Involuntary hospitalization is a legal procedure used to compel an individual to receive inpatient treatment for a mental health disorder against his or her will. The legal justifications vary somewhat from state to state, but are generally based on a determination that a person is imminently dangerous to self or others; is gravely disabled; or clearly needs immediate care and treatment. Involuntary hospitalization is synonymous with involuntary commitment or involuntary treatment, and is an extremely controversial course of action. It is generally a last resort used in dealing with a person who is so ill that he/she is unable to use proper judgment or insight in deciding to refuse treatment.
Civil commitment laws in the United States have been justified on the historical foundation of two fundamental powers and responsibilities of government. First, governments are responsible for protecting each citizen from injury by another. This power of protection is commonly called police powers. The second power, known as parens patriae (Latin for "parent of the nation") is based on the government's responsibility to care for a disabled citizen as a loyal parent would care for a child. A person with a significant mental illness may be civilly committed, or involuntarily hospitalized, under either of these powers. It is understood that the purpose of civil commitment is protecting the safety of the public or of the ill person.
Thirty-four states currently permit some type of involuntary commitment procedure. Most require proof of dangerousness, which can be interpreted in ambiguous ways but generally means the danger is imminent or provable. The legal process usually requires a court hearing within 24–72 hours after the emergency commitment procedure to assure due process.
Beyond safety issues, mental health professionals have thought that proper psychiatric treatment, even when administered against a person's wishes, is preferable to the continued worsening of a serious mental illness. There is some question currently about the effectiveness of forced treatment in the legal and mental health communities. Indeed "involuntary treatment" is considered by many patients' rights advocates and mental health consumers to be an oxymoron (a figure of speech that uses seeming contradictions). It may, in fact, protect public safety at the expense of the liberty, dignity and health of the person with a mental illness.
The use of involuntary hospitalization or any other form of forced treatment is perhaps the most controversial issue in the wider mental health community, pitting family members, citizen advocacy groups, professionals and consumers against one another on the subject. In addition, legal advocates and the courts take very seriously the denial of a person's liberty. Involuntary hospitalization is one of the most extreme examples of denial of liberty in a democratic society.
Most people involved in the debate would agree that forced treatment is indicative of a failed treatment system. There is some evidence that forced treatment is generally harmful and counterproductive. Yet, many people with an intensely personal stake in such a decision may see the necessity of forced treatment to prevent harm to the person with an illness or to others. Outspoken advocates may believe that in the case of involuntary intervention , only custodial care should be provided. There is great concern, often based on experience, that a person who has been civilly committed to a treatment facility, will also receive such forced treatment as strong antipsychotic medications or electroconvulsive therapy (ECT). The issue of a person's ability to exercise informed consent about his/her treatment is clouded when the legal process of civil commitment has been initiated. In addition, there is concern that inpatient treatment will add to the stigma of being diagnosed with a mental illness. One research study found that persons who had been hospitalized (voluntarily or involuntarily) for treatment of a mental illness were even more likely to suffer discrimination in the job market than those who had received only outpatient treatment.
On the other hand, there are many mental health consumers who claim that an incident of involuntary hospitalization in their own treatment history may not only have saved their lives, but enabled them to receive treatment at a time when they were not capable of making a decision to do so. Family members sometimes consider involuntary hospitalization their only recourse to prevent the downward spiral of a loved one into a severe and debilitating mental illness, contact with the criminal justice system, or the devastation and dangers of homelessness .
As of 2002, involuntary hospitalization is a complex process because of the legal requirements that have been put in place to protect citizens from being hospitalized because of a family quarrel or similar interpersonal issue. In the nineteenth century, for example, it was commonplace for husbands who wanted to end a marriage to have wives hospitalized against their will, or for parents to commit "disobedient" children. At present, however, most states require the person who thinks someone else should be hospitalized to call 911 or their local police department. A general summary of the events that may follow the call to 911 follows, but it should be noted that procedures vary from state to state and that the following is a general synopsis. In many cases, the department will send a patrol team rather than only one officer. If the person who has made the call is in the same house (or other location) as the person needing treatment, one officer will usually talk to the caller in one room while the other talks to the affected person in a different room (if circumstances permit). The officers may also interview other family members, neighbors, bystanders, or others who may know the affected person or have witnessed their behavior. Then the two police officers will compare their evaluations of the situation. In most jurisdictions the police officers can make one of three decisions: they can decide that the person who made the call has misjudged the situation (for example, the other person may simply be intoxicated); they can decide that the affected person is mentally ill but not necessarily dangerous; or they can take the affected person to the nearest hospital emergency room. They may ask the person who called them to accompany them to the hospital. In some states, however, the officers themselves must witness the affected person attempting to harm him- or herself or someone else before they can take him or her to the emergency room.
In the emergency room, the psychiatrist on duty will evaluate the affected person for dangerousness as well as the presence of mental illness. He or she will interview the police officers and anyone who accompanied them as well as the affected person. If the affected person has been receiving treatment for a mental disorder, the psychiatrist will usually contact the therapist. In some cases the person will need a medical evaluation, including assessment for substance abuse or withdrawal, before the doctor can proceed with a psychiatric assessment. The psychiatric assessment will be thorough, and documented as completely as possible; laboratory tests will be ordered if necessary. When the assessment is complete, the doctor is legally required to decide in favor of the least restrictive environment to which the patient can be safely discharged for continued care .
If the doctor decides that the person is dangerous but not mentally ill, he or she will turn the person over to law enforcement. If the person has threatened to kill themselves, but the psychiatrist does not consider the threat to be lethal, he or she may allow the patient to leave the emergency room after assessment. A decision to hospitalize the person involuntarily is based on three considerations: loss of emotional control; clear evidence of a psychotic disorder; evidence of impulsivity with serious thoughts, threats, or plans to kill self or others. In most cases, the affected person will be reassessed the next day. Most states stipulate that the affected person is entitled to a hearing before a judge who specializes in mental health law within 72 hours of hospitalization. The judge can order the person released if he or she thinks the person is not dangerous.
Readers who are concerned about the mental health of a family member, roommate, or friend are advised to gather information about the legal requirements for involuntary hospitalization in their state ahead of time, because it is not easy to think clearly when someone is acting in a bizarre or frightening manner. It is also a good idea to write down the name and telephone number of the person's therapist (if they have one), and the names of any medications that the person is taking.
A number of factors in the early 1980s led to a trend toward declining use of involuntary hospitalization for people with significant mental illnesses. The development and effectiveness of a range of new medications meant that treatment in general was more successful. The continued move toward deinstitutionalization , or moving people out of hospitals and into their communities, contributed as well. Treating people in hospitals is inherently expensive and was being viewed as less effective, compared to more innovative and less costly forms of treatment in smaller community-based programs. Finally, a continuing concern about civil liberties led to closer court scrutiny, the right to a hearing and legal counsel, and laws establishing a person's rights to the least restrictive form of treatment.
Recently, however, after a number of tragic and highly publicized violent incidents involving people with severe untreated mental illness, there appears to be a trend toward modification of the criteria required for involuntary hospitalization, court-ordered treatment, and outpatient commitment. Those who advocate liberalizing the process would like a person's previous mental health history to be included in the court's consideration and the standard of dangerousness to be broadened.
Most persons involved in the mental health community believe that an adequately funded, community-based continuum of care and treatment would drastically reduce the number of cases in which involuntary treatment of any kind is necessary. The use of psychiatric advance directives may have an effect on the use of involuntary treatment as well. A psychiatric advance directive is a clearly written statement of an individual's psychiatric treatment preferences or instructions, somewhat like a living will for medical conditions. Psychiatric advance directives have not yet been tested in the court system but are widely endorsed throughout the mental health community as an alternative to involuntary treatment.
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"Psychiatric Emergencies Requiring Hospitalization or Other Institutional Support." Section 15, Chapter 194 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.
Wahl, Otto F. Telling Is Risky Business: Mental Health Consumers Confront Stigma. New Brunswick, NJ: Rutgers University Press, 1999.
Stavis, Paul F. "Involuntary Hospitalization in the Modern Era: Is Dangerousness Ambiguous or Obsolete?" Quality of Care Newsletter Issue 41, August-September 1989.
Judge David L. Bazelon Center for Mental Health Law. 1101 15th St. NW, Suite 1212, Washington, DC 20005. <http://www.bazelon.org> .
National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd, Suite 300, Arlington, VA 22201. <http://www.nami.org> .
National Mental Health Association. 1021 Prince St. Alexandria, VA 22314. <http://www.nmha.org > .
National Mental Health Consumers' Self-Help Clearinghouse. 1211 Chestnut Street, Suite 1207, Philadelphia, PA 19107. <http://www.mhselfhelp.org> .
Judy Leaver, M.A.