Thoughts on Mandatory Treatment

Recently, California passed a law making it easier to force someone into treatment for substance dependence or other mental health issues. As with many things, I have opinions, mainly that mandating mental health treatment is not a good idea.

Yes, there are times when a person needs help but is not willing to seek it. Under the current system, when someone is actively suicidal, the options are death or involuntary commitment. I don’t have every answer, but it certainly is not “put more people in treatment against their will.” In fact, I believe if we fixed many of the barriers to getting support and resources, we could prevent people from getting to the crisis points that we use as justification for these holds.

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Informed Consent

According to the APA Ethics Code, 3.10, Informed Consent:

When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code.

In other words, we must obtain informed consent before providing mental health services. That means the client understands and agrees to the treatment. Other ethics codes have similar requirements.

Is it really “consent” if someone agrees to treatment because they are mandated to do so? Are they agreeing to treatment, or are they trying to escape or avoid an involuntary hold? It would be impossible to know.

Effectiveness of Treatment

Much of my therapy practice is children and adolescents (so much so that I wrote an entire book on ethics and clinical documentation with this population), a group that often comes for services because someone else told them to. Usually, it is the parent who decides that a minor needs treatment, and the adults provide consent.

Side note, even though it is considered legally and ethically permissible for someone else to make the minor’s medical decisions on their behalf, I am still required to get assent (explain treatment at a developmentally appropriate level and ensure that the client agrees to participate).

When a client does not want therapy, they tend not to engage. When they don’t engage, treatment does not help them. When they are forced to continue treatment against their will, they learn that mental health treatment is unhelpful, awful, and harmful. It is unlikely to be helpful.

While writing this blog post, I spoke to a friend who has been mandated into treatment in the past. They asked to remain anonymous but said that I could share from their experience:

I lied to get discharged earlier than I should’ve been able to. I was still in crisis but figured I had better chances of getting the support I needed outpatient than I did staying there.

This is a common occurrence in involuntary inpatient treatment. This likely contributes to the high instance of suicide and self-harm following discharge from such programs.

Harm and Abuse

Not only is it unlikely that mandated treatment can benefit clients, many face harm and abuse in the system. There is already a power dynamic in place within the healthcare system, and when the client does not have the option to refuse support, that increases the risk for abuse.

Listen to testimonials from people who experience abuse when in an involuntary hold. And many share that, when they express anger, frustration, or disagreement with staff or providers, they are further pathologized.

Imagine you are forced into treatment against your will. Not only does it not help you, but you are harmed in the course of your involuntary treatment. Later, you are ready to seek support. How likely are you to return to that system? Forcing people into care makes them less likely to seek help.

When involuntary treatment is the only resource we have, it feels impossible to imagine anything else. But with these systems causing more harm, expanding them is not the answer.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. She completed her internship at the National Psychology Training Consortium with specializations in assessment and rural mental health. Currently, she specializes in trauma-informed and neurodiversity-affirming care, and she is certified in telemental health. Dr. Marschall runs a private practice, RMH Therapy, where she provides individual and family therapy as well as psychological assessments across the lifespan. Dr. Amy Marschall is an author and professional speaker.

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