Opinion | Britney Spears and the Last Resort of Mental Health Care

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Britney Spears’s testimony last week about her conservatorship — over the past 13 years, she said, she had been financially exploited, forced to take lithium and prevented from removing her birth control device — was to many a shocking revelation, made all the more so by her celebrity status. For others, though, the reaction was one of recognition.

“As troubling and extreme as Britney’s circumstances may seem,” Erica Schwiegershausen wrote in The Cut, “much of what she recounted — such as being medicated without consent and subjected to involuntary psychiatric evaluations and institutionalizations — likely feels familiar to anyone with experience of mental illness.”

What broader lessons can be drawn from Spears’s story about the way Americans with serious mental illnesses can be stripped of their rights, and how should the system change? Here’s what people are saying.

Conservatorships and commitment, explained

Conservatorship — also known as guardianship in some states — is a legal arrangement typically reserved as a last resort for those who are severely disabled. If a court deems someone unable to take care of himself or susceptible to financial exploitation, a judge designates a representative to manage the person’s affairs and estate. In Spears’s case, that representative was her father, who petitioned the court for control after she was hospitalized twice in 2008 for involuntary psychiatric evaluations.

“Conservatorship means the court is taking away the civil liberties from one person and giving them to someone else,” Zoe Brennan-Krohn, a staff lawyer with the American Civil Liberties Union’s Disability Rights Project, said last year. “It is the court weighing into the person’s life and saying you, as a person with a disability, are no longer able to make decisions about yourself and livelihood — such as where you live, and how you support and feed yourself — and we are putting someone else in charge of making those decisions.”

By the numbers: The Justice Department estimated in 2017 that there were around 1.3 million adults and at least $50 billion in assets under conservatorships. A far larger number, 13.1 million adults — about one in 20 — are estimated to have a serious mental illness that substantially interferes with or limits their ability to function.

Yet conservatorship is only one form of restriction this population faces. Another is involuntary civil commitment, in which a judge may order a person deemed to have a serious mental illness to be confined in a psychiatric hospital or to receive supervised outpatient treatment, like the medication regimen Spears described.

Despite the controversial nature of the practice, “a striking amount of basic information about civil commitment, including annual numbers of involuntary psychiatric hospitalizations, remains unknown to the U.S. public,” Dr. Nathaniel Morris, a psychiatrist at Stanford University, wrote last year.

The troubled history of depriving mentally ill people of their autonomy

For some people struggling with a serious mental illness, involuntary commitment can be salutary, even life saving. One 2003 study, for example, found that involuntary outpatient treatment can decrease hospital recidivism and increase patient quality of life, in part by improving adherence to treatment. Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center, has estimated that more than 90 percent of people with psychosis could be stabilized and discharged within a few weeks or so.

But the history and ethics of involuntary commitment in the United States are extremely fraught. The first mental hospitals in the United States were created in the 1800s with the intention of providing a humane, protective environment where patients could receive adequate care. But by the early 20th century, as funds and staffing shrank, many asylums had effectively become warehouses for people whom society had judged “unfit” — a determination shaped by the eugenicist politics of the day.

“Historically, many have been deemed insane for simply having unpopular opinions, or for behaving in ways that were offensive to common attitudes and contrary to convention,” Moira Donegan writes in The Guardian. “This is particularly true of women, who have a long history of being deemed insane for trivial reasons by those who are either committed to misogyny or interested in their money.”

The abuses wrought by institutionalization were in many cases profound and irreversible: From the 1920s and to the 1950s, some 20,000 people in California alone were sterilized in state institutions.

The second half of the 20th century saw a turn away from institutionalization, spurred in part by the advent of anti-psychotic drugs. In 1963, President John F. Kennedy signed the Community Mental Health Act, which promised to replace mental institutions with a system of community-based care. “The idea was that those released from the institutions would move back into neighborhoods, with easy access to a doctor, therapists, at-home services if needed,” Benedict Carey wrote for The Times in 2018. “The money saved by closing the hospitals would be used to support independent living.”

But state governments largely did not make good on Kennedy’s promise. His plan was supposed to create 1,500 well-staffed, well-funded community mental health centers across the country, but only about 750 were ever built, and zero were ever fully funded. Today, more than a third of people with serious mental illness do not receive medical help, and the‌ ‌country’s‌ ‌largest‌ ‌facilities‌ ‌housing‌ ‌mentally ill people ‌are‌ ‌jails.

The upshot: “Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness — a disparity larger than for race, ethnicity, geography or socioeconomic status,” Dhruv Khullar wrote for The Times in 2018. “The extraordinary life expectancy gains of the past half-century have left these patients behind, with the result that Americans with serious mental illness live shorter lives than those in many of the world’s poorest countries.”

What would a more humane system look like?

The question tends to divide people into one of two camps, as the Times editorial board wrote in 2018: one that calls for more psychiatric beds in hospitals, which have plummeted by 95 percent since the 1950s, and another that argues that the problem is not the lack of psychiatric facilities but how little has been done to fill the void since they were shut down.

“Neither side wants to return to the era of ‘insane asylums,’” the board wrote. “Nor does anyone disagree that the ‘system’ that replaced them is a colossal failure.” What’s needed, they argued, were three major reforms:

A continuum of care: The community-based care model envisioned in the 1960s should be given a chance, with “community mental health centers, short-term care facilities, and — yes — longer-term arrangements for the small portion of people who can’t live safely in the community.”

Insurance equity: On paper, health insurers are required to provide the same level of benefits for mental health treatments and services as they provide for other medical services. But in practice, insurers often act as a barrier to mental health care.

Sensible commitment standards: In general, people cannot be hospitalized against their will unless they pose a clear and significant danger to themselves or others, but the standard varies by state and is not always properly enforced.

Another view: Adults without disabilities make decisions that run counter to their best interest all the time, and some argue that disabled people should have the right to do the same as long as they’re not harming someone else.

“If a nondisabled person decides, ‘I’m going to skip work and have a couple of drinks and eat a whole bunch of doughnuts and then take a nap,’ that person isn’t going to have any of their fundamental rights taken away,” the journalist Sara Luterman tells Slate. “That’s a thing that normal people are allowed to do. But if you have a disability and you do those things, that’s seen as further evidence of your incapacity and inability to responsibly manage your own life.”

Even in cases where involuntary commitment is justified, its benefits have to be weighed against its potential costs, which include hopelessness, fear and trauma. “I’m grateful for the medical care I got in the hospital; I know now that I needed it,” Schwiegershausen writes of her experience being hospitalized for a manic episode. “But there were ways that I was still myself throughout the experience, and I’ll never forget what it was like to have people question my sanity.”

Do you have a point of view we missed? Email us at [email protected]. Please note your name, age and location in your response, which may be included in the next newsletter.

READ MORE

“Amber Tamblyn: Britney Spears’s Raw Anger, and Mine” [The New York Times]

“Now Mental Health Patients Can Specify Their Care Before Hallucinations and Voices Overwhelm Them” [The New York Times]

“The Darker Story Just Outside the Lens of ‘Framing Britney Spears’ [The New Republic]

“When Mental Illness Is Severe” [The New York Times]

“When Will People Like Britney and I Get to Control Our Own Bodies?” [Elite Daily]

WHAT YOU’RE SAYING

Here’s what readers had to say about the last debate: Can ranked-choice voting cure American politics?

David from California: “Ballot exhaustion cannot happen if voters are allowed to rank all candidates: If there are 10 candidates, I should be allowed to rank them one through 10, not just my top five as in New York, or top three as in Oakland, Calif. It makes no sense to criticize a flaw that itself is caused by the use of a compromised hybrid of ranked choice.”

Dennis from New Jersey: “Approval voting is a much simpler, faster and fairer approach to allow voters to choose multiple candidates in an election. It’s easier for voters to understand: Just vote for every candidate you find acceptable.”

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