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 the Eastern State Hospital (Virginia)?

Introduction

Eastern State Hospital is a psychiatric hospital in Williamsburg, Virginia. Built in 1773, it was the first public facility in the present-day United States constructed solely for the care and treatment of the mentally ill. The original building had burned but was reconstructed in 1985.

Francis Fauquier and the Enlightenment

Eastern State Hospital traces its foundation to a speech by Francis Fauquier, Royal Governor of the colony of Virginia, on 06 November 1766. At the House of Burgesses’ first meeting since the Stamp Act and Virginia Resolves, Fauquier primarily discussed the relationship between the Mother Country and these colonists, and expressed optimism for their future. His speech also unexpectedly addressed the mentally ill, as follows:

“It is expedient I should also recommend to your Consideration and Humanity a poor unhappy set of People who are deprived of their senses and wander about the Country, terrifying the Rest of their fellow creatures. A legal Confinement, and proper Provision, ought to be appointed for these miserable Objects, who cannot help themselves. Every civilized Country has an Hospital for these People, where they are confined, maintained and attended by able Physicians, to endeavor to restore to them their lost reason.”

About a year later, on 11 April 1767, Governor Fauquier addressed the same issue before the next House of Burgesses, thus:

“There is a subject which gives me concern, on which I shall particularly address myself to you, as it is your peculiar province to provide means for the subsistence of the poor of any kind. The subject I mean is the case of the poor lunatics. I find on your journals that it was Resolved, That an hospital be erected for the reception of persons who are so unhappy as to be deprived of their reason; And that it was Ordered, that the Committee of Propositions and Grievances do prepare and bring in a bill pursuant to the above resolution. But I do not find that any thing more was done in it. It was a measure which I think could offend no party, and which I was in hopes humanity would have dictated to every man, as soon as he was made acquainted with the call for it. It also concerns me much on another account; for as the case now stands, I am as it were compelled to the daily commission of an illegal act, by confining without my authority, a poor lunatic, who, if set at liberty, would be mischievous to society; and I would choose to be bound by, and observant of, the laws of the country. As I think this is a point of some importance to the ease and comfort of the whole community, as well as a point of charity to the unhappy objects, I shall again recommend it to you at your next meeting; when I hope, after mature reflection, it will be found to be more worth your attention than it has been in this.”

Governor Fauquier’s benevolent and bold expressions did eventually lead to the establishment of the Eastern State Hospital, although he died 03 March 1768, before it was built. His compassion and humanitarian care for those who needed it the most, made it easier for his ideas to be developed and a facility built.

Fauquier’s concern probably rested in Enlightenment principles, which were so widespread throughout the time. The 18th century was a time for rejecting superstitions and religions, and substituting science and logical reasoning. The philosophers David Hume and Voltaire were studying and investigating the worth of human life, which would ultimately alter perceptions of the mentally ill. During this time in London, insane people were viewed and used for as entertainment and comical relief. The Bethlehem Royal Hospital (sometimes called Bedlam) attracted many tourists and even held frequent parades of inmates. Enlightenment attitudes encouraged more sensitivity towards the mentally ill, rather than treating them as outcasts and fools. Some started to believe that being mentally ill was, in fact, an illness of the mind, much like a physical disease or sickness, and that these mental illnesses were also treatable.

Before Governor Fauquier’s speeches, a person who was mentally ill was not diagnosed by a doctor, but rather judged by 12 citizens, much like a jury, to be either a criminal, lunatic or Idiot. Most classified as lunatic were placed in the Public Gaol in Williamsburg. Taxpayers probably appreciated the hospital idea only if they had a family member or close friend who was mentally ill. The only hospital where mentally ill patients were sometimes taken before Eastern State Hospital was built, was the Pennsylvania Hospital, a Quaker institution in Philadelphia. Until a campaign by Benjamin Rush in 1792 to establish a separate treatment wing, mentally ill patients were kept in the basement and out of the way of regular patients who needed medical assistance.

Percival Goodhouse was is thought to be one of the first patients admitted to the Eastern State Hospital after its opening on 12 October 1773.

Civil War and Decline

In 1841, Dr. John Galt was appointed superintendent of the hospital, with roughly 125 patients (then called “inmates”) at the time. Dr. Galt introduced Moral treatment practices, a school of thought which viewed those with mental illness as deserving of respect and dignity rather than punishment for their behaviour. Galt provided his patients with talk therapy and occupational therapy, and argued for in-house research. He decreased the use of physical restraints, even going an entire year without using them, relying instead on calming drugs (including laudanum), and also proposed deinstitutionalizing patients in favour of community-based care, though this proposal was repeatedly rejected. As the head of the hospital, Galt was successful in pressing for admission for enslaved people with mental illness, and taught the enslaved people owned by the hospital to provide talk therapy alongside nurses and aides. Although he claimed to treat patients equally regardless of their race, Galt did not publish racial breakdowns of his patients.

When the Civil War came to Williamsburg, the hospital found itself alternately on one side of the lines and then the other. On 06 May 1862, Union troops captured the asylum. Two weeks later, on 17 or 18 May, Dr. Galt died of an overdose of laudanum, though it is unclear whether this was intentional or accidental. When the hospital was captured, Union soldiers found that the 252 patients had been locked in without food or supplies by the fleeing white employees. Somersett Moore was the only non-African American employee to return following the capture, and he gave the keys to release the patients to the occupying men.

In the following decades, the increasingly crowded hospital saw a regression in methodology as science was increasingly viewed as an ineffective means of dealing with mental illness. During this era of custodial care, the goal became not to cure patients, but to provide a comfortable environment for them, separate from society. On 07 June 1885, the original 1773 hospital burned to the ground due to a fire that had started in the building’s newly added electrical wiring, a consequence of the great expansion of facilities at this time.

Restoration

By 1935 Eastern State Hospital housed some 2,000 patients with no more land for expansion. The restoration of Colonial Williamsburg and development of the Williamsburg Inn resulted in the facility being at the centre of a thriving tourist trade. The hospital’s location and space issues made a move necessary. Between 1937 and 1968, all of Eastern State’s patients were moved to a new facility on the outskirts of Williamsburg, Virginia, where it continues to operate today.

In 1985, the original hospital was reconstructed on its excavated foundations by the Colonial Williamsburg Foundation.

Mexico: The Abandoned (2013)

Introduction

Today, over 10% of the global population suffers from mental health problems. Three decades of collaboration between scientists and Buddhist scholars have revealed techniques that allow us to develop our mental well-being and improve the impact we have on our planet.

Part of the Dispatches documentary series (see below).

Outline

Ade Adepitan, Daniel Bogado and former hospital patients gain access to Mexico’s psychiatric institutions to secretly film the horrific and inhumane conditions endured by thousands of men and women.

Dispatches

Dispatches is a British current affairs documentary programme on Channel 4, first broadcast on 30 October 1987. The programme covers issues about British society, politics, health, religion, international current affairs and the environment, and often features a mole inside organisations under journalistic investigation.

Production & Filming Details

  • Director(s):
  • Producer(s):
  • Writer(s):
  • Music:
  • Cinematography:
  • Editor(s):
  • Production:
  • Distributor(s):
  • Release Date: 25 October 2013.
  • Running Time: 25 minutes.
  • Rating: Unknown.
  • Country: UK.
  • Language: English.

Video Link

What is a Psychiatric Hospital?

Introduction

Psychiatric hospitals, also known as mental health units or behavioural health units, are hospitals or wards specialising in the treatment of serious mental disorders, such as major depressive disorder, schizophrenia and bipolar disorder.

Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients. Others may specialise in the temporary or permanent containment of patients who need routine assistance, treatment, or a specialised and controlled environment due to a psychological disorder. Patients often choose voluntary commitment, but those whom psychiatrists believe to pose significant danger to themselves or others may be subject to involuntary commitment and involuntary treatment.

Psychiatric hospitals may also be called psychiatric wards/units (or “psych” wards/units) when they are a subunit of a regular hospital.

The modern psychiatric hospital evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint. With successive waves of reform, and the introduction of effective evidence-based treatments, most modern psychiatric hospitals emphasize treatment, and attempt where possible to help patients control their lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy. Exceptions include Japan, where many psychiatric hospitals still use physical restraints on patients, tying them to their beds for days or even months at a time, and India, where the use of restraint and seclusion is endemic.

Brief History

Modern psychiatric hospitals evolved from, and eventually replaced, the older lunatic asylum. Their development also entails the rise of organised institutional psychiatry.

Hospitals known as bimaristans were built in Persia (old name of Iran) beginning around the early 9th century, with the first in Baghdad under the leadership of the Abbasid Caliph Harun al-Rashid. While not devoted solely to patients with psychiatric disorders, they often contained wards for patients exhibiting mania or other psychological distress. Because of cultural taboos against refusing to care for one’s family members, mentally ill patients would be surrendered to a bimaristan only if the patient demonstrated violence, incurable chronic illness, or some other extremely debilitating ailment. Psychological wards were typically enclosed by iron bars owing to the aggression of some of the patients.

Western Europe would later adopt these views with the advances of physicians like Philippe Pinel at the Bicêtre Hospital in France and William Tuke at the York Retreat in England. They advocated the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In the Western world, the arrival of institutionalisation as a solution to the problem of madness was very much an advent of the nineteenth century. The first public mental asylums were established in Britain; the passing of the County Asylums Act 1808 empowered magistrates to build rate-supported asylums in every county to house the many ‘pauper lunatics’. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every county compulsory with regular inspections on behalf of the Home Secretary, and required asylums to have written regulations and a resident physician.

At the beginning of the nineteenth century there were a few thousand “sick people” housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism. The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint.

In the late 19th and early 20th centuries, terms such as “madness”, “lunacy” or “insanity” – all of which assumed a unitary psychosis – were split into numerous “mental diseases”, of which catatonia, melancholia and dementia praecox (modern day schizophrenia) were the most common in psychiatric institutions.

In 1961 sociologist Erving Goffman described a theory of the “total institution” and the process by which it takes efforts to maintain predictable and regular behaviour on the part of both “guard” and “captor”, suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of “institutionalising” them. Asylums was a key text in the development of deinstitutionalisation.

With successive waves of reform and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment; and further, they attempt – where possible – to help patients control their own lives in the outside world with the use of a combination of psychiatric drugs and psychotherapy. These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement. Most psychiatric hospitals now restrict internet access and any device that can take photos. In the US state of Connecticut, involuntary patients must be examined annually by a court-appointed psychiatrist. Patients may also apply for release at any time and receive a full hearing on the application.

Types

There are a number of different types of modern psychiatric hospitals, but all of them house people with mental illnesses of widely variable severity. In the United Kingdom, both crisis admissions and medium-term care are usually provided on acute admissions wards. Juvenile or youth wards in psychiatric hospitals or psychiatric wards are set aside for children or youth with mental illness. Long-term care facilities have the goal of treatment and rehabilitation within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house.

Crisis Stabilisation

The crisis stabilisation unit is effectively an emergency department for psychiatry, often treating suicidal, violent, or otherwise critical individuals.

Open Units

Open psychiatric units are not as secure as crisis stabilisation units. They are not used for acutely suicidal persons; instead, the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits, depending on the type of patients admitted.

Medium Term

Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective.

Juvenile Wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children or adolescents with mental illness. However, there are a number of institutions specialising only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illness.

Long-Term Care Facilities

In the UK, long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security, and being locally situated to help with reintegration into society once medication has stabilised the condition are often features of such units. Examples of this include the Three Bridges Unit, in the grounds of St Bernard’s Hospital in West London and the John Munroe Hospital in Staffordshire. However, these modern units have the goal of treatment and rehabilitation to allow for transition back into society within a short time-frame (two or three years). However, not all patients’ treatment can meet this criterion, so the large hospitals mentioned above often retain this role.

These hospitals provide stabilisation and rehabilitation for those who are actively experiencing uncontrolled symptoms of mental disorders such as depression, bipolar disorders, eating disorders, and so on.

Halfway Houses

One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living for an extended period of time for patients with mental illnesses, and they often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding.

Political Imprisonment

In some countries, the mental institution may be used for the incarceration of political prisoners as a form of punishment. A notable historical example was the use of punitive psychiatry in the Soviet Union and China.

Secure Units

In the UK, criminal courts or the Home Secretary can, under various sections of the Mental Health Act, order the admission of offenders for detainment in a psychiatric hospital, but the term “criminally insane” is no longer legally or medically recognised. Secure psychiatric units exist in all regions of the UK for this purpose; in addition, there are a few specialist hospitals which offer treatment with high levels of security. These facilities are divided into three main categories: High, Medium and Low Secure. Although the phrase “Maximum Secure” is often used in the media, there is no such classification. “Local Secure” is a common misnomer for Low Secure units, as patients are often detained there by local criminal courts for psychiatric assessment before sentencing.

Run by the National Health Service, these facilities which provide psychiatric assessments can also provide treatment and accommodation in a safe hospital environment which prevents absconding. Thus there is far less risk of patients harming themselves or others. The Central Mental Hospital in Dublin performs a similar function

Community Hospital Utilisation

Community hospitals across the United States regularly see mental health discharges. A study of community hospital discharge data from 2003-2011 showed that mental health hospitalisations were increasing for both children (patients aged 0-17 years) and adults (patients aged 18-64). Compared to other hospital utilisation, mental health discharges for children were the lowest while the most rapidly increasing hospitalisations were for adults under 64. Some units have been opened to provide “Therapeutically Enhanced Treatment” and so form a subcategory to the three main unit types.

The general public in the UK are familiar with the names of the High Secure Hospitals due to the frequency that they are mentioned in the news reports about the people who are sent there. Those in the UK include Ashworth Hospital in Merseyside, Broadmoor Hospital in Crowthorne, Berkshire, Rampton Secure Hospital in Retford, Nottinghamshire, and Scotland’s The State Hospital in Carstairs. Northern Ireland and the Isle of Man have their own Medium and Low Secure units but use the mainland facilities for High Secure, to which smaller Channel Islands also transfer their patients as Out of Area (Off-Island Placements) Referrals under the Mental Health Act 1983. Of the three unit types, Medium Secure is most prevalent throughout the UK. As of 2009, there were 27 women-only units in England alone. Irish units include those at prisons in Portlaise, Castelrea and Cork.

Criticism

Hungarian-born psychiatrist Thomas Szasz argued that psychiatric hospitals are like prisons unlike other kinds of hospitals, and that psychiatrists who coerce people (into treatment or involuntary commitment) function as judges and jailers, not physicians. Historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilisation. He argued that Tuke and Pinel’s asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family-Children (paternal authority), Fault–Punishment (immediate justice), Madness-Disorder (social and moral order).

Erving Goffman coined the term “Total Institution” for mental hospitals and similar places which took over and confined a person’s whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organisations, orphanages, and monasteries. In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone “dull, harmless and inconspicuous”; in turn, it reinforces notions of chronicity in severe mental illness. The Rosenhan experiment of 1973 demonstrated the difficulty of distinguishing sane patients from insane patients.

Franco Basaglia, a leading psychiatrist who inspired and planned the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents. Patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the “total institution”: labelling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over those of the persons whom it was ostensibly there to serve: the patients.

The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals; due to the extreme conditions in them. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but it generally does not object to any psychiatric treatments that are consensual, provided that both parties can withdraw consent at any time.

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.

On This Day … 15 May

Events

  • 1817 – Opening of the first private mental health hospital in the United States, the Asylum for the Relief of Persons Deprived of the Use of Their Reason (now Friends Hospital, Philadelphia, Pennsylvania).

Friends Hospital

Friends Hospital is a mental hospital located in Philadelphia, Pennsylvania, United States.

Founded in 1813 by Quakers as The Asylum for the Relief of Persons Deprived of the Use of Their Reason, the institution was later renamed the Frankford Asylum for the Insane. It was the first private mental hospital in the nation, and is the oldest such institution with a continuous history of operation. Its campus, which dates to its founding, is a National Historic Landmark.

Friends Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations and licensed by the Commonwealth of Pennsylvania.

Mission

The 1813 mission statement of the hospital was “To provide for the suitable accommodation of persons who are or may be deprived of the use of their reason, and the maintenance of an asylum for their reception, which is intended to furnish, besides requisite medical aid, such tender, sympathetic attention as may soothe their agitated minds, and under the Divine Blessing, facilitate their recovery.”

History

The Quakers established Friends Hospital in 1813, drawing on a belief that all persons could live a “moral, ordered existence if treated with kindness, dignity, and respect”, despite disabilities. The influential minister Thomas Scattergood decried what he considered the harsh conditions faced by patients in mental asylums; Scattergood instead called for the “moral treatment” of patients. This model served as an inspiration for the establishment of the Friends Asylum for Persons Deprived of the Use of Their Reason; it was the nation’s first privately run psychiatric hospital.

Services

  • Patient Services:
    • Adolescent Programme:
      • A dedicated treatment programme specifically design for young people 13-17 years of age.
      • 24 bed acute care psychiatric unit with separate wings for male and female patients (12 for males, 12 for females).
      • Private bedrooms with unit access to an enclosed outside courtyard.
      • Treatment of all major psychiatric disorders and co-occurring substance issues.
      • Holistic and patient centred approach, including regular group and family therapy, as well as individual therapy when indicated.
      • Individualised treatment, wellness and safety and discharge plans.
      • Academic support including an educational assessment and daily education instruction provide by a certified teacher.
    • Adult Programmes:
      • Dedicated Adult Units offering a rand of programming design for the varied needs of patients ages 18 to 65.
      • Private patient bedrooms with unit access to an enclosed outside courtyard.
      • Treatment for all major psychiatric disorders and co-occurring substance issues.
      • Recovery-oriented approach emphasizing each patient’s own support systems, strength and community connections in collaboration in professional treatment.
      • Individualised treatment, wellness, and safety, and discharge plans.
    • Older Adult Programme:
      • A dedicated treatment programme specifically design for older adults.
      • Private patient bedrooms with unit access to an enclosed outside courtyard.
      • Treatment for all major psychiatric disorders, including behavioural symptoms related to dementia.
      • Treatment for co-occurring substance issues.
      • Holistic and patient centred approach, including regular group and family therapy, as well as individual therapy when indicated.
      • Age sensitive, individualised treatment, wellness, and safety, and discharge plans.

Greystone Program at Friends Hospital Located on the grounds of the Friends Hospital, the Greystone Programme is a long-term community residence designed to meet the special needs for individuals with severe and persistent mental illnesses. Consisting of two houses, Greystone House and Hillside House, the programme is dedicated to helping its residents move toward recovery, greater independence, and an enhanced quality of life. The Greystone Programme emphasizes the development of skills of daily living, socialisation, purposeful activity, and recovery enables residents to realise their dignity, worth and highest individual potential. Many residents have chosen to make the Greystone Programme their permanent home while other will successfully transition to a less structured environment.

Book: How Can I Help?: A Week in My Life as a Psychiatrist

Book Title:

How Can I Help?: A Week in My Life as a Psychiatrist.

Author(s): David Goldbloom (MD) and Pier Bryden (MD).

Year: 2017.

Edition: First (1st), Canadian Origin Edition.

Publisher: Touchstone.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

A humane behind-the-scenes account of a week in the life of a psychiatrist at one of Canada’s leading mental health hospitals. How Can I Help? takes us to the frontlines of modern psychiatric care.

How Can I Help? portrays a week in the life of Dr. David Goldbloom as he treats patients, communicates with families, and trains staff at CAMH, the largest psychiatric facility in Canada. This highly readable and touching behind-the-scenes account of his daily encounters with a wide range of psychiatric concerns – from his own patients and their families to Emergency Department arrivals – puts a human face on an often misunderstood area of medical expertise. From schizophrenia and borderline personality disorder to post-traumatic stress syndrome and autism, How Can I Help? investigates a range of mental issues.

What is it like to work as a psychiatrist now? What are the rewards and challenges? What is the impact of the suffering – and the recovery – of people with mental illness on families and the clinicians who treat them? What does the future hold for psychiatric care?

How Can I Help? demystifies a profession that has undergone profound change over the past twenty-five years, a profession that is often misunderstood by the public and the media, and even by doctors themselves. It offers a compassionate, realistic picture of a branch of medicine that is entering a new phase, as increasingly we are able to decode the mysteries of the brain and offer new hope for sufferers of mental illness.

What is a Community Mental Health Service?

Introduction

Centre for Mental Health Services, also known as community mental health teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health difficulties) in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient’s community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.

Community services include supported housing with full or partial supervision (including halfway houses), psychiatric wards of general hospitals (including partial hospitalisation), local primary care medical services, day centres or clubhouses, community mental health centres, and self-help groups for mental health.

The services may be provided by government organisations and mental health professionals, including specialised teams providing services across a geographical area, such as assertive community treatment and early psychosis teams. They may also be provided by private or charitable organisations. They may be based on peer support and the consumer/survivor/ex-patient movement.

The World Health Organisation (WHO) states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have fewer possibilities for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care.

New legal powers have developed in some countries, such as the United States, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment or assisted outpatient treatment or community treatment orders.

Brief History

Origins

Community mental health services began as an effort to contain those who were “mad” or considered “lunatics”. Understanding the history of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services.

Pre-Deinstitutionalisation

On 03 July 1946, US President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949. At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.

Deinstitutionalisation

Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanisation and increased immigration led to a gross overwhelming of the state’s mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.

Mental Health Movements

Reform MovementEraSettingFocus of Reform
Moral Treatment1800-1850AsylumHumane, restorative treatment
Mental Hygiene1890-1920Mental hospital or clinicPrevention, scientific orientation
Community Mental Health1955-1970Community mental health centreDeinstitutionalisation, social integration
Community Support1975-PresentCommunitiesMental illness as a social welfare problem (e.g. treatment housing, employment, etc.)

Post-Deinstitutionalisation

Following deinstitutionalisation, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalisation, the Mental Health Study Act was passed. With the passing of this Act, the US Congress called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” Following Congress’ mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centres across the country. In 1963, the Community Mental Health Centres Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalisation by moving mental patients into their “least restrictive” environments. The Community Mental Health Centres Act funded three main initiatives:

  • Professional training for those working in community mental health centres;
  • Improvement of research in the methodology utilised by community mental health centres; and
  • Improving the quality of care of existing programmes until newer community mental health centres could be developed.

That same year the Mental Retardation Facilities and Community Mental Health Centres Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy’s ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centres that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children. As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.

20th Century

From 1965 to 1969, $260 million was authorised for community mental health centres. Compared to other government organisations and programmes, this number is strikingly low. The funding drops even further under Richard Nixon from 1970-1973 with a total of $50.3 million authorised. Even though the funding for community mental health centres was on a steady decline, deinstitutionalisation continued into the 1960s and 1970s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalisation without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975, Congress passed an Act requiring community mental health centres to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act of 1980, which provided federal funding for ongoing support and development of community mental health programmes. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter’s Mental Health Commission. Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.’s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. The C.S.P. established the ten elements of a community support system listed below:

  • Responsible team.
  • Residential care.
  • Emergency care.
  • Medicare care.
  • Halfway house.
  • Supervised (supported) apartments.
  • Outpatient therapy.
  • Vocational training and opportunities.
  • Social and recreational opportunities.
  • Family and network attention.

This conceptualisation of what makes a good community programme has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community. In 1986, Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centres to expand their range of treatment options and services. As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbour negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, “many American jails have become housing for persons with severe mental illnesses arrested for various crimes.” In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.

21st Century and Modern Trends

In 2002, President George W. Bush increased funding for community health centres. The funding aided in the construction of additional centres and increased the number of services offered at these centres, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to “conduct a comprehensive study of the United States mental health delivery system…” Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment. As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centres grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centres are becoming to the general population’s wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialised treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with their primary care provider, they are more likely for a number of reasons to receive less care than with a specialised clinician. Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centres. Political views aside, it is clear that these community mental health centres exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilised community mental health centres with 35% being insured through Medicaid, and 38% being uninsured. As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centres stayed steady.

Purpose and Examples

Cultural knowledge and attitude is passed from generation to generation. For example, the stigma with therapy may be passed from mother to daughter. San Diego county has a diverse range of ethnicities. Thus, the population diversity in San Diego include many groups with historical trauma and trans-generational trauma within those populations. For example, witnesses of war can pass down certain actions and patterns of survival mechanism to generations. Refugee groups have trans-generational trauma around war and PTSD. Providing services and therapy to these communities is important because it affects their day-to-day lives, where their experiences lead to trauma or the experiences are traumatic themselves. Knowledge and access to mental health resources are limited in these multicultural communities. Government agencies fund community groups that provide services to these communities. Therefore, this creates a power hierarchy. If their missions do not align with each other, it will be hard to provide benefits for the community, even though the services are imperative to the wellbeing of its residents.

The combination of a mental illness as a clinical diagnosis, functional impairment with one or more major life activities, and distress is highest in ages 18-25 years old. Despite the research showing the necessity of therapy for this age group, only one fifth of emerging adults receive treatment. Psychosocial interventions that encourage self-exploration and self-awareness, such as acceptance and mindfulness-based therapies, is useful in preventing and treating mental health concerns. At the Centre for Community Counselling and Engagement, 39% of their clients are ages 1-25 years old and 40% are in ages 26-40 years old as well as historically underrepresented people of colour. The centre serves a wide range of ethnicities and socio-economic statuses in the City Heights community with counsellors who are graduate student therapists getting their Master’s in Marriage and Family Therapy or Community Counselling from San Diego State University, as well as post-graduate interns with their master’s degree, who are preparing to be licensed by the state of California. Counselling fees are based on household incomes, which 69% of the client’s annual income is $1-$25,000 essentially meeting the community’s needs. Taking into account of San Diego’s population, the clinic serves as an example of how resources can be helpful for multicultural communities that have a lot of trauma in their populations.

Future

On one hand, despite the field’s movement toward community mental health services, currently “insufficient empirical research exists regarding the effectiveness of community treatment programmes, and the evidence that does exist does not generalise to all types of community treatment.” In addition to the fact that community mental health’s overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilises. On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role community mental health services will play. In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organisations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system’s goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalisation, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centres substantially. Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

On This Day … 06 August

  • 2001 – Erwadi fire incident, 28 mentally ill persons tied to a chain were burnt to death at a faith based institution at Erwadi, Tamil Nadu.

What is the Erwadi Fire Incident?

Erwadi fire incident is an accident that occurred on 06 August 2001, when 28 inmates of a faith-based mental asylum died in the fire. All these inmates were bound by chains at Moideen Badusha Mental Home in Erwadi Village in Tamil Nadu.

Large number of mental homes existed in Erwadi which was famous for the dargah of Quthbus Sultan Syed Ibrahim Shaheed Valiyullah, from Medina, Saudi Arabia who came to India to propagate Islam. Various people believe that holy water from the dargah and oil from the lamp burning there have the power to cure all illnesses, especially mental problems.

The treatment also included frequent caning, beatings supposedly to “drive away the evil”. During the day, patients were tied to trees with thick ropes. At night, they were tied to their beds with iron chains. The patients awaited a divine command in their dreams to go back home. For the command to come, it was expected to take anything from two months to several years.

As the number of people seeking cure at dargah increased, homes were set up by individuals to reportedly take care of the patients. Most of these homes were set up by people who themselves had come to Erwadi seeking cure for their relatives.

The origins of the fire are unknown, but once it spread, there was little hope of saving most of the 45 inmates, who were chained to their beds in the ramshackle shelter in which they slept, though such shackling was against Indian law. Some inmates whose shackles were not as tight escaped, and five people were hospitalised for severe burns. The bodies of the dead were not identifiable.

Aftermath

All mental homes of this type were closed on 13 August 2001, and more than 500 inmates were placed under the government’s care.

As per Supreme Court directions, a commission headed by N. Ramdas was set up to enquire into these deaths. The commission recommended that care of mentally ill people is to be improved, that anybody wishing to set up a mental home to acquire a license, and that all inmates be unchained.

In 2007, the owner of the Badsha Home for the Mentally Challenged, his wife and two relatives were sentenced to seven years imprisonment by a magistrate Court.