The Problem with Involuntary Psychiatric Treatment

The problems with involuntary psychiatric treatment - graphic of a brain in a cage

Mental illness is fairly unique in that laws allow for treatment to be imposed involuntarily. I’m not against involuntary psychiatric treatment entirely, and it can play an important role, but there are some things that can and should be done better.

When involuntary treatment is necessary

Working as a nurse in community mental health, there were plenty of times when I was involved in sending people to hospital involuntarily. They were just too ill to keep in the community, whether that be because of suicidality or severe psychosis or what have you. I had a pretty high threshold for what I considered too ill to manage in the community, and the doctors I worked with were the same, so I don’t think we were overdoing that.

Three of my four hospitalizations were involuntary. For the first and fourth, I don’t dispute that I needed to be involuntary, although I certainly wasn’t happy about it. For my third hospital stay, my doctor and I had agreed that I would go in voluntarily. When I got there, they committed me and locked me in seclusion. Immediately, I requested a review panel to contest it, and the whole time I was there, it was really adversarial. I came out not doing any better than when I went in. I’m very independent, and my reaction when my autonomy is taken away is to fight back however I can.

Locked doors

There’s somewhat of a philosophical debate within the mental health care world about having open vs. locked units. The inpatient unit I worked on for the first five years of my career was an open, unlocked unit. That’s all well and good in theory, but when you’re forcing people to be there involuntarily but at the same time making it easy to walk away, that’s a bit of a contradiction. And sending police to haul people back into hospital seemed all very unnecessary and traumatizing, especially when it involved the same patient repeatedly. The police sometimes got pretty annoyed with us, understandably so.

My first hospital stay, other than my time in psych ICU, was on an open unit. The other three were locked units. Whether or not the door was locked really didn’t make that much of a difference in how I felt about being there, other than it would have been easier to AWOL, and therefore more likely that I would have, had the units not been locked.

Arbitrary restrictions

What I found far more frustrating and dehumanizing than locked doors while in hospital was the many arbitrary rules and restrictions. Sure, some are necessary for safety. But within the confines of what’s necessary for safety, I firmly believe that the treatment team should be going out of their way to promote as much autonomy as possible. Treating people like children and refusing reasonable requests simply because they’re against the unreasonable rules is not helpful. What’s worse is when staff get annoyed at patients for daring to ask for something that doesn’t fit within the arbitrary rules, and give no thought to how they themselves might feel to be treated with scorn for making a reasonable request.

I’ve seen this as both nurse and patient, and I can’t stand it. Restrictions should be for safety or otherwise somehow therapeutic. They should not be put in place to establish a power hierarchy and force conformity to whatever “proper patient” stereotype the staff have constructed.

Community treatment orders

Exactly what involuntary treatment in the community looks like will vary depending on local laws. Where I am, it’s called “extended leave” under the Mental Health Act, meaning someone is released from hospital under extended leave with conditions to follow. Typically, that’s seeing the treatment team and taking meds. If people don’t follow the conditions, or if they start to get really sick, they can be “recalled” back to hospital.

Often, people on extended leave were on long-acting injectable antipsychotics. If someone missed an injection, they could be recalled to hospital. That often meant the police (or the police/nurse mental health car) would track the person down, haul them into ER to get their injection, and then they’d be released. The team I worked at was pretty proactive about doing outreach to track people down rather than recalling them, but I don’t think that was the case at other teams.

I don’t have a problem with making sure someone gets their meds, but the whole police-hospital shebang seems unnecessarily traumatizing. There’s got to be a better way.

Concurrent disorders

Concurrent disorders, co-occurring disorders, dual diagnosis… whatever you want to call it, this is people who have a substance use disorder as well as some other form of mental illness. My job, although I haven’t worked in a year, is at a concurrent disorders transitional program. Clients arrive there from one of two concurrent disorders treatment programs.

The treatment facility is a designated facility under the Mental Health Act, which means they’re able to provide treatment involuntarily as a designated hospital would. Often, clients would end up being sent there involuntarily because their concurrent disorders made them very difficult to manage in the community.

The hope with involuntary treatment, in that case, is that if you force some clean time on people and get whatever else is going on treated and under control, they’ll develop some desire to stay clean, and recovery can progress from there. They may be kept involuntary during their nine months or so at the treatment centre, and then they may be discharged on extended leave to the transitional program.

All of this involuntariness is one thing if it helps. But that “if” is pretty iffy. And the longer it’s drawn out, the iffier it is. It’s awfully hard to treat an addiction without a decent level of buy-in from the patient and even a smidge of intrinsic motivation. I can absolutely see it taking a few months to get people well enough to be in a position to actually make a decision about what they want. Beyond that, though, I’m not convinced, especially when clients are expressing that they have no interest in being clean.

I’m not sure how this would compare to court-mandated treatment, but I would guess that mental health legislation isn’t as compelling a motivator as the courts.

Can the system do better?

I do think there’s a role for involuntary psychiatric treatment. What I would really like to see, though, is mental health care providers seriously considering how they might feel if they, or a loved one, were in the position of an involuntary patient. That us vs. them gulf is often a wide one, and I think everyone would benefit by narrowing it.

If inpatient care was better and more respectful, then it would be easier for people to make the decision to seek out treatment voluntarily, making involuntary care less necessary.

What are your thoughts on involuntary treatment? Is it something you’ve experienced?

The post Cell Phones on Psych Wards—Yea or Nay? is the hub for all psychiatric hospitalization-related content on Mental Health @ Home.

41 thoughts on “The Problem with Involuntary Psychiatric Treatment”

  1. Thank you for posting this, because it is an important discussion and it doesn’t always have a clear right or wrong. Reading this one idea I had is that perhaps an involuntary hospitalization should automatically assign an attorney to the case to advocate on behalf of the patient since it can be so hard for the patient to advocate for themselves in those situations. Thanks again for posting this.

    1. That’s a good idea. In my province, people have access to free legal representation if they request a review of their commitment, but something put in place as a standard course would be nice to see.

  2. Involuntary treatment can save lives when necessary (for instance, a suicidal person can be kept under watch), but it won’t actually fix the problem. No one will help themselves until they’re ready to.

    I’m actually at the point that my care team (psychiatrist, therapist, and PCP) are discussing involuntarily committing me to a residential place for the ED. My psychiatrist seems to be under the impression I’ll go there and come out “all better”. At least my therapist (who specializes in EDs) knows that it’d only keep me healthy physically and I’d come out just as bad mentally, if not worse. She’s not as on board with the involuntary route. She’s trying to either get me working on this here, or wanting to sign myself in.

  3. I feel very fortunate that all the alcohol I used to drink, was my self-medicating rather than a co-occurring diagnosis! I literally drank to self-medicate, so am grateful that I was able to put an end to that once I became medicated regularly. I guess I am one of the lucky ones, and I was never involuntarily committed. I do think that process could stand some definite restructuring, in both the mental illness and co-occurring disorder sides of things. I am saddened that so many patients want to continue drinking even while in treatment for it! Someone’s either not doing their job properly, or the system is broken, or both.

  4. I was involuntarily committed and what you said about the whole police/hospital thing not being very helpful is so true. No one told me that I was being involuntarily committed as I was being committed and I was already in a state of psychosis. Had no idea what was going on where they were trying to take me inside the hospital so I made the nurse, the security guard, and the police tackle me. They Shot me up with some kind of sedative And I woke up on the seventh floor of the hospital (which is the psych ward)to them injecting me with in Vega (which is an injectable antipsychotic) I never consented to that shot and I have been forced to go and get that shot monthly since I was let out of the psych ward. Seems a little unreasonable to me.

      1. WhereI was involuntarily committed that seems like a big experiment. they even had company that manufactured the toilet paper and paper towel dispensers in the bathrooms that had the words “OP” in them. That didn’t seem to help when I was in the middle of a psychotic breakdown.😂😂😂🤪

  5. We have heard that Some addiction that resists treatment may be trauma-based. So trauma treatment is sometimes recommended. For our friend whom we met in such a program, the trauma treatment came decades too late. This friend did not survive.

  6. I am personally very against any involuntary treatment for anyone who does not pose immediate danger to themselves or someone else and I’d state that it should have to be proved like murder with an “innocent until proven guilty” assumption and in court with lawyers.
    The fact is, it is very easy to misdiagnose or to misunderstand mental health and the possible outcomes for any patient especially given the case loads our providers face, it’s not like our providers are spending hours with us daily. They can’t really know us well enough, in many cases, to make that call without serious investigation. Taking freedoms from people based on an individual’s opinion.. even an educated one.. is a slippery slope indeed.

    1. The problem I see with that is that courts and lawyers take time, and if someone is stable enough that to wait for that to happen, they’re probably not sick enough to need to be committed in the first place.

      1. I get that but the person could be held temporarily while waiting for court, have a lawyer advocating for them and preparing the case. I honestly feel that taking a person’s freedom beyond a temporary hold (very temporary) really should require an investigation and a legal decision. If it was set up that these cases had a special court room designated, they could seen faster as well.

        1. Interesting idea. Where I live, the courts really don’t play much of a role, but a concern I would have is that the courts have expertise in the law, but not in mental illness. But I can definitely see the value in having some sort of an independent tribunal reviewing all commitments.

          1. I can agree with your concern but lawyers always call in experts and you could have a tribunal rather than a judge certainly. I think the most important part of this is it would require real investigation that would actually determine if it was a good idea for the patient and if it really was necessary. It would also mean that it would never or at least hardly ever be used in cases where they did not feel it was truly necessary and would make providers really question the decision before making it. This way, it would be used as it should be and every patient would have an advocate on their side which would go a long way towards ensuring facilities treated patients properly.

            1. I agree, everyone should have an advocate. But the resources required for everyone to have a full trial would be enormous, and on the part of the hospital, that would involve a massive shift of psychiatrist time away from patient care and into the legal system. I can see that making sense for longer committals, though, like beyond a month or something like that.

            2. I can agree with that. Beyond a month should definitely require something major.

  7. My first and second time in treatment was involuntary. First was attempted suicide, I woke up the next morning in the Mental Health Ward. If they wouldn’t have found me I probably would have died that night. The second time was because I was in the midst of planning. My best friend caught on and called the police. I am not one that fights, I am glad I accepted my situation and worked to get better.
    While in treatment I have seen police bring people in with handcuffs. There would be fighting, shouting, and wrestling. It usually was something I didn’t need to see.
    In America I feel that is what the problem is, the police sent to a scene, not educated on handling a person in the throes of mania and such. Too many fatal outcomes because of it. Not sure of the remedy is, but, things have to change and change fast.

  8. You’ve pointed out some really important problems. I also never liked people being treated like kids, being a nurse and a patient. It’s humiliating and this really doesn’t help when you’re locked up and treated in many ways like you aren’t there because you need, but because you’ve done something very wrong and you aren’t able to think for yourself in any way. This is what I disliked the most.
    Thanks for bringing up this topic, we need to repeat some topics often and this is one of them.

  9. I think it’s awful when people come out of hospital the same, or even worse than when they went in. It sounds like a really difficult environment, so it’s a shame more can’t be done to make it more theraputic.

  10. Thank you for posting this Ashley. I have someone I love very much who struggles with pain and a resulting diagnosis that keeps him in and out of involuntary hospitalizations. It is painful to see his struggle and to often feel helpless in knowing how to support him. When he can (and at times he does) talk about the experience of hospitalization he talks about the lack of autonomy (phrased very differently for him in his colorful and sometimes justifiably angry language). I think the system here in my area, as systems sometimes are, is flawed in large ways. I value your insights. I think your voice and writing brings much to this on-going discussion.

    I do think hospitalizations should be utilized as a last resort. I would like to see improved understanding and adequate assessment involving a solid look at ones history in making the diagnosis, a better understanding of interacting from a relational basis while in the facility, along with solid follow up care that is genuinely supportive and relationally based.

  11. This is a fairly fresh topic for me as I’ve just come out of involuntary hospitalization a few weeks ago.

    Like you, I agreed to go voluntarily and then they went and turned it into involuntary for 12 days. I was pissed. I was scared and I felt like the entire system was shit by that point. I don’t understand how they can get away with taking every single thing you own away from you and basically lock you in a room all alone and expect you to feel better. And the best is when they ask multiple times a day if you are suicidal–because leaving someone alone for hours at a time without any contact is going to do wonders for their mental health.

    I literally told my psychiatrist that I was planning my escape because I felt so trapped in there. It did nothing for my anxiety and abandonment issues. If she hadn’t told me she’d send the police after me if I tried to escape I think I seriously would’ve done it.

    The system needs a major overhaul in my opinion.

    At this point I’m terrified to even mention suicide to my therapist because I will not go back to the hospital unless it’s in handcuffs.

    1. I wish people in the system realized how much harm they can do, both while it’s happening and afterwards. There’s no way I would tell anyone about active suicidal ideation, because I don’t want to be stuck in hospital. You can’t lock someone in a room with nothing but their thoughts and expect that to be therapeutic.

  12. This is bringing up some unpleasant memories — not in the sense of its being a PTSD trigger, but only that it brings back an unhappy period of my life that I don’t usually think about. In California, I was first committed involuntarily in 2004, and later again in 2009. Though treatment wasn’t entirely unhelpful, a couple things you wrote rang a forgotten bell:

    “What I found far more frustrating and dehumanizing than locked doors while in hospital was the many arbitrary rules and restrictions.”

    A keyword here is “arbitrary.” In addition to the sense the purpose of some of the rules was unclear, patients were often reprimanded for not following a rule, without having prior been advised what the rule was. So I found myself afraid that at any moment, I might not only break some rule that I had never heard of, but that after breaking the unknown rule, I would be punished for it. This is why a second statement of yours also resonated with me:

    “Treating people like children and refusing reasonable requests simply because they’re against the unreasonable rules is not helpful.”

    In general, it seems you’re suggesting that clinicians in such environments ought to abide by the Golden Rule, and consider how they would feel if they were treated with such indignity. I of course agree, but a problem with modern society in general is that not everyone believes in the Golden Rule.

    I agree that there’s a place for involuntary treatment, but I suspect that, at least in California where I lived, it was often used out of place. Hasn’t happened at all in Idaho, nor do I suspect it will. But there may be reasons for that unrelated to geography.

    Another excellent and thought-provoking, if disturbing, post.

    1. I don’t think many staff on inpatient psych wards realize how much they stereotype the patient role, and how much they expect that patients will automatically conform to that role. Being chastised for not following rules that were never made explicit happens all the time, but it doesn’t make any sense.

  13. I believe you’re right that a lot of this stems from unawareness on the part of clinicians, rather than outright maliciousness. I did perceive that certain environments appeared to attract “control freaks” among the hired staff.

  14. Unfortunately, involuntary admissions were often a necessary evil in some cases i.e. where the person was a risk to themselves or others. Obviously some clinicians were more heavy handed than others and admitted people because of their own fears of what might go wrong if a patient was left in the community.

    As a senior clinician I’d see people in the mental health emergency clinic and felt confident in assessing and referring patients to the home treatment team or back to their Community Team rather than admit them voluntarily or otherwise. However, some colleagues admitted every ‘second’ person they saw, again due to their own anxieties.

    And the ward staff? Oh yes, many with their own agendas and rules! They’d tell patients they couldn’t have a cup of tea because it’s not 10.30 yet, I’d ‘suggest’ they make that cup of tea and would get “Yes, but if I make them one, everyone else will want one.”
    “Okay, so make them one too.” 🙂

    Then you’d get staff who’d literally switch the t.v. off in the middle of a film because at 23.00 hours – it’s bed time. Let the patients watch the end of the damn film! Don’t get me started on all the petty rules lol.

    1. The cup of tea is such a good example! Especially when the person who doesn’t want to make it is holding the cup of tea they’ve just made for themselves. 😉

  15. It can be frustrating for us as relatives/friends. An analogy I think of is similar to a medical emergency like someone is turning blue, bleeding profusely, etc, your not sending them to the hospital to be cruel, it just the situation is severe and requires trained people/equipment/meds. I honestly feel like cops are not really emotionally intelligent and are taught to be paranoid and intimidating hence the handcuffs. I’m 110% against handcuffing people unless they’re violent or trying to escape. Especially victims of crime since it traumatizing them more. And it’s not our fault if the staff in the ward is bitchy and hates life! That’s on them. And the hospital that continues to employ them w/o repercussions. If you’re hesitant to go to the hospital but your friends/family etc is worried, please just tell us why! We don’t understand and hopefully your family etc is loving and we can talk about it! We can’t read minds!

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