Stacey Dooley: Back on the Psych Ward (2021)

Introduction

Stacey Dooley returns to Springfield Hospital to work with the team again, looking after patients over six months as they battle through the pandemic.

Refer to Stacey Dooley: On the Psych Ward (2020).

Outline

Mental health across society has worsened since the pandemic began. Stacey Dooley returns to Springfield Hospital, and over six months, including the second nationwide lockdown, works with the team to experience first-hand how the pandemic is impacting patients in crisis. Stacey assists staff as they treat a wide range of mental health conditions and takes part in the tough decisions necessary to keep patients safe.

Stacey meets Coral, who is brought into Springfield by the police one night after attempting to take her life. Coral tells Stacey and the team about her long-running battle with anxiety and depression, which she attempts to self-medicate by drinking alcohol.

The pandemic has seen a rise in suicidal behaviour, especially amongst young people. Stacey meets Oskar, a 20-year-old university student whose struggle with intense suicidal thoughts brings him into the hospital in crisis.

For those with pre-existing mental health conditions, waiting lists and delays to treatment caused by the pandemic are pushing them to breaking point. Suziee is diagnosed with emotionally unstable personality disorder, which causes extreme highs and lows to her moods. But with her therapy now cancelled, she is struggling to cope on her own and turns to the hospital for help.

Stacey also gets to know 21-year-old Ali, an inpatient at Springfield, which is home to the only inpatient unit of its kind in the country for those with severe obsessive compulsive disorder (OCD). Since childhood, Ali’s OCD rituals have changed from repetitive tapping during stressful exams and blinking to keep her parents safe in the car to extreme bathroom routines. For severe OCD cases like Ali’s, this ward is her last chance at beating this devastating condition, and over the months Stacey sees a dramatic change in Ali’s obsessions.

Production & Filming Details

  • Presenter(s):
    • Stacey Dooley.
  • Director(s):
    • Erica Jenkin.
    • Katie Rice.
  • Producer(s):
    • Gabi Adams … assistant producer.
    • Carla Grande … producer.
    • Erica Jenkin … producer.
    • Katie Rice … producer.
    • Brian Woods … producer.
  • Writer(s):
  • Music:
    • Alexander Parsons.
  • Cinematography:
  • Editor(s):
    • Paddy Garrick.
  • Production:
    • True Vision.
  • Distributor(s):
    • BBC Three (2021) (UK) (video).
  • Release Date: 13 April 2021 (Internet).
  • Running Time: 59 minutes.
  • Rating: TV-MA.
  • Country: UK.
  • Language: English.

What is Emergency Psychiatry?

Introduction

Emergency psychiatry is the clinical application of psychiatry in emergency settings.

Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behaviour. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work. The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving emergency psychiatry is complex.

Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilisation of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions.

Definition

Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behaviour. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician’s or a nurse’s ability to identify and intervene with these and other medical conditions is critical.

Delivery of Services

The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centres, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine, nursing, psychology, and social work in these settings alongside psychiatrists and emergency physicians. The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week.

Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalisation for the patient, and to treat those patients whose symptoms can be improved within that brief period of time. Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency services are to assess patients’ problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilise teams to carry out interventions at patients’ residences, utilise emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counselling.

Brief History

Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalisation both in Europe and the United States. Deinstitutionalisation, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas.

Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. The individualised care needed for patients utilising psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach.

Scope

Suicide Attempts and Suicidal Thoughts

As of 2000, the World Health Organisation (WHO) estimated one million suicides in the world each year. There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of completed suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.

Violent Behaviour


Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behaviour. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.

Psychosis

Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient suffering from a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan.

An individual could also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention. The lack of identification and treatment can result in suicide, homicide, or other violence.

Substance Dependence, Abuse and Intoxication

Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterised by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short term memory loss which could result in behavioural change causing injury or death, levels of alcohol below 60 milligrams per decilitre of blood are usually considered non-lethal. However, individuals at 200 milligrams per decilitre of blood are considered grossly intoxicated and concentration levels at 400 milligrams per decilitre of blood are lethal, causing complete anaesthesia of the respiratory system.

Beyond the dangerous behavioural changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms.

Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centres, or hospitals. Both the immediate and long term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse.

Hazardous Drug Reactions and Interactions

Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone. Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring.

Personality Disorders

Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and impulse control can be considered personality disorders. Patients suffering from a personality disorder will usually not complain about symptoms resulting from their disorder. Patients suffering an emergency phase of a personality disorder may showcase combative or suspicious behaviour, suffer from brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals suffering from personality disorders in inpatient psychiatric settings is usually 7-25% higher. Clinicians working with such patients attempt to stabilise the individual to their baseline level of function.

Anxiety

Patients suffering from an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalised anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a “safe harbour” for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients suffering from anxiety disorders have a higher risk of premature death.

Disasters

Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria.

Due to the typically disorganised and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may suffer from both chronic or acute post-traumatic stress disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilise the individual.

Abuse

Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable.

Treatment

Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilise life-threatening conditions. Once stabilised, patients suffering chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation. Prescribed treatments within the emergency service setting vary dependent upon the patient’s condition. Different forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency setting. The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilisation of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication.

Medications

With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication. A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. Medication can also be administered through intramuscular injection, or through intravenous injection.

The amount of time required for absorption varies dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood-brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly. Antipsychotics, especially Haloperidol, as well as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation.

Psychotherapy

Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realising psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place their problem in the proper perspective. If the physician determines that deeper psychotherapy sessions are required, they can transition the patient out of the emergency setting and into an appropriate clinic or centre.

ECT

Electroconvulsive therapy (ECT) is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting themselves or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur.

Observation and Collateral Information

There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient’s behaviour is an important aspect of emergency psychiatry inasmuch as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one’s basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behaviour in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed.

Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behaviour can be confirmed or disproven.

Disposition

Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry.

Hospital Admission

The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible.

Involuntary Commitment

Involuntary commitment, or sectioning, refers to situations where police officers, health officers, or health professionals classify an individual as dangerous to themselves, others, gravely disabled, or mentally ill according to the applicable government law for the region. After an individual is transported to a psychiatric emergency service setting, a preliminary professional assessment is completed which may or may not result in involuntary treatment. Some patients may be discharged shortly after being brought to psychiatric emergency services while others will require longer observation and the need for continued involuntary commitment will exist. While some patients may initially come voluntarily, it may be realised that they pose a risk to themselves or others and involuntary commitment may be initiated at that point.

Referrals and Voluntary Hospitalisation

In some locations, such as the United States, voluntary hospitalisations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalisation unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centres. Therefore, patients who are not admitted will be referred to services in the community.

Involuntary Commitment by Country

Introduction

Involuntary commitment or civil commitment is a legal process through which an individual with symptoms of severe mental illness is court-ordered into treatment in a hospital (inpatient) or in the community (outpatient).

Criteria for civil commitment are established by laws, which vary between nations.

Refer to Chronology of UK Mental Health Legislation and Mental Health Tribunal.

United Nations

United Nations General Assembly (resolution 46/119 of 1991), “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care” is a non-binding resolution advocating certain broadly-drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programmes in some countries to assist in this process.

Australia

In Australia, court hearings are not required for involuntary commitment. Mental health law is constitutionally under the state powers. Each state thus has different laws, many of which have been updated in recent years.

Referral for Service

The usual requirement is that a police officer or a physician determine that a person requires a psychiatric examination, usually through a psychiatric hospital. If the person is detained in the hospital, they usually must be seen by an authorised psychiatrist within a set period of time. In some states, after a further set period or at the request of the person or their representative, a tribunal hearing is held to determine whether the person should continue to be detained. In states where tribunals are not instituted, there is another form of appeal.

Some Australian states require that the person is a danger to the society or themselves; other states only require that the person be suffering from a mental illness that requires treatment. The Victorian Mental Health Act (1986) specifies in part that:

(1) A person may be admitted to and detained in an approved mental health service as an involuntary patient in accordance with the procedures specified in this Act only if—
(a) the person appears to be mentally ill; and
(b) the person’s mental illness requires immediate treatment and that treatment can be obtained by admission to and detention in an approved mental health service; and
(c) because of the person’s mental illness, the person should be admitted and detained for treatment as an involuntary patient for his or her health or safety (whether to prevent a deterioration in the person’s physical or mental condition or otherwise) or for the protection of members of the public; and
(d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and
(e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of that person’s freedom of decision and action.

There are additional qualifications and restrictions but the effect of these provisions is that people who are assessed by doctors as being in need of treatment may be admitted involuntarily without the need of demonstrating a risk of danger. This overcomes the pressure described above to exaggerate issues of violence, or to verbal statements, to obtain an admission.

Treatment

In general, once the person is under involuntary commitment, treatment may be instituted without further requirements. Some treatments, such as electroconvulsive therapy (ECT), often require further procedures to comply with the law before they may be administered involuntarily.

Community treatment orders can be used in the first instance or after a period of admission to hospital as a voluntary/involuntary patient. With the trend towards deinstitutionalisation, this situation is becoming increasingly frequent, and hospital admission is restricted to people with severe mental illnesses.

Finland

Involuntary commitment requires three criteria:

  1. Severe mental illness with impaired insight;
  2. That a lack of treatment would worsen the condition or endanger the safety or security of the patient or others; and
  3. Other treatments or services are insufficient or inapplicable.

If found insane, criminal offenders may not be sentenced. Instead, they must be referred to THL (National Institute for Health and Welfare) for involuntary treatment. Niuvanniemi hospital specialises in involuntary commitment of criminal patients.

France

About 2.4% in of patients in French psychiatric wards are committed involuntarily. A person may be committed if they are an imminent danger or at the request of either a third party, usually a family member or a representative of the state.

  • Classic admission:
    • To involuntarily commit a person, two items are needed: (1) a handwritten request from a third party with a relationship to the person (e.g. a member of the patient’s family or a care giver), excluding care givers working in the institution caring for the sick person, and (2) two supporting medical certificates, at least one of which is drawn up by a doctor outside of the institution giving care to the person.
  • Admission in case of imminent danger:
    • In the case of imminent danger, a single medical certificate drawn up by a doctor who is not part of any establishment caring for the person, suffices to involuntarily commit a person.
  • Admission in case of emergency:
    • A handwritten request from a third party and a medical certificate suffice to involuntarily commit a person.

From an admission at the request of a representative the state to occur, the mentally ill person must a danger to themselves or others, or cause a serious breach of public order, in which case the mayor (temporarily and only when there is a danger to the safety of persons) or the prefect, may issue a decree in support of a medical certificate issued by a doctor outside the receiving institution to admit that person

Germany

In Germany, there is a growing tendency to use the law on legal guardianship instead of mental health law for justification of involuntary commitment or treatment. The ward’s legal guardian decides that he/she must go into mental hospital for treatment, and the police then acts on this decision. This is simpler for the government and family members than the formal process for commitment under mental health laws.

In German criminal law, a person who was convicted of certain crimes can also be sentenced to be kept in preventive detention; see article on preventive detention.

Israel

The Mental Health Care Act of 1991 regulates the rights of the mentally ill in Israel and defines the conditions under which the patient’s freedom of choice can be restricted. The law replaced the Mental Health Law of 1955.

Italy

In Italy the physician Giorgio Antonucci, in his work at the hospitals of Gorizia, Cividale del Friuli and Imola since the late 1960s, has avoided involuntary hospitalisation and any kind of coercion, rejecting the diagnosis as psychiatric prejudice. During the years 1973-1996 he worked on the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli in Imola. He currently collaborates with the Italian branch of the Citizens Commission on Human Rights.

Japan

In Japan, the Law on mental health and welfare for the mentally disabled (Japanese: 精神保健及び精神障害者福祉に関する法律) establishes the legal framework for involuntary commitment.

Netherlands

In Dutch criminal law, a convict can be sentenced to involuntary psychiatric treatment in a special institute called a ”TBS” clinic. TBS is an abbreviation for ter beschikkingstelling, literally meaning “being placed at disposal” (of the state). Legally, such a sentence is not regarded as punishment like a prison sentence, but as a special measure. Often, when a convict is sentenced to TBS, they first serve a prison sentence. The convict will then be placed in a clinic after serving time in prison (usually two-thirds of the original prison sentence, although this practice is under discussion).

According to Dutch law, meeting three conditions is required for a convict to be sentenced to TBS. These conditions are:

  • The crime committed must have been directly related to a psychiatric disorder,
  • Recidivism must be likely, and
  • The convict can not, or only partially, be held accountable for the crime.

To determine if these conditions are met, the suspect is observed in a forensic psychiatric detention centre, the Pieter Baan Centre. Neither the prosecution or the defence can effectively challenge the Pieter Baan Centre’s report, since it is the only institution that can conduct such investigations. Fatal mistakes have occurred, for instance, when a child molester regarded by the Pieter Baan Centre as “not dangerous” killed a child after the molester was released. The conclusions in the centre’s report are not binding; the judge can decide to ignore, or only partially accept them.

Every convict detained in a TBS clinic may get temporary leave after serving a certain time or after some progress in treatment. This is regarded as an essential part of treatment, as the convict will be gradually re-entering society this way. At first the convict will be escorted by a therapist, and will be allowed outside the clinic for only a few hours. After evaluation, time and freedom of movement will be expanded until the convict can move freely outside the clinic without escort (usually for one day at a time). At that time, the convict will find work or follow an education. Generally, the convict is released after being in this situation for one or two years without incident.

The time to be served in TBS can be indefinite, and it may be used as a form of preventive detention. Evaluation by the court will occur every one or two years. During these evaluations the court determines if any progress is made in treatment of the convict, and if it will be safe to release the convict into society. In general, the court will follow conclusions made by the TBS clinic.

Average time served in a TBS clinic by a convict is slightly over eight years.

Dutch TBS Clinics

In the Netherlands there are currently 12 institutions regarded as TBS clinics:

  • Inforsa/Arkin, Amsterdam.
  • Dr. Henri van der Hoevenstichting, Utrecht.
  • Dr. S. van Mesdagkliniek, Groningen.
  • Hoeve Boschoord, Boschoord.
  • FPC Veldzicht, Balkbrug.
  • Pompestichting, Nijmegen.
  • Oostvaarderskliniek, Almere.
  • De Kijvelanden/FPC Tweelanden, Poortugaal.
  • FPC Oldenkotte, Rekken (Closed on 04 September 2014).
  • FPC De Rooyse Wissel, Venray.
  • GGz Drenthe, Assen.
  • GGz Eindhoven/De Woenselse Poort, Eindhoven.

These institutions combined currently are holding about 1840 convicts.

By the end of the 20th century, it was concluded that some convicts could not be treated and therefore could not be safely released into society. For these convicts, TBS clinics formed special wards, called “long-stay wards”. Transfer to such a ward means that the convict will no longer be actively treated, but merely detained. This is regarded as more cost-effective. In general, the convicts in these wards will be incarcerated for the rest of their lives, although their detention is eligible for regular review by the court.

Controversy

Since the latter half of the 1990s, considerable controversy has grown in Dutch society, about the TBS system. This controversy has two main areas. The first level of controversy resulted from the media increasingly reporting cases of convicts committing crimes while still in, or after, treatment in a TBS clinic.

Some examples of these cases are:

  • During 1992, a truck driver was convicted of raping and murdering three young children.
    • Eight years earlier he was released from a TBS clinic after being treated for child molestation.
  • A convict, about to be released from a TBS clinic, murdered the owner of a garage in 1996 while under the influence of drugs.
  • An ex-convict, treated in a TBS clinic, murdered two women in 1994 and 1997.
  • A convict, still being treated by a TBS-clinic, randomly killed a man in the city of Groningen in 1999.
  • Between 2000 and 2004, an ex-convict tortured several animals and killed a homeless man.
    • He had been treated in a TBS clinic.
  • In 2002 an ex-convict was sentenced for triple murder.
    • He also had been released earlier by TBS.
  • In 2005 a convict escaped his escort during leave.
    • He was arrested several days later after killing a man.

Political and social attention increased, and debate started about the effectiveness of the TBS system and whether convicts should be granted leave from TBS clinics. Especially right-wing politicians suggested the TBS system be discarded altogether. Numerous articles in newspapers, magazines, television and radio programs and a revealing book written by an ex-convict (which for the first time openly questioned the effectiveness of the TBS-system) boosted discussion. Prior to that, any problems had been mostly denied by officials of the TBS-clinics themselves.

The centre of attention became a highly renowned TBS clinic, Dr. S. Van Mesdagkliniek in the city of Groningen. Events that took place there, by the end of the 1990s and the first years of the 21st century, provoked the second reason for controversy. Concern rose about claims of unprofessional behaviour by staff working in TBS clinics, and the Dr. S. Van Mesdagkliniek developed a poor reputation over these problems. This TBS clinic has been plagued with unprofessional and even criminal acts by its staff since 1999.

During that year, the clinic came under investigation by Dutch police after rumours about female staff members committing sexual offenses against convicts emerged. Five such cases were discovered during the investigation, and also numerous cases of drug-abuse, smuggling and trading of contraband such as alcohol, mobile phones, pornographic material, and hard drugs. It became apparent that staff members did not have the required education, had not been informed about rules and regulations, disregarded legal procedures, gave false testimonies, tampered with evidence, uttered false accusations against convicts, and intimidated colleagues. At least one psychiatrist, employed as such by the clinic, proved to be not qualified, and treatment of convicts was in many cases simply non-existent.

These problems had been known for long by the management but were kept hidden. After public outcry about this situation, management was replaced and all of the nine (at the time) TBS clinics in the Netherlands were subjected to investigation. Six of them proved to be below the required legal standards. However, problems did not end there. In spite of many measures taken by the government, convicts still were released without proper treatment. As a consequence, numerous crimes were committed by convicts that were regarded as treated by TBS clinics. Also, sexual offenses against convicts by staff members and smuggling of contraband did not cease in several TBS clinics. In 2006, the Dutch government formed a committee to investigate the TBS system. Some problems, however not the worst[clarification needed], were recognised and countermeasures were implemented. One of the known actual results is that fewer convicts escape during temporary release.

Controversy regarding the, often praised, Dutch TBS system continued. In 2005, a staff member working in the Dr. S. Van Mesdagkliniek was caught smuggling liquor to convicts suffering from alcohol-related problems. In 2007, a female staff member committed sexual offenses against a convict, and had smuggled contraband. She was sentenced to three months in prison in 2009. That same year, investigation proved convicts still had ample access to illicit drugs and four inmates from the Dr. S. Van Mesdagkliniek were arrested for possession of child pornography. Many crimes committed by released convicts treated in TBS clinics escape statistics because the crimes were committed in other countries, or because they differ from the crime the convict was originally convicted for (many convicts released from TBS clinics find their way in illegal drug trade and related crimes). Because there seems to be no acceptable alternative available, political support for the much troubled TBS system remains, in spite of the controversy.

Russia

Individuals in Russia can be involuntarily admitted by psychiatrists directly with an appeal process.

New Zealand

The Mental Health (Compulsory Assessment and Treatment) Act 1992, replaced the previous Act, enacted in 1969. Although there were several reasons to replace the previous act, one key aspect was the lack of review, as once the Reception Order had been made by a District Court judge and two doctors, that the proposed patient be taken to hospital: “Subject to the provisions of this Act, every reception order, whether made before or after the commencement of this Act, shall continue in force until the patient is discharged.” (MHA 1969 s28(2)) Despite the deinstitutionalisation that began in New Zealand during the 1960s, as in many other Western countries, many patients stayed at the psychiatric hospital for years, as the original reception order remained in force. Another reason to review the former act was that patients appeared at the District Court (formerly the Magistrates Court until 1980) – which hears all but the most serious criminal cases. The present Act emphasises that Mental Health Hearings be heard at the Family Court instead, to remove any implication that the patient is being detained in hospital due to a criminal act. It does, however, provide that Mental Health Hearings may take place at the District Court, if there is no other suitable alternative. Often the Family Court will sit at the Mental Health Inpatient Unit.

There are multiple checks and balances built into the present committal procedures. As in the United Kingdom, the process is generally known as “sectioning”.

Section 8A provides that any person, aged 18 or over, who has seen the proposed patient within the last 72 hours, may apply to the Director of Area Mental Health Services (DAMHS), to have that person seen by a psychiatrist, against their wishes. The person must be a danger to themselves or others, or be unable to care for themselves. Section 8B requires that the person be seen by a doctor, preferably their own General Practitioner, to give their opinion as to whether the applicant is correct in their statements about the proposed patient’s behaviour. If the doctor is satisfied, this paperwork is signed, and the process continues to Section 9 where Duly Authorised Officers (DAOs) – operating as agents of the DAMHS, have the power to detain the person for six hours, and during that time, they have the power to transport the proposed patient to the psychiatrist. This is usually at a hospital, but the patient may be seen at a police station, depending on the circumstances. If the proposed patient refuses to accompany them, the Police will assist under the Memorandum of Understanding between the Ministry of Health and the New Zealand Police.

Under s10 they are formally interviewed by the psychiatrist, and if they are to be admitted, a s11 is issued that detains the patient for assessment and treatment at an inpatient mental health unit, for up to five days. Following this, a s12 review is held, and if necessary the patient can be held under s13 for fourteen days. At the end of this time, the psychiatrist must apply for a Court Hearing as to whether the patient can be treated compulsorily for any longer. Section 14(4) gives up to fourteen days for the hearing to occur. The detention sections (11, 13, & 14(4)) can be done in the outpatient setting, but in practice, most compulsory patients are detained at a hospital.

Two compulsory treatment orders are available. Section 29 is a Community Treatment Order, and the Act states that this should be applied for.

The patient can only be recalled to hospital twice for two fourteen-day periods in the six months that it lasts.

If a community order is not suitable (for example, due to the risk posed by the patient to themselves or others), a s30 Inpatient Treatment Order can be applied for, where the patient is either in hospital, or on leave from hospital.

In either case, two health professionals must apply to the Family Court – the psychiatrist, backed by a second health professional, usually a registered nurse, sometimes a social worker.

People who have committed a crime while mentally unwell are subject to the Criminal Procedure (Mentally Impaired Persons) Act 2003, although the Mental Health Act also refers to their care. If taken into custody, it is a matter for the Court as to whether they will go to prison and have their mental health issues treated whilst imprisoned, or whether they are “insane” in the legal sense, in which case they are detained at a Forensic Mental Health Unit. These are located at Auckland, Hamilton, Wellington, Christchurch, and Dunedin. The Acts described provide also for the transfer of patients between prisons and Forensic Mental Health Units, and the reasons for doing this.

New Zealand has found that closing its large country psychiatric hospitals and replacing them with small inpatient units, and a community care model, does not always mean better care. While many people were released who were able to adapt to, and become part of, their communities, some patients were unable to adapt. The current system is not set up for people who require long term closely supervised mental health care.

Singapore

The Mental Health (Care and Treatment) Act was passed in 2008 to regulate the involuntary detention of a person in a psychiatric institution for the treatment of a mental disorder, or in the interest of the health and safety of the person or the persons around him.

Switzerland

Switzerland has a high proportion of involuntary commitments (German: Zwangzulassung, French: placement forcé) compared to other European countries. Almost 25% of psychiatric patients were admitted involuntarily according to a 2009 study.

The conditions and procedure of involuntary commitments are regulated by Articles 426 to 439 of the Swiss Civil Code.

United Kingdom

In the United Kingdom, the process known in the United States as involuntary commitment is informally known as “detaining” or “sectioning,” using various sections of the Mental Health Act 1983 (covering England and Wales), the Mental Health (Northern Ireland) Order 1986 and the Mental Health (Care and Treatment) (Scotland) Act 2003 that provide its legal basis.

In England and Wales, approved mental health professionals have a lead role in coordinating Mental Health Act assessments, which they conduct in cooperation with usually two medical practitioners. Under the Mental Health Act, detention is determined by utility and purpose. Mentally ill individuals may be detained under Section 2 for a period of assessment lasting up to 28 days or Section 3 for a period of treatment lasting up to 6 months (though this period can be renewed). Patients already on a ward may be detained under section 5(2) for up to 72 hours for the purposes of allowing an assessment to take place for Section 2 or 3. Separate sections deal with mentally ill criminal offenders. In all cases detention needs to be justified on the basis that the person has a mental disorder and poses a risk of harm to his/her own health, safety, or the safety of others (as determined by the ‘Approved’ Mental Health Professional(s)). A Section 3 detention can be applied for by the person’s nearest relative or, if the nearest relative agrees, by an approved mental health professional (AMHP). More specifically, according to Article 11 of the Mental Health Act the AMHP can make an application that a person be detained for treatment under section 3 only if the AMHP has consulted the person who appears to be the patient’s nearest relative (unless it is not reasonably practicable or would cause unreasonable delay) and if the nearest relative has not told the AMHP or the LSSA that they object.

Under the amended Mental Health Act 2007, which came into force in November 2008 to be detained under Section 3 for treatment, appropriate treatment must be available in the place of detention. Supervised Community treatment orders signifies that people can be discharged to the community on a conditional basis, remaining liable to recall to hospital if they break the conditions of the community treatment order.

In 2020, as part of the response to COVID-19, Parliament passed the Coronavirus Act 2020 which amends the Mental Health Act to allow for sectioning with the approval of only one medical practitioner.

Refer to Chronology of UK Mental Health Legislation.

United States

State law governs involuntary commitment, and procedures vary from state to state. In some jurisdictions, laws regarding the commitment of juveniles may vary, with what is the de facto involuntary commitment of a juvenile perhaps de jure defined as “voluntary” if his parents agree, though he may still have a right to protest and attempt to get released. However, there is a body of case law governing the civil commitment of individuals under the Fourteenth Amendment through Supreme Court rulings beginning in 1975 with the ruling that involuntary hospitalisation and/or treatment violates an individual’s civil rights in O’Connor v. Donaldson. This ruling forced individual states to change their statutes. For example, the individual must exhibit behaviour that poses a danger to himself or others in order to be held, the hold must be for evaluation only, and a court order must be received for more than very short term treatment or hospitalisation (typically no longer than 72 hours). This ruling has severely limited involuntary treatment and hospitalisation in the US. In the US the specifics of the relevant statutes vary from state to state.

In 1979, Addington v. Texas set the bar for involuntary commitment for treatment by raising the burden of proof required to commit persons from the usual civil burden of proof of “preponderance of the evidence” to the higher standard of “clear and convincing evidence”.

An example of involuntary commitment procedures is the Baker Act used in Florida. Under this law, a person may be committed only if they present a danger to themselves or others. A police officer, doctor, nurse or licensed mental health professional may initiate an involuntary examination that lasts for up to 72 hours. Within this time, two psychiatrists may ask a judge to extend the commitment and order involuntary treatment. The Baker Act also requires that all commitment orders be reviewed every six months in addition to ensuring certain rights to the committed including the right to contact outsiders. Also, a person under an involuntary commitment order has a right to counsel and a right to have the state provide a public defender if they cannot afford a lawyer. While the Florida law allows police to initiate the examination, it is the recommendations of two psychiatrists that guide the decisions of the court.

In the 1990s, involuntary commitment laws were extended under various state laws commonly recognized under the umbrella term, SVP laws, to hold some convicted sex offenders in psychiatric facilities after their prison terms were completed (This is generally referred to as “civil commitment,” not “involuntary commitment,” since involuntary commitment can be criminal or civil). This matter has been the subject of a number of cases before the Supreme Court, most notably Kansas v. Hendricks and United States v. Comstock in regard to the Adam Walsh Child Protection and Safety Act, which does not require a conviction on sex offenses, but only that the person be in federal custody and be deemed a “sexually dangerous person”.

Specific Requirements by State

In Arizona, the government can mandate inpatient treatment for anyone determined to be “persistently or acutely disabled.” Virtually anyone who suspects that someone has mental problems and needs help could file an application to a state-licensed healthcare agency for a court-ordered evaluation.

In Connecticut, someone can be committed only if he or she has “psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled”. “Gravely disabled” has usually been interpreted to mean that the person is unable on their own to obtain adequate food, shelter and clothing.

In Iowa, any “interested person” may begin commitment proceedings by submitting a written statement to the court. If the court finds that the respondent is “seriously mentally impaired,” he or she will be placed in a psychiatric hospital for further evaluation and possibly treatment. Further hearings are required at specific intervals for as long as the person is being involuntarily held.

The Michigan Mental Health Code provides that a person “whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behaviour as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others” may be subjected to involuntary commitment, a provision paralleled in the laws of many other jurisdictions. The Michigan Mental Health Code allows for one to petition a court to order assisted outpatient treatment for patients with such impaired judgment, which compels them to comply with treatment to avoid relapses. One can petition for assisted outpatient treatment along with, or instead of, hospitalisation.

In Nevada, prior to confining someone, the state must demonstrate that the person “is mentally ill and, because of that illness, is likely to harm himself or others if allowed his liberty.”

In Oregon, the standard that the allegedly mentally ill person “Peter [h]as been committed and hospitalized twice in the last three years, is showing symptoms or behavior similar to those that preceded and led to a prior hospitalization and, unless treated, will continue, to a reasonable medical probability, to deteriorate to become a danger to self or others or unable to provide for basic needs” may be substituted for the danger to self or others standard.

In Texas, the standard is that, in the judgement of the person seeking involuntary commitment:

  1. The person is mentally ill; and
  2. Because of that mental illness “there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained”.

The Utah standard is that the proposed patient has a mental illness that poses a substantial danger. “Substantial danger” means the person, by his or her behaviour, due to mental illness:

  • (a) Is at serious risk to:
    • (i) commit suicide;
    • (ii) inflict serious bodily injury on himself or herself; or
    • (iii) because of his or her actions or inaction, suffer serious bodily injury because he or she is incapable of providing the basic necessities of life, such as food, clothing, and shelter;
  • (b) is at serious risk to cause or attempt to cause serious bodily injury; or
  • (c) has inflicted or attempted to inflict serious bodily injury on another.

In Wisconsin, the District II Wisconsin Court of Appeals ruled in 2011 that patients with Alzheimer’s disease cannot be involuntary committed under Chapter 51 and can only be involuntarily committed for residential care and custody under Chapter 55. The court left open whether this applies also to persons with a dual diagnosis.

Controversy about Liberty

The impact of involuntary commitment on the right of self-determination has been a cause of concern. Critics of involuntary commitment have advocated that “the due process protections… provided to criminal defendants” be extended to them. The Libertarian Party opposes the practice in its platform. Thomas Szasz and the anti-psychiatry movement have also been prominent in challenging involuntary commitment. The American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH) was an organization founded in 1970 by Thomas Szasz, George Alexander, and Erving Goffman for the purpose of abolishing involuntary psychiatric intervention, particularly involuntary commitment, against individuals. The founding of the AAAIMH was announced by Szasz in 1971 in the American Journal of Public Health and American Journal of Psychiatry. The association provided legal help to psychiatric patients and published a journal, The Abolitionist. The organisation was dissolved in 1980.

A small number of individuals in the US have opposed involuntary commitment in those cases in which the diagnosis forming the justification for the involuntary commitment rests, or the individuals say it rests, on the speech or writings of the person committed, saying that to deprive the person of liberty based in whole or part on such speech and writings violates the First Amendment. Other individuals have opposed involuntary commitment on the basis that they claim (despite the amendment generally being held to apply only to criminal cases) it violates the Fifth Amendment in a number of ways, particularly its privilege against self-incrimination, as the psychiatrically examined individual may not be free to remain silent, and such silence may actually be used as “proof” of his “mental illness”.

Although patients involuntarily committed theoretically have a legal right to refuse treatment, refusal to take medications or participate in other treatments is noted by hospital staff. Court reviews usually are heavily weighted toward the hospital staff, with the patient input during such hearings minimal. In Kansas v. Hendricks, the US Supreme Court found that civil commitment is constitutional regardless of whether any treatment is provided.

Alternatives

Accompanying deinstitutionalisation was the development of laws expanding the power of courts to order people to take psychiatric medication on an outpatient basis. Though the practice had occasionally occurred earlier, outpatient commitment was used for many people who would otherwise have been involuntarily committed. The court orders often specified that a person who violated the court order and refused to take the medication would be subject to involuntary commitment.

Involuntary commitment is distinguished from conservatorship and guardianship. The intent of conservatorship or guardianship is to protect those not mentally able to handle their affairs from the effects of their bad decisions, particularly with respect to financial dealings. For example, a conservatorship might be used to take control of the finances of a person with dementia, so that the person’s assets and income are used to meet their basic needs, e.g. by paying rent and utility bills.

Advance psychiatric directives may have a bearing on involuntary commitment.

Examples of Individual State Policies and Procedures

US military

The service member can be held under the so-called Boxer law (DoD Directive 6490.04).

District of Columbia

In the District of Columbia, any police officer, physician, or mental health professional can request to have an individual evaluated at St. Elizabeths Hospital, where they may be detained for up to 48 hours at the direction of the physician on duty. A family member or concerned citizen can also petition the Department of Mental Health, but the claim will be evaluated prior to the police acting upon it. To be held further requires that a request be filed with the Department of Mental Health. However, this only can keep the patient involuntary admitted for up to seven days. For further commitment, the patient is evaluated by a mental health court, part of family court, for which the public defender assists the patient. This can result in the patient being held up to one year at which point the patient returns to mental health court.

This is different for someone first admitted to St. Elizabeths Hospital due to criminal charges. If found to not ever become competent for trial, they will be evaluated via a Jackson hearing for possible continued commitment to protect the public. If they have been found not guilty by reason of insanity, their dangerousness is evaluated at a Bolton Hearing.

Maryland

In Maryland, any person may request, via an Emergency Evaluation form, that another individual be evaluated against their will by an emergency room physician for involuntary admission. If the judge concurs, he will direct the police to escort the individual to the hospital. A licensed physician, psychologist, social worker, or nurse practitioner who has examined the patient or a police officer may bring a potential patient to the emergency room for forced evaluation without approval from a judge. The patient may be kept in the hospital for up to thirty hours. If by then two physicians, or one physician and one psychologist then decide that the patient meets the Maryland criteria for an involuntary psychiatric admission, then he or she may be kept inpatient involuntarily for up to ten days. During this time, an administrative law judge determines if the following criteria for longer civil commitment are met:

  • A person has a mental illness;
  • A person needs inpatient care or treatment;
  • A person presents a danger to themselves or to others;
  • A person is unable or unwilling to be admitted voluntarily; and
  • There is no available, less restrictive form of care or treatment to meet the person’s needs.

Texas

In Texas a person may be subject to involuntary commitment by:

  • A peace officer, without a warrant, if A) the officer believes that 1) the person is mentally ill, 2) because of that mental illness “there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained”, and B) the officer also believes that there is insufficient time to obtain a warrant.
  • A guardian of the person of a ward under the age of 18, if the guardian believes that 1) the ward is mentally ill, 2) because of that mental illness “there is a substantial risk of serious harm to the ward or to others unless the ward is immediately restrained”.
  • An adult may file an application for emergency detention of another person; the application must meet seven outlined items which indicate that, in the applicant’s belief, that the person to be detained is mentally ill and poses a threat to the person or to others, why the person considers this to be the case, and the relationship of the applicant to the person.

A person cannot be held for more than 48 hours, and must be released by 4:00 pm on the day the 48-hour period ends, unless:

  • A written order for protective custody is obtained;
  • The 48-hour period ends on a Saturday, Sunday, or legal holiday, or before 4:00 pm on the first succeeding business day (in which case the person may only be held until 4:00 pm on the first succeeding business day); or
  • If extremely hazardous weather events exist or a disaster occurs (in which case, the period may be extended in 24-hour increments by written order specifically stating the weather event or disaster).

Upon release, unless the person was arrested or objects, the person (at the expense of the county where s/he was apprehended) must be transported to either 1) the place where s/he was apprehended, 2) the person’s residence in the state, or 3) another suitable location.

Virginia

As of 2008, Virginia was one of only five states requiring imminent danger to involuntarily commit someone. But after the Virginia Tech Massacre, there was significant political consensus to strengthen the protections for society and allow more leniency in determining that an individual needed to be committed against their will.

  • The person has a mental illness and there is a substantial likelihood that, as a result of mental illness, the person will, in the near future, (1) cause serious physical harm to himself or others as evidenced by recent behaviour causing, attempting, or threatening harm and other relevant information, if any.
  • The person has a mental illness and there is a substantial likelihood that, as a result of mental illness, the person will, in the near future, (2) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs.

“Imminent danger” was found to have too much variability throughout Virginia due to vagueness. The new standard is more specific in that substantial likelihood is more clear. However, to not limit potential detainee’s freedoms too much it is characterized by the time limit of near future. “Recent acts” is legally established to require more than a mere recitation of past events.

What is Involuntary Commitment?

Introduction

Involuntary commitment, civil commitment, or involuntary hospitalisation (also known informally as sectioning or being sectioned in some jurisdictions, such as the United Kingdom) is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily.

This treatment may involve the administration of psychoactive drugs including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community, this is sometimes referred to as outpatient commitment and shares legal processes with commitment.

Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalisation, during which an individual with acute psychiatric symptoms is confined for a relatively short duration (e.g. 72 hours) in a treatment facility for evaluation and stabilisation by mental health professionals who may then determine whether further civil commitment is appropriate or necessary. Civil commitment procedures may take place in a court or only involve physicians. If commitment does not involve a court there is normally an appeal process that does involve the judiciary in some capacity, though potentially through a specialist court.

Historically, until the mid-1960s in most jurisdictions in the United States, all committals to public psychiatric facilities and most committals to private ones were involuntary. Since then, there have been alternating trends towards the abolition or substantial reduction of involuntary commitment, a trend known as “deinstitutionalisation”. In many currents, individuals can voluntarily admit themselves to a mental health hospital and may have more rights than those who are involuntarily committed. This practice is referred to as voluntary commitment.

In the United States, an indefinite form of commitment is applied to people convicted of sexual offences.

Refer to Mental Health Tribunal, Mental Health Court, and Chronology of UK Mental Health Legislation.

Purpose

In most jurisdictions, involuntary commitment is applied to individuals believed to be experiencing a mental illness that impairs their ability to reason to such an extent that the agents of the law, state, or courts determine that decisions will be made for the individual under a legal framework. In some jurisdictions, this is a proceeding distinct from being found incompetent. Involuntary commitment is used in some degree for each of the following although different jurisdictions have different criteria. Some jurisdictions limit involuntary treatment to individuals who meet statutory criteria for presenting a danger to self or others. Other jurisdictions have broader criteria. The legal process by which commitment takes place varies between jurisdictions. Some jurisdictions have a formal court hearing where testimony and other evidence may also be submitted where subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. Other jurisdictions have delegated these power to physicians, though may provide an appeal process that involves the judiciary but may also involve physicians. For example in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative.

First Aid

Training is gradually becoming available in mental health first aid to equip community members such as teachers, school administrators, police officers, and medical workers with training in recognising, and authority in managing, situations where involuntary evaluations of behaviour are applicable under law. The extension of first aid training to cover mental health problems and crises is a quite recent development. A mental health first aid training course was developed in Australia in 2001 and has been found to improve assistance provided to persons with an alleged mental illness or mental health crisis. This form of training has now spread to a number of other countries (Canada, Finland, Hong Kong, Ireland, Singapore, Scotland, England, Wales, and the United States). Mental health triage may be used in an emergency room to make a determination about potential risk and apply treatment protocols.

Observation

Observation is sometimes used to determine whether a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person should be committed.

Containment of Danger

Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, Russia, Taiwan, Ontario (Canada), and the United States have adopted commitment criteria based on the presumed danger of the defendant to self or to others.

People with suicidal thoughts may act on these impulses and harm or kill themselves.

People with psychosis are occasionally driven by their delusions or hallucinations to harm themselves or others. Research suggests that those who suffer from schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public (Fazel et al., 2009). However, because other confounding factors such as childhood adversity and poverty are correlated with both schizophrenia and violence it can be difficult to determine whether this effect is due to schizophrenia or other factors. In an attempt to avoid these confounding factors, researchers have tried comparing the rates of violence amongst people diagnosed with schizophrenia to their siblings in a similar manner to twin studies. In these studies people with schizophrenia are found to be between 1.3 and 1.8 times more likely to engage in violent behaviour.

People with certain types of personality disorders can occasionally present a danger to themselves or others.

This concern has found expression in the standards for involuntary commitment in every US state and in other countries as the danger to self or others standard, sometimes supplemented by the requirement that the danger be imminent. In some jurisdictions, the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as “gravely disabled”.

Deinstitutionalisation

Starting in the 1960s, there has been a worldwide trend toward moving psychiatric patients from hospital settings to less restricting settings in the community, a shift known as “deinstitutionalisation“. Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalization has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. In some jurisdictions, laws authorising court-ordered outpatient treatment have been passed in an effort to compel individuals with chronic, untreated severe mental illness to take psychiatric medication while living outside the hospital (e.g. Laura’s Law, Kendra’s Law).

Before the 1960s deinstitutionalisation there were earlier efforts to free psychiatric patients. Philippe Pinel (1745-1826) ordered the removal of chains from patients.

In a study of 269 patients from Vermont State Hospital done by Courtenay M. Harding and associates, about two-thirds of the ex-patients did well after deinstitutionalisation.

Around the World

Refer to Involuntary Commitment by Country.

United Nations

United Nations General Assembly Resolution 46/119, “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care”, is a non-binding resolution advocating certain broadly drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programmes in some countries to assist in this process.

Wrongful Involuntary Commitment

Mental health professionals have, on occasion, wrongfully deemed individuals to have symptoms of a mental disorder, and thereby commit the individual for treatment in a psychiatric hospital. Claims of wrongful commitment are a common theme in the anti-psychiatry movement.

In 1860, the case of Elizabeth Packard, who was wrongfully committed that year and filed a lawsuit and won thereafter, highlighted the issue of wrongful involuntary commitment. In 1887, investigative journalist Nellie Bly went undercover at an asylum in New York City to expose the terrible conditions that mental patients at the time had to deal with. She published her findings and experiences as articles in New York World, and later made the articles into one book called Ten Days in a Mad-House.

In the first half of the twentieth century there were a few high-profile cases of wrongful commitment based on racism or punishment for political dissenters. In the former Soviet Union, psychiatric hospitals were used as prisons to isolate political prisoners from the rest of society. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals. Stoppard was inspired by a meeting with a Russian exile. In 1927, after the execution of Sacco and Vanzetti in the United States, demonstrator Aurora D’Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists. Throughout the 1940s and 1950s in Canada, 20,000 Canadian children, called the Duplessis orphans, were wrongfully certified as being mentally ill and as a result were wrongfully committed to psychiatric institutions where they were forced to take psychiatric medication that they did not need, and were abused. They were named after Maurice Duplessis, the premier of Quebec at the time, who deliberately committed these children to in order to misappropriate additional subsidies from the federal government. Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. In 1958, black pastor and activist Clennon Washington King Jr. tried enrolling at the University of Mississippi, which at the time was white, for summer classes; the local police secretly arrested and involuntarily committed him to a mental hospital for 12 days.

Patients are able to sue if they believe that they have been wrongfully committed. In one instance, Junius Wilson, an African American man, was committed to Cherry Hospital in Goldsboro, North Carolina in 1925 for an alleged crime without a trial or conviction. He was castrated. He continued to be held at Cherry Hospital for the next 67 years of his life. It turns out he was deaf rather than mentally ill.

In many American states sex offenders who have completed a period of incarceration can be civilly committed to a mental institution based on a finding of dangerousness due to a mental disorder. Although the United States Supreme Court determined that this practice does not constitute double jeopardy, organisations such as the American Psychiatric Association (APA) strongly oppose the practice. The Task Force on Sexually Dangerous Offenders, a component of APA’s Council on Psychiatry and Law, reported that “in the opinion of the task force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry, particularly with regard to defining mental illness and the clinical conditions for compulsory treatment. Moreover, by bending civil commitment to serve essentially non-medical purposes, statutes threaten to undermine the legitimacy of the medical model of commitment.”

Reference

Fazel, S., Gulati, G., Linsell, L., Geddes, J.R. & Grann, M. (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLOS Medicine. 6(8), pp.e1000120. doi:10.1371/journal.pmed.1000120.