. But I think it just sends the wrong message that this is just too awful to say out loud, to do it under a pseudonym. And in retrospect, she said I was right and she was wrong. So, that was kind of interesting. So, things may be changing.

MARTIN: Professor Elyn Saks, thank you so much for talking with us today.

SAKS: Thank you for inviting me to talk.