Elyn R. Saks, Refusing Care: Forced Treatment and the Rights of the Mentally Ill

Journal of Sociology and Social Welfare, June, 2004 by Kia J. Bentley

Elyn R. Saks, Refusing Care: Forced Treatment and the Rights of the Men tally III. Chicago: University of Chicago Press, 2003. $35.00 hardcover, $24.50 papercover.

Legal scholar and trained psychoanalyst, Elyn Saks acknowledges several times throughout her book that treatment refusal, the topic of this most recent treatise, is not the most pressing issue in mental health today, rather societal neglect and our lack of will to provide adequate community treatment to those who need and want it is. Nevertheless, she persuasively purports that a detailed exploration of the "overinterventionalist pole" in the pendulum swing of mental health care is important as well. I am completely convinced. As I read, I began to see this contribution as a provocative demonstration of the centrality of choice in mental health service delivery. Indeed, one of the most refreshing aspects of the book is her implicit argument that the humanity and dignity of clients should be at the center of the mental health system, and should dictate our structures of decision-making about care and treatment. Saks helps us imagine what that would look like. And what could be more important than that.

There are a number of good paraphrases for the guiding question of the book: When should we treat those who don't want treatment, and when are their choices, as Saks puts it, "worthy of respect," or, on what basis should people with mental illness be treated differently than the non-mentally ill, or, how do we go about deciding who gets to decide about treatment? Saks argues that taking extremes of positions on these topics is both irrational and unrealistic; instead she suggests solutions will lie in a balance between patient autonomy and paternalism. Her assumption is that the treatment of people with mental illness should be logical and consistent. She really goes beyond that, however: Early on Saks' clearly defines herself as someone who most strongly values autonomy, and finds the lingering prejudice toward people with mental illness to be a totally unacceptable basis for practice or policy.

While avoiding caricatures, Saks' opening chapter compares and contrasts the socialization and subsequent values of physicians versus lawyers. The importance of understanding the differing "fears and fantasies, empirical suppositions and predictions" of the healer versus the advocate cannot be underestimated. Indeed, it could be said that the tension between these two professional meta-perspectives is the backdrop for current conflicts and contradictions in rules and regulations about treatment refusal today. A less effective Chapter 2 visits the topic of the so-called myth of mental illness--is mental illness a real phenomena, and if so what it is? Admittedly, the author may need to make her position on this tired question known, and she does: "I am persuaded that a concept of mental illness is useful and necessary" (p. 42). Before she gets to that conclusion, she exhaustively critiques every possible criterion for defining mental illness and notes the numerous definitional problems of "under- and over-exclusively." The exhaustive nature of the analysis there is a foreshadowing of what is to come.

The heart of the book, then, is the systematic consideration of three special cases of forced care-involuntary commitment, forced medication, and the use of seclusion and restraints. Regarding commitment, Saks argues why the standard should require serious impairment, the patient's "transformation into a different person," serious danger or grave disability, and in many cases, a likelihood of treatment benefit. Likewise, she provides exquisite detail in favor of a "robust" right to refuse medication. In both cases, however, she also argues for what she calls the "one-short-rule," that gives doctors much more leeway to intervene during the first psychotic break. After that the patient should develop a set of advanced directives that dictate what should occur in the future, should she or he become incompetent again. She notes about medication in particular, "what the refusing patient needs most is talk, not force (p. 104). She argues for a focus on gaining and maintaining consent. She even offers lengthy psychoanalytic interpretations of medication refusal from the client's perspective, which includes topics like transference, secondary gain and even something about sexual imagery. Here more than anywhere, Saks' pro-medication bias is evident. There is no acknowledgement of a more sociopolitical perspective on medication use and refusal, or that not everyone, especially the anti-psychiatrists, is as gung-ho and optimistic about the effectiveness of psychiatric medication. Her strongest language is saved for her discussion of restraints: "barbaric," "degrading," "humiliating," "drastic," and "brutal." She states unequivocally that "tying a patient to a bed spread-eagled should simply be abolished in a civilized country" (p. 159). Even seclusion, while defensible in a small set of circumstances according to Saks, is empirically unjustified and likely counter therapeutic.