Rethinking Involuntary Psychiatric Hospitalization
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Involuntary commitment raises ethical concerns, compromising the autonomy of individuals in crisis and, despite its protective intent, can foster mistrust and cause long-term psychological harm
You’ve probably seen it in TV shows, movies, books or the news: someone has a breakdown, wants to hurt themselves or others and is committed to a psychiatric hospital, sometimes against their will. Right now, hospitals across the country are overwhelmed by the number of mental health patients. It’s important to have resources for emergency situations, but is hospitalization always the right solution?
There are two different kinds of hospitalization, voluntary and involuntary. Voluntary hospitalization means the patient chooses to go to the hospital willingly. They may have been encouraged by health providers, family, friends, coworkers, or other members of their community to access this level of care, and they ultimately admit themselves to the hospital. Involuntary hospitalization, on the other hand, is when the patient is taken to the hospital against their will. This can be by force (e.g., police, ambulance, etc.), coercion (feeling threatened or seemingly given no other option) or mis- or disinformation (being told untrue or misleading information about the experience, consequences and potential harms of hospitalization).
The difference in these situations is significant for many reasons, and most of them connect to agency. When someone knowingly and willingly goes to the hospital for mental health needs, they are acting from a place of agency and empowerment, even if hospitalization is not an ideal situation. When someone is involuntarily hospitalized, their agency and right to self-determination are violated. This is a violation of human rights according to the United Nations (UN) and inherently counterproductive to therapy.
In 2016, a UN working group studying involuntary commitment in the United States specifically called this practice “inherently discriminatory” and recommended the government "enact an enforceable right under legislation for persons with psychosocial disability to live in the community and be provided with health services that are free from coercion and restriction” (Human Rights Council, 2017). Similarly, the Convention on the Rights of Persons with Disability (2015) supports the absolute prohibition of detention on the basis of impairment, including mental health impairment. No exceptions are made for cases of danger to self or others. In sum, when we participate in the involuntary commitment of someone for the purpose of treating a mental health crisis, we are knowingly violating their human rights.
Problematic on its own, this violation has consequences specifically for the issue hospitalization is attempting to treat. This is a rare instance in our "progressive" society where we discredit the marginalized, for the same reason they are marginalized, while simultaneously claiming to help them. Research identifies negative outcomes of forced hospitalization and highlights inherent issues in the quality and validity of prior research. In these studies, involuntarily committed patients report decreased trust in the mental health system, a lack of willingness to be honest about mental health challenges in the future, and direct harms such as dehumanization, experiencing moral judgment, violence, neglect, humiliation, forced drugging and more (Jones et al., 2021; Borecky et al., 2019; Saya et al., 2019; Callaghan et al., 2013). Some researchers go as far as to say that given the negative consequences, involuntary hospitalization primarily benefits therapists and other caretakers (Saya et al., 2019). In this way, we are putting people in distress at higher risk of serious physical, sexual, psychological and financial harm to make ourselves feel more comfortable knowing our clients and/or loved ones are locked away.
This may come across as harsh because our intention is to assist people, yet we might feel powerless in the face of these decisions. Discussing the violation of human rights and the potential for harm can be uncomfortable but necessary. We can’t continue this practice without recognizing the ethical and practical challenges it presents. It's a complex issue with tough questions and even tougher answers
Staying informed about current perspectives on involuntary hospitalization better equips us to make difficult judgment calls. We may encounter situations that force us to make decisions we wish we didn’t have to, but the least we can do is be transparent about the risks and benefits involved. I encourage you to reflect on this perspective and consider: Who are you serving, and who are you protecting?
References
Borecky, A., Thomsen, C., & Dubov, A. (2019). Reweighing the ethical tradeoffs in the involuntary hospitalization of suicidal patients. The American Journal of Bioethics, 19(10), 71–83. https://doi.org/10.1080/15265161.2019.1654557
Callaghan, S., Ryan, C., & Kerridge, I. (2013). Risk of suicide is insufficient warrant for coercive treatment for mental illness. International Journal of Law and Psychiatry, 36(5-6), 374–385. https://doi.org/10.1016/j.ijlp.2013.06.021
Committee on the Rights of Persons with Disabilities, Guidelines on article 14 of the Convention on the Rights of Persons with Disabilities (2015).
Human Rights Council, Report of the Working Group on Arbitrary Detention on its visit to the United States of America (2017).
Jones, N., Gius, B. K., Shields, M., Collings, S., Rosen, C., & Munson, M. (2021). Investigating the impact of involuntary psychiatric hospitalization on youth and Young Adult Trust and help-seeking in pathways to care. Social Psychiatry and Psychiatric Epidemiology, 56(11), 2017–2027. https://doi.org/10.1007/s00127-021-02048-2
Mental Health and Developmental Disabilities Code, 405 ILCS 5/Ch. III (n.d.) https://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=040500050HCh.+III&ActID=1496&ChapterID=34&SeqStart=8000000&SeqEnd=19600000
Saya, A., Brugnoli, C., Piazzi, G., Liberato, D., Di Ciaccia, G., Niolu, C., & Siracusano, A. (2019). Criteria, procedures, and future prospects of involuntary treatment in psychiatry around the world: A narrative review. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00271
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