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A word about involuntary care.


Ideally, no one would require our services.  We would be thrilled if societal enlightenment regarding the severely mentally ill led to radical systemic reform: everyone would receive the care they required as soon as they required it and for as long as they required it, and we would have no such work left to do.  In the meantime, we’d like to address the possible concern of all who are mindful of patients’ rights that we may be working with families to obtain treatment which their loved ones do not want. 


The vast majority of those diagnosed with psychiatric disorders are not gravely disabled or dangerous to themselves or others due to their symptoms, and they have the capacity to decide whether or not they will receive treatment.  Of those who provide informed consent nearly all will incorporate treatment into largely-unchanged lives or otherwise remain in open settings, and most of those who articulate informed refusal cannot be forced to accept treatment.  If the families of such clients seek our services, we will provide education and recommend voluntary resources they can suggest to their loved ones.  It would be unethical to do more.


A comparatively small number of those diagnosed with psychiatric disorders are catastrophically impaired by their symptoms and intermittently or continually lack the capacity to consent to or refuse treatment without which they and/or others would face grave danger.  These severely mentally ill individuals must be treated on an involuntary basis while they lack capacity.  In fact, when they are unable to provide informed consent it is illegal and unethical to admit them to a locked psychiatric unit on a voluntary basis merely because they do not refuse it.

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Despite the high stakes of failing to treat these catastrophically impaired individuals, failure is commonplace.  There are not enough acute-care locked hospital beds, not enough long-term locked hospital beds, not enough PERT clinicians, not enough licensed board-and-care facilities.  While stories in the papers bring disproportionate attention to sporadic marginal improvements – a few hospital beds, or a small homeless shelter with no mental health component – new mental health dollars are more often allocated to relatively inexpensive resources like community-based case management.  But even the most dedicated intensive case managers cannot keep their severely impaired clients safe, healthy, and thriving in unstructured, poorly-supported open settings where treatment is unenforceable and stressors proliferate.  Decompensation is a foregone conclusion for those who have never been allowed to achieve true stability in the first place.


Our many years of work have been exclusively on behalf of these catastrophically impaired, severely mentally ill individuals and their families.  Our expertise lies not just in providing direct service, but in the evaluation of client capacity and the determination of what treatment and systemic service is necessary and appropriate.  We will always work to optimize treatment and service for those whose lives depend on it but who lack the capacity to refuse or consent to it, and we will never endorse unwanted involuntary treatment for any client with capacity.

(While we’re on the subject, if you believe that abuse, neglect, or discrimination have befallen you or someone you know at a behavioral health facility in San Diego, or if you just have questions about patients’ rights, you could not ask for a better resource than the Patient Advocate program at Jewish Family Service.)

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