The Shame(lessness) of the States

Thank god for scientology.

Or, more specifically, the “Commission des Citoyens pour les Droits de l’Hommes,” a front organization for the church dedicated to denouncing the “human rights violations” of French psychiatry. Their broad-brush condemnation of medication is probably unhelpful. But they are, as far as I can tell, the only group that has put in the painstaking work of compiling the annual reports from each of France’s Departmental Commissions on Psychiatric Care, which gives the best portrait I can find of involuntary hospitalizations in the country:

In its defense, the French government actually does publish how many people it treats without consent each year, and, in the defense of the French state and media more generally, some people actually seem to care that this number appears to be going up (not to mention the much-appreciated outrage at the truly insane idea that involuntary psychiatric internments should be used to police those suspected of terrorist sympathies):

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These two charts tell somewhat different stories. The scientologists, for all their indignation, find a stable number of involuntary hospitalizations since 2004, while the government’s own statisticians report that an increasing proportion of people cared for in the public system receive at least some involuntary care. I’ve been puzzling through the data. The story changes if you count involuntary hospitalizations (stable) or people hospitalized involuntary at some point in the year (going up). And the government’s numbers are bigger because they include “programmes des soins,” which is where you get to leave the hospital but you have to take your meds. If you don’t, you have to come back to the hospital, although who brings you there isn’t exactly clear. Constraint? Sure. The same kind of constraint as being shut up in a hospital? Probably not.

There are similar stories from around the world. In England, even as the number of hospital beds has collapsed, the number of involuntary detentions has gone up–not just a proportion of those filling the remaining beds, but in an absolute number:

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The conservatives found this rise in detentions – particularly, the fact that some people were held in jail cells – distressing enough to mention it in the election campaign. Their data is good enough to show that they’ve gone from having a rate of hospitalization way lower than that in France to one that is pretty comparable.

And the U.S.? The government published statistics on the proportion of people entering the hospital involuntarily in 1980, and then took at hiatus until… 2016. You can only find these numbers if you frantically ctrl+f every SAMHSA report you can find looking for the word “involuntary.” The way they measured it in 2016 is useless enough that you can’t actually count the total number of hospitalizations, so this graph I made is both dramatic and probably somewhat misleading:

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I still haven’t found a way to work some regressions into my dissertation. But I’ve found this kind of data sleuthing to be seductive – and frustrating. My research assistants have been FOIA-ing various state departments of mental health. Most of them keep track of state hospital admissions – which are almost 100% involuntary and, after 50 years of de-institutionalization, a tiny fraction of total psychiatric hospital admissions. But I’ve been told, over and over again, that they “do not compile or maintain” statistics on the most profound mental health intervention that actually takes place in their state.

If you heroically extrapolate from Florida and California – who actually handed over some data – you wind up with something like 1.7 million involuntary adult hospitalizations per year. The U.S. rate is at least three times that in France, but reports like that of the President’s “New Freedom Commission” on mental health don’t even mention it. In an era of recovery and neuroscience, civil commitment isn’t sexy. But at least in California, loosening civil commitment statutes has been pushed as the solution to recalcitrant, ‘service-resistant’ (or refusing) homeless people.

Count me in with the scientologists in thinking it might be nice to measure who we’re hospitalizing, how frequently, and what happens to them, before we think about ramping it up. Or call me crazy.

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