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Book Reviews   |    
Refusing Care: Forced Treatment and the Rights of the Mentally Ill
Reviewed by Denise C. Kellaher, D.O.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.1.92
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by Elyn R. Saks; Chicago, University of Chicago Press, 2002, 304 pages, $24.50

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In Refusing Care: Forced Treatment and the Rights of the Mentally Ill, Elyn R. Saks, a professor of law and psychiatry at University of Southern California Law School, writes about the overinterventionalism of treatment—fueled by paternalistic tendencies—in mental health practice. Saks, who professes to have volunteered on a psychiatric ward, addresses three types of forced treatment: civil commitment, medication administration, and application of seclusion or restraint, and suggests a standard for the implementation of each. She is well intentioned in her elaborate discussions but obviously biased by her affiliation with the legal profession.

Saks dutifully presents the typical views of the psychiatrist versus the lawyer, clearly demonstrating the main contention of debate about forced treatment: the promotion of well-being—thus predicted long-term autonomy—versus preserved autonomy. This theme of offender versus defender of the individual's liberty in the mental health arena plays out relentlessly throughout the book, reminding the reader that strides made to empower persons with mental illness continue to be dissatisfactory to some.

Saks cites the inappropriate use of civil commitment by doctors who have overpredicted the risk of danger, wrongly labeled persons with mental illness as incompetent, and promoted the stigmatization of these individuals, thereupon curtailing their liberty. Indeed, per Saks, people would be better off incarcerated than hospitalized, because they have better employability after release. Since when have medical records interfaced with employment applications?

Saks submits that involuntary commitment should be used only when a person is severely impaired, is not him- or herself, and is treatable with medication during a first psychotic break. Then, the patient is expected to accept a new diagnosis and to make a decision about adherence to medication. What is lost in Saks' arduous protection of patient liberty is that the patient may be subject to yet more loss of liberty through worsening psychosis, because he or she will not have had sufficient experience with the illness to make decisions about adherence to treatment. Shouldn't the patient be allowed to undergo the stages of bereavement for the partial loss of consistent mental stability before making such decisions?

Saks scoffs at the practice of diagnosis due to stigmatization. She alleges that psychiatry tends to medicalize ordinary human conflict and to consider these interventions as benign. In fact, it is this view that maintains stigmatization, because diagnoses—she agrees with some—should be openly discussed in order to promote widespread acceptance. After all, by educating lay persons and patients about the validity of mental illness, shouldn't such concern about social stigma wane with time? Even celebrities have become outspoken about their own diagnoses, perhaps in part to educate the public—this helping to dispel the negative associations with being mentally ill. Truly, in Saks' efforts to destigmatize persons with mental illness, she stigmatizes psychiatrists as dictatorial administrators of treatments that are convenient for the doctor and for society at large but not for the patient.

I do recommend this book to all mental health providers for its thought-provoking perspectives. Although the book is fraught with seemingly irresponsible generalizations, psychiatrists should be aware of these negative views and become even more resolved to educate patients, the general public, and, especially, mental health lawyers.

Dr. Kellaher is resident psychiatrist (PGY-3) at the University of Hawaii in Honolulu.

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