What is Bethlem Royal Hospital?

Introduction

Bethlem Royal Hospital, also known as St Mary Bethlehem, Bethlehem Hospital and Bedlam, is a psychiatric hospital in London. Its famous history has inspired several horror books, films and TV series, most notably Bedlam, a 1946 film with Boris Karloff.

Bethlem Royal Hospital Main Building.

The hospital is closely associated with King’s College London and, in partnership with the Institute of Psychiatry, Psychology and Neuroscience, is a major centre for psychiatric research. It is part of the King’s Health Partners academic health science centre and the NIHR Biomedical Research Centre for Mental Health.

Originally the hospital was near Bishopsgate just outside the walls of the City of London. It moved a short distance to Moorfields in 1676, and then to St George’s Fields in Southwark in 1815, before moving to its current location in Monks Orchard in 1930.

The word “bedlam”, meaning uproar and confusion, is derived from the hospital’s nickname. Although the hospital became a modern psychiatric facility, historically it was representative of the worst excesses of asylums in the era of lunacy reform.

1247 to 1633

Foundation

The hospital was founded in 1247 as the Priory of the New Order of our Lady of Bethlehem in the city of London during the reign of Henry III. It was established by the Bishop-elect of Bethlehem, the Italian Goffredo de Prefetti, following a donation of personal property by the London alderman and former sheriff, Simon FitzMary. The original location was in the parish of St Botolph, Bishopsgate’s ward, just beyond London’s wall and where the south-east corner of Liverpool Street Station now stands. Bethlem was not initially intended as a hospital, in the clinical sense, much less as a specialist institution for the insane, but as a centre for the collection of alms to support the Crusader Church and to link England to the Holy Land.

De Prefetti’s need to generate income for the Crusader Church and restore the financial fortunes of his see had been occasioned by two misfortunes: his bishopric had suffered significant losses following the destructive conquest of Bethlehem by the Khwarazmian Turks in 1244, and his immediate predecessor had further impoverished his cathedral chapter through the alienation of a considerable amount of its property. The priory, obedient to the Church of Bethlehem, would also house the poor and, if they visited, provide hospitality to the bishop, canons and brothers of Bethlehem. Thus, Bethlem became a hospital, in medieval usage, “an institution supported by charity or taxes for the care of the needy”. The subordination of the priory’s religious order to the bishops of Bethlehem was further underlined in the foundational charter, which stipulated that the prior, canons and inmates were to wear a star upon their cloaks and capes to symbolise their obedience to the church of Bethlehem.

Politics and Patronage

During the thirteenth and fourteenth centuries, with its activities underwritten by episcopal and papal indulgences, the hospital’s role as a centre for alms collection persisted, but its linkage to the Order of Bethlehem increasingly unravelled, putting its purpose and patronage in doubt. In 1346 the master of Bethlem, a position at that time granted to the most senior of London’s Bethlemite brethren, applied to the city authorities seeking protection; thereafter metropolitan office-holders claimed power to oversee the appointment of masters and demanded in return an annual payment of 40 shillings. It is doubtful whether the city really provided substantial protection and much less that the mastership fell within their patronage but, dating from the 1346 petition, it played a role in the management of Bethlem’s finances. By this time the Bethlehemite bishops had relocated to Clamecy, France, under the surety of the Avignon papacy. This was significant as, throughout the reign of Edward III (1327-1377), the English monarchy had extended its patronage over ecclesiastical positions through the seizure of priories under the control of non-English religious houses. As a dependent house of the Order of Saint Bethlehem in Clamecy, Bethlem was vulnerable to seizure by the crown and this occurred in the 1370s when Edward III took control. The purpose of this appropriation was, in the context of the Hundred Years’ War between France and England, to prevent funds raised by the hospital from enriching the French monarchy via the papal court. After this event the masters of the hospital, semi-autonomous figures in charge of its day-to-day management, were normally crown appointees and it became an increasingly secularised institution. The memory of its foundation became muddied and muddled; in 1381 the royal candidate for the post of master claimed that from its beginnings it had been superintended by an order of knights and he confused its founder, Goffredo de Prefetti, with the Frankish crusader, Godfrey de Bouillon. The removal of the last symbolic link to the Bethlehemites was confirmed in 1403 when it was reported that master and inmates no longer wore the star of Bethlehem

In 1546 the Lord Mayor of London, Sir John Gresham, petitioned the crown to grant Bethlem to the city. This petition was partially successful and Henry VIII reluctantly ceded to the City of London “the custody, order and governance” of the hospital and of its “occupants and revenues”. This charter came into effect in 1547. The crown retained possession of the hospital while its administration fell to the city authorities. Following a brief interval when it was placed under the management of the governors of Christ’s Hospital, from 1557 it was administered by the governors of Bridewell, a prototype house of correction at Blackfriars. Having been thus one of the few metropolitan hospitals to have survived the dissolution of the monasteries physically intact, this joint administration continued, not without interference by both the crown and city, until incorporation into the National Health Service in 1948.

From Bethlem to Bedlam

It is unknown when Bethlem, or Bedlam, began to specialise in the care and control of the insane, but it has been frequently asserted that Bethlem was first used for the insane from 1377. This date is derived from the unsubstantiated conjecture of the Reverend Edward Geoffrey O’Donoghue, chaplain to the hospital, who published a monograph on its history in 1914. While it is possible that Bethlem was receiving the insane during the late fourteenth century, the first definitive record of their presence in the hospital is in the details of a visitation of the Charity Commissioners in 1403. This recorded that amongst other patients there were six male inmates who were “mente capti”, a Latin term indicating insanity. The report of the visitation also noted the presence of four pairs of manacles, 11 chains, six locks and two pairs of stocks but it is not clear if any or all of these items were for the restraint of the inmates. While mechanical restraint and solitary confinement are likely to have been used for those regarded as dangerous, little else is known of the actual treatment of the insane for much of the medieval period. The presence of a small number of insane patients in 1403 marks Bethlem’s gradual transition from a diminutive general hospital into a specialist institution for the confinement of the insane. This process was largely completed by 1460.

From the fourteenth century, Bethlem had been referred to colloquially as “Bedleheem”, “Bedleem” or “Bedlam”. Initially “Bedlam” was an informal name but from approximately the Jacobean era the word entered everyday speech to signify a state of madness, chaos, and the irrational nature of the world. This development was partly due to Bedlam’s staging in several plays of the Jacobean and Caroline periods, including The Honest Whore, Part I (1604); Northward Ho (1607); The Duchess of Malfi (1612); The Pilgrim (c. 1621); and The Changeling (1622). This dramatic interest in Bedlam is also evident in references to it in early seventeenth-century plays such as Epicœne, or The Silent Woman (1609), Bartholomew Fair (1614), and A New Way to Pay Old Debts (c. 1625). The appropriation of Bedlam as a theatrical locale for the depiction of madness probably owes no little debt to the establishment in 1576 in nearby Moorfields of The Curtain and The Theatre, two of the main London playhouses; it may also have been coincident with that other theatricalisation of madness as charitable object, the commencement of public visiting at Bethlem.

Management

The position of master was a sinecure largely regarded by its occupants as means of profiting at the expense of the poor in their charge. The appointment of the masters, later known as keepers, had lain within the patronage of the crown until 1547. Thereafter the city, through the Court of Aldermen, took control and, as with the King’s appointees, the office was used to reward loyal servants and friends. Compared to the masters placed by the monarch, those who gained the position through the city were of much more modest status. In 1561 the Lord Mayor succeeded in having his former porter, Richard Munnes, a draper by trade, appointed to the position. The sole qualification of his successor in 1565, a man by the name of Edward Rest, appears to have been his occupation as a grocer. Rest died in 1571, at which point the keepership passed on to John Mell in 1576, known for his abuse of “the governors, those who gave money to the poor, and the poor themselves.” The Bridewell Governors largely interpreted the role of keeper as that of a house manager and this is clearly reflected in the occupations of most appointees as they tended to be inn-keepers, victualers or brewers and the like. When patients were sent to Bethlem by the Governors of the Bridewell the keeper was paid from hospital funds. For the remainder, keepers were paid either by the families and friends of inmates or by the parish authorities. It is possible that keepers negotiated their fees for these latter categories of patients.

John Mell’s death in 1579 left the keepership open for the long-term keeper Roland Sleford, a London cloth-maker, who left his post in 1598, apparently of his own volition, after a 19-year tenure. Two months later, the Bridewell Governors, who had until then shown little interest in the management of Bethlem beyond the appointment of keepers, conducted an inspection of the hospital and a census of its inhabitants for the first time in over 40 years. Their purpose was “to view and p[er]use the defaultes and want of rep[ar]ac[i]ons”. They found that during the period of Sleford’s keepership the hospital buildings had fallen into a deplorable condition with the roof caving in and the kitchen sink blocked, and reported that “…it is not fitt for anye man to dwell in wch was left by the Keeper for that it is so loathsomly filthely kept not fit for any man to come into the house”.

The committee of inspection found 21 inmates with only two having been admitted during the previous 12 months. Of the remainder, six at least had been resident for a minimum of eight years and one inmate had been there for around 25 years. Three were from outside London, six were charitable cases paid for out of the hospital’s resources, one was supported by a parochial authority, and the rest were provided for by family, friends, benefactors or, in one instance, out of their own funds. The reason for the Governors’ new-found interest in Bethlem is unknown but it may have been connected to the increased scrutiny the hospital was coming under with the passing of poor law legislation in 1598 and to the decision by the Governors to increase hospital revenues by opening it up to general visitors as a spectacle. After this inspection, the Governors initiated some repairs and visited the hospital at more frequent intervals. During one such visit in 1607 they ordered the purchase of clothing and eating vessels for the inmates, presumably indicating the lack of such basic items.

Helkiah Crooke

At the bidding of James VI and I, Helkiah Crooke (1576-1648) was appointed keeper-physician in 1619. As a Cambridge graduate, the author of an enormously successful English language book of anatomy entitled Microcosmographia: a Description of the Body of Man (1615) and a member of the medical department of the royal household, he was clearly of higher social status than his city-appointed predecessors (his father was a noted preacher, and his elder brother Thomas was created a baronet). Crooke had successfully ousted the previous keeper, the layman Thomas Jenner, after a campaign in which he had castigated his rival for being “unskilful in the practice of medicine”. While this may appear to provide evidence of the early recognition by the Governors that the inmates of Bethlem required medical care, the formal conditions of Crooke’s appointment did not detail any required medical duties. Indeed, the Board of Governors continued to refer to the inmates as “the poore” or “prisoners” and their first designation as patients appears to have been by the Privy Council in 1630.

From 1619, Crooke unsuccessfully campaigned through petition to the king for Bethlem to become an independent institution from the Bridewell, a move that while likely meant to serve both monarchial and personal interest would bring him into conflict with the Bridewell Governors. Following a pattern of management laid down by early office-holders, his tenure as keeper was distinguished by his irregular attendance at the hospital and the avid appropriation of its funds as his own. Such were the depredations of his regime that an inspection by the Governors in 1631 reported that the patients were “likely to starve”. Charges against his conduct were brought before the Governors in 1632. Crooke’s royal favour having dissolved with the death of James I, Charles I instigated an investigation against him in the same year. This established his absenteeism and embezzlement of hospital resources and charged him with failing to pursue “any endeavour for the curing of the distracted persons”. It also revealed that charitable goods and hospital-purchased foodstuffs intended for patients had been typically misappropriated by the hospital steward, either for his own use or to be sold to the inmates. If patients lacked resources to trade with the steward they often went hungry. These findings resulted in the dismissal in disgrace of Crooke, the last of the old-style keepers, along with his steward on 24 May 1633.

Conditions

In 1632 it was recorded that the old house of Bethlem had “below stairs a parlour, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in”. It is likely that this arrangement was not significantly different in the sixteenth century. Although inmates, if deemed dangerous or disturbing, were chained up or locked up, Bethlem was an otherwise open building with its inhabitants at liberty to roam around its confines and possibly the local neighbourhood. The neighbouring inhabitants would have been quite familiar with the condition of the hospital as in the 1560s, and probably for some considerable time before that, those who lacked a lavatory in their own homes had to walk through “the west end of the long house of Bethlem” to access the rear of the hospital and reach the “common Jacques”. Typically the hospital appears to have been a receptacle for the very disturbed and troublesome and this fact lends some credence to accounts such as that provided by Donald Lupton in the 1630s who described the “cryings, screechings, roarings, brawlings, shaking of chaines, swearings, frettings, chaffings” that he observed.

Bethlem had been built over a sewer that served both the hospital and its precinct. This common drain regularly blocked, resulting in overflows of waste at the entrance of the hospital. The 1598 visitation by the Governors had observed that the hospital was “filthely kept”, but the Governors rarely made any reference to the need for staff to clean the hospital. The level of hygiene reflected the inadequate water supply, which, until its replacement in 1657, consisted of a single wooden cistern in the back yard from which water had to be laboriously transported by bucket. In the same yard since at least the early seventeenth century there was a “washhouse” to clean patients’ clothes and bedclothes and in 1669 a drying room for clothes was added. Patients, if capable, were permitted to use the “house of easement”, of which there were two at most, but more frequently “piss-pots” were used in their cells. Unsurprisingly, inmates left to brood in their cells with their own excreta were, on occasion, liable to throw such “filth & Excrem[en]t” into the hospital yard or onto staff and visitors. Lack of facilities combined with patient incontinence and prevalent conceptions of the mad as animalistic and dirty, fit to be kept on a bed of straw, appear to have promoted an acceptance of hospital squalor. However, this was an age with very different standards of public and personal hygiene when people typically were quite willing to urinate or defecate in the street or even in their own fireplaces.

For much of the seventeenth century the dietary provision for patients appears to have been inadequate. This was especially so during Crooke’s regime, when inspection found several patients suffering from starvation. Corrupt staff practices were evidently a significant factor in patient malnourishment and similar abuses were noted in the 1650s and 1670s. The Governors failed to manage the supply of victuals, relying on “gifts in kind” for basic provisions, and the resources available to the steward to purchase foodstuffs was dependent upon the goodwill of the keeper. Patients were fed twice a day on a “lowering diet” (an intentionally reduced and plain diet) consisting of bread, meat, oatmeal, butter, cheese and generous amounts of beer. It is likely that daily meals alternated between meat and dairy products, almost entirely lacking in fruit or vegetables. That the portions appear to have been inadequate also likely reflected contemporary humoral theory that justified rationing the diet of the mad, the avoidance of rich foods, and a therapeutics of depletion and purgation to restore the body to balance and restrain the spirits.

1634 to 1791

Medical Regime

The year 1634 is typically interpreted as denoting the divide between the mediaeval and early modern administration of Bethlem. It marked the end of the day-to-day management by an old-style keeper-physician and its replacement by a three-tiered medical regime composed of a non-resident physician, a visiting surgeon and an apothecary, a model adopted from the royal hospitals. The medical staff were elected by the Court of Governors and, in a bid to prevent profiteering at the expense of patients that had reached its apogee in Crooke’s era, they were all eventually salaried with limited responsibility for the financial affairs of the hospital. Personal connections, interests and occasionally royal favour were pivotal factors in the appointment of physicians, but by the measure of the times appointees were well qualified as almost all were Oxbridge graduates and a significant number were either candidates or fellows of the College of Physicians. Although the posts were strongly contested, nepotistic appointment practices played a significant role. The election of James Monro as physician in 1728 marked the beginning of a 125-year Monro family dynasty extending through four generations of fathers and sons. Family influence was also significant in the appointment of surgeons but absent in that of apothecaries.

The office of physician was largely an honorary and charitable one with only a nominal salary. As with most hospital posts, attendance was required only intermittently and the greater portion of the income was derived from private practice. Bethlem physicians, maximising their association with the hospital, typically earned their coin in the lucrative “trade in lunacy” with many acting as visiting physicians to, presiding over, or even, as with the Monros and their predecessor Thomas Allen, establishing their own mad-houses. Initially both surgeons and apothecaries were also without salary and their hospital income was solely dependent upon their presentation of bills for attendance to the Court of Governors. This system was frequently abused and the bills presented were often deemed exorbitant by the Board of Governors. The problem of financial exploitation was partly rectified in 1676, when surgeons received a salary, and from the mid-eighteenth century elected apothecaries were likewise salaried and normally resident within the hospital. Dating from this latter change, the vast majority of medical responsibilities within the institution were undertaken by the sole resident medical officer, the apothecary, owing to the relatively irregular attendance of the physician and surgeon.

The medical regime, being married to a depletive or antiphlogistic physic until the early nineteenth century, had a reputation for conservatism that was neither unearned nor, given the questionable benefit of some therapeutic innovations, necessarily ill-conceived in every instance. Bathing was introduced in the 1680s at a time when hydrotherapy was enjoying a recrudescence in popularity. “Cold bathing”, opined John Monro, Bethlem physician for 40 years from 1751, “has in general an excellent effect”; and remained much in vogue as a treatment throughout the eighteenth century. By the early nineteenth century, bathing was routine for all patients of sufficient hardiness from summer “to the setting-in of the cold weather”. Spring signalled recourse to the traditional armamentarium; from then until the end of summer Bethlem’s “Mad Physick” reigned supreme as all patients, barring those deemed incurable, could expect to be bled and blistered and then dosed with emetics and purgatives. Indiscriminately applied, these curative measures were administered with the most cursory physical examination, if any, and with sufficient excess to risk not only health but also life. Such was the violence of the standard medical course, “involving voiding of the bowels, vomiting, scarification, sores and bruises,” that patients were regularly discharged or refused admission if they were deemed unfit to survive the physical onslaught.

The reigning medical ethos was the subject of public debate in the mid-eighteenth century when a paper war erupted between John Monro and his rival William Battie, physician to the reformist St Luke’s Asylum of London, founded in 1751. The Bethlem Governors, who had presided over the only public asylum in Britain until the early eighteenth century, looked upon St Luke’s as an upstart institution and Battie, formerly a Governor at Bethlem, as traitorous. In 1758 Battie published his Treatise on Madness which castigated Bethlem as archaic and outmoded, uncaring of its patients and founded upon a despairing medical system whose therapeutic transactions were both injudicious and unnecessarily violent. In contrast, Battie presented St Luke’s as a progressive and innovative hospital, oriented towards the possibility of cure and scientific in approach. Monro responded promptly, publishing Remarks on Dr. Battie’s Treatise on Madness in the same year.

Bethlem Rebuilt at Moorfields

Although Bethlem had been enlarged by 1667 to accommodate 59 patients, the Court of Governors of Bethlem and Bridewell observed at the start of 1674 that “the Hospitall House of Bethlem is very olde, weake & ruinous and to[o] small and streight for keepeing the greater numb[e]r of lunaticks therein att p[re]sent”. With the increasing demand for admission and the inadequate and dilapidated state of the building it was decided to rebuild the hospital in Moorfields, just north of the city proper and one of the largest open spaces in London. The architect chosen for the new hospital, which was built rapidly and at great expense between 1675 and 1676, was the natural philosopher and City Surveyor Robert Hooke. He constructed an edifice that was monumental in scale at over 500 feet (150 m) wide and some 40 feet (12 m) deep.[n 8] The surrounding walls were some 680 feet (210 m) long and 70 feet (21 m) deep while the south face at the rear was effectively screened by a 714-foot (218 m) stretch of London’s ancient wall projecting westward from nearby Moorgate. At the rear and containing the courtyards where patients exercised and took the air, the walls rose to 14 feet (4.3 m) high. The front walls were only 8 feet (2.4 m) high but this was deemed sufficient as it was determined that “Lunatikes… are not to [be] permitted to walk in the yard to be situate[d] betweene the said intended new Building and the Wall aforesaid.” It was also hoped that by keeping these walls relatively low the splendour of the new building would not be overly obscured. This concern to maximise the building’s visibility led to the addition of six gated openings 10 feet (3.0 m) wide which punctuated the front wall at regular intervals, enabling views of the façade. Functioning as both advertisement and warning of what lay within, the stone pillars enclosing the entrance gates were capped by the figures of “Melancholy” and “Raving Madness” carved in Portland stone by the Danish-born sculptor Caius Gabriel Cibber.

At the instigation of the Bridewell Governors and to make a grander architectural statement of “charitable munificence”, the hospital was designed as a single- rather than double-pile building, accommodating initially 120 patients. Having cells and chambers on only one side of the building facilitated the dimensions of the great galleries, essentially long and capacious corridors, 13 feet (4.0 m) high and 16 feet (4.9 m) wide, which ran the length of both floors to a total span of 1,179 feet (359 m). Such was their scale that Roger L’Estrange remarked in a 1676 text eulogising the new Bethlem that their “Vast Length … wearies the travelling eyes’ of Strangers”. The galleries were constructed more for public display than for the care of patients as, at least initially, inmates were prohibited from them lest “such persons that come to see the said Lunatickes may goe in Danger of their Lives”.

The architectural design of the new Bethlem was primarily intended to project an image of the hospital and its governors consonant with contemporary notions of charity and benevolence. In an era prior to the state funding of hospitals and with patient fees covering only a portion of costs, such self-advertisement was necessary to win the donations, subscriptions and patronage essential for the institution’s survival. This was particularly the case in raising funds to pay for major projects of expansion such as the rebuilding project at Moorfields or the addition of the Incurables Division in 1725-1739 with accommodation for more than 100 patients. These highly visible acts of civic commitment could also serve to advance the claims to social status or political advantage of its Governors and supporters. However, while consideration of patients’ needs may have been distinctly secondary, they were not absent. For instance, both the placement of the hospital in the open space of Moorfields and the form of the building with its large cells and well-lit galleries had been chosen to provide “health and Aire” in accordance with the miasmatic theory of disease causation.

It was London’s first major charitable building since the Savoy Hospital (1505-1517) and one of only a handful of public buildings then constructed in the aftermath of the Great Fire of London (1666). It would be regarded, during this period at least, as one of the “Prime Ornaments of the City … and a noble Monument to Charity”. Not least due to the increase in visitor numbers that the new building allowed, the hospital’s fame and latterly infamy grew and this magnificently expanded Bethlem shaped English and international depictions of madness and its treatment.

Public Visiting

Visits by friends and relatives were allowed and it was expected that the family and friends of poor inmates would bring food and other essentials for their survival. Bethlem was and is best known for the fact that it also allowed public and casual visitors with no connection to the inmates. This display of madness as public show has often been considered the most scandalous feature of the historical Bedlam.

On the basis of circumstantial evidence, it is speculated that the Bridewell Governors may have decided as early as 1598 to allow public visitors as means of raising hospital income. The only other reference to visiting in the sixteenth-century is provided in a comment in Thomas More’s 1522 treatise The Four Last Things, where he observed that “thou shalt in Bedleem see one laugh at the knocking of his head against a post”. As More occupied a variety of official positions that might have occasioned his calling to the hospital and as he lived nearby, his visit provides no compelling evidence that public visitation was widespread during the sixteenth century. The first apparently definitive documentation of public visiting derives from a 1610 record which details Lord Percy’s payment of 10 shillings for the privilege of rambling through the hospital to view its deranged denizens. It was also at this time, and perhaps not coincidentally, that Bedlam was first used as a stage setting with the publication of The Honest Whore, Part I, in 1604.

Evidence that the number of visitors rose following the move to Moorfields is provided in the observation by the Bridewell Governors in 1681 of “the greate quantity of persons that come daily to see the said Lunatickes”. Eight years later the English merchant and author, Thomas Tryon, remarked disapprovingly of the “Swarms of People” that descended upon Bethlem during public holidays. In the mid-eighteenth-century a journalist of a topical periodical noted that at one time during Easter Week “one hundred people at least” were to be found visiting Bethlem’s inmates. Evidently Bethlem was a popular attraction, yet there is no credible basis to calculate the annual number of visitors. The claim, still sometimes made, that Bethlem received 96,000 visitors annually is speculative in the extreme. Nevertheless, it has been established that the pattern of visiting was highly seasonal and concentrated around holiday periods. As Sunday visiting was severely curtailed in 1650 and banned seven years later, the peak periods became Christmas, Easter and Whitsun.

The Governors actively sought out “people of note and quallitie” – the educated, wealthy and well-bred – as visitors. The limited evidence would suggest that the Governors enjoyed some success in attracting such visitors of “quality”. In this elite and idealised model of charity and moral benevolence the necessity of spectacle, the showing of the mad so as to excite compassion, was a central component in the elicitation of donations, benefactions and legacies. Nor was the practice of showing the poor and unfortunate to potential donators exclusive to Bethlem as similar spectacles of misfortune were performed for public visitors to the Foundling Hospital and Magdalen Hospital for Penitent Prostitutes. The donations expected of visitors to Bethlem – there never was an official fee – probably grew out of the monastic custom of alms giving to the poor. While a substantial proportion of such monies undoubtedly found their way into the hands of staff rather than the hospital poors’ box, Bethlem profited considerably from such charity, collecting on average between £300 and £350 annually from the 1720s until the curtailment of visiting in 1770. Thereafter the poors’ box monies declined to about £20 or £30 per year.

Aside from its fund-raising function, the spectacle of Bethlem offered moral instruction for visiting strangers. For the “educated” observer Bedlam’s theatre of the disturbed might operate as a cautionary tale providing a deterrent example of the dangers of immorality and vice. The mad on display functioned as a moral exemplum of what might happen if the passions and appetites were allowed to dethrone reason. As one mid-eighteenth-century correspondent commented: “[there is no] better lesson [to] be taught us in any part of the globe than in this school of misery. Here we may see the mighty reasoners of the earth, below even the insects that crawl upon it; and from so humbling a sight we may learn to moderate our pride, and to keep those passions within bounds, which if too much indulged, would drive reason from her seat, and level us with the wretches of this unhappy mansion”.

Whether “persons of quality” or not, the primary allure for visiting strangers was neither moral edification nor the duty of charity but its entertainment value. In Roy Porter’s memorable phrase, what drew them “was the frisson of the freakshow”, where Bethlem was “a rare Diversion” to cheer and amuse. It became one of a series of destinations on the London tourist trail which included such sights as the Tower, the Zoo, Bartholomew Fair, London Bridge and Whitehall. Curiosity about Bethlem’s attractions, its “remarkable characters”, including figures such as Nathaniel Lee, the dramatist, and Oliver Cromwell’s porter, Daniel, was, at least until the end of the eighteenth-century, quite a respectable motive for visiting.

From 1770 free public access ended with the introduction of a system whereby visitors required a ticket signed by a Governor. Visiting subjected Bethlem’s patients to many abuses, including being poked with sticks by visitors or otherwise taunted, given drinks and physically assaulted or sexually harassed, but its curtailment removed an important element of public oversight. In the period thereafter, with staff practices less open to public scrutiny, the worst patient abuses occurred.

1791 to 1900

Despite its palatial pretensions, by the end of the eighteenth century Bethlem was suffering physical deterioration with uneven floors, buckling walls and a leaking roof. It resembled “a crazy carcass with no wall still vertical – a veritable Hogarthian auto-satire”. The financial cost of maintaining the Moorfields building was onerous and the capacity of the Governors to meet these demands was stymied by shortfalls in Bethlem’s income in the 1780s occasioned by the bankruptcy of its treasurer; further monetary strains were imposed in the following decade by inflationary wage and provision costs in the context of the Revolutionary wars with France. In 1791, Bethlem’s Surveyor, Henry Holland, presented a report to the Governors detailing an extensive list of the building’s deficiencies including structural defects and uncleanliness and estimated that repairs would take five years to complete at a cost of £8,660: only a fraction of this sum was allocated and by the end of the decade it was clear that the problem had been largely unaddressed. Holland’s successor to the post of Surveyor, James Lewis, was charged in 1799 with compiling a new report on the building’s condition. Presenting his findings to the Governors the following year, Lewis declared the building “incurable” and opined that further investment in anything other than essential repairs would be financially imprudent. He was, however, careful to insulate the Governors from any criticism concerning Bethlem’s physical dilapidation as, rather than decrying either Hooke’s design or the structural impact of additions, he castigated the slipshod nature of its rapid construction. Lewis observed that it had been partly built on land called “the Town Ditch”, a receptacle for rubbish, and this provided little support for a building whose span extended to over 500 feet (150 m). He also noted that the brickwork was not on any foundation but laid “on the surface of the soil, a few inches below the present floor”, while the walls, overburdened by the weight of the roofs, were “neither sound, upright nor level”.

Bethlem Rebuilt at St George’s Fields

While the logic of Lewis’s report was clear, the Court of Governors, facing continuing financial difficulties, only resolved in 1803 behind the project of rebuilding on a new site, and a fund-raising drive was initiated in 1804. In the interim, attempts were made to rehouse patients at local hospitals and admissions to Bethlem, sections of which were deemed uninhabitable, were significantly curtailed such that the patient population fell from 266 in 1800 to 119 in 1814. Financial obstacles to the proposed move remained significant. A national press campaign to solicit donations from the public was launched in 1805. Parliament was successfully lobbied to provide £10,000 for the fund under an agreement whereby the Bethlem Governors would provide permanent accommodation for any lunatic soldiers or sailors of the French Wars. Early interest in relocating the hospital to a site at Gossey Fields had to be abandoned due to financial constraints and stipulations in the lease for Moorfields that precluded its resale. Instead, the Governors engaged in protracted negotiations with the City to swap the Moorfields site for another municipally owned location at St. George’s Fields in Southwark, south of the Thames. The swap was concluded in 1810 and provided the Governors with a 12 acres (4.9 ha; 0.019 sq mi) site in a swamp-like, impoverished, highly populated, and industrialised area where the Dog and Duck tavern and St George’s Spa had been.

A competition was held to design the new hospital at Southwark in which the noted Bethlem patient James Tilly Matthews was an unsuccessful entrant. The Governors elected to give James Lewis the task. Incorporating the best elements from the three winning competition designs, he produced a building in the neoclassical style that, while drawing heavily on Hooke’s original plan, eschewed the ornament of its predecessor. Completed after three years in 1815, it was constructed during the first wave of county asylum building in England under the County Asylum Act (“Wynn’s Act”) of 1808.] Extending to 580 feet (180 m) in length, the new hospital, which ran alongside the Lambeth Road, consisted of a central block with two wings of three storeys on either side.[186] Female patients occupied the west wing and males the east; as at Moorfields, the cells were located off galleries that traversed each wing. Each gallery contained only one toilet, a sink and cold baths. Incontinent patients were kept on beds of straw in cells in the basement gallery; this space also contained rooms with fireplaces for attendants. A wing for the criminally insane – a legal category newly minted in the wake of the trial of a delusional James Hadfield for attempted regicide – was completed in 1816. This addition, which housed 45 men and 15 women, was wholly financed by the state.

The first 122 patients arrived in August 1815 having been transported to their new residence by a convoy of Hackney coaches. Problems with the building were soon noted as the steam heating did not function properly, the basement galleries were damp and the windows of the upper storeys were unglazed “so that the sleeping cells were either exposed to the full blast of cold air or were completely darkened”. Although glass was placed in the windows in 1816, the Governors initially supported their decision to leave them unglazed on the basis that it provided ventilation and so prevented the build-up of “the disagreable effluvias peculiar to all madhouses”. Faced with increased admissions and overcrowding, new buildings, designed by the architect Sydney Smirke, were added from the 1830s. The wing for criminal lunatics was increased to accommodate a further 30 men while additions to the east and west wings, extending the building’s façade, provided space for an additional 166 inmates and a dome was added to the hospital chapel. At the end of this period of expansion Bethlem had a capacity for 364 patients.

1815-1816 Parliamentary Inquiry

The late eighteenth and early nineteenth centuries are typically seen as decisive in the emergence of new attitudes towards the management and treatment of the insane. Increasingly, the emphasis shifted from the external control of the mad through physical restraint and coercion to their moral management whereby self-discipline would be inculcated through a system of reward and punishment. For proponents of lunacy reform, the Quaker-run York Retreat, founded in 1796, functioned as an exemplar of this new approach that would seek to re-socialise and re-educate the mad. Bethlem, embroiled in scandal from 1814 over its inmate conditions, would come to symbolise its antithesis.

Through newspaper reports initially and then evidence given to the 1815 Parliamentary Committee on Madhouses, the state of inmate care in Bethlem was chiefly publicised by Edward Wakefield, a Quaker land agent and leading advocate of lunacy reform. He visited Bethlem several times during the late spring and early summer of 1814. His inspections were of the old hospital at the Moorfields site, which was then in a state of disrepair; much of it was uninhabitable and the patient population had been significantly reduced. Contrary to the tenets of moral treatment, Wakefield found that the patients in the galleries were not classified in any logical manner as both highly disturbed and quiescent patients were mixed together indiscriminately. Later, when reporting on the chained and naked state of many patients, Wakefield sought to describe their conditions in such a way as to maximise the horror of the scene while decrying the apparently bestial treatment of inmates and the thuggish nature of the asylum keepers. Wakefield’s account focused on one patient in particular, James Norris, an American marine reported to be 55 years of age who had been detained in Bethlem since 01 February 1800. Housed in the incurable wing of the hospital, Norris had been continuously restrained for about a decade in a harness apparatus which severely restricted his movement. Wakefield stated that:

… a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection, which being fashioned to and enclosing each of his arms, pinioned them close to his sides. This waist bar was secured by two similar iron bars which, passing over his shoulders, were riveted to the waist both before and behind. The iron ring about his neck was connected to the bars on his shoulders by a double link. From each of these bars another short chain passed to the ring on the upright bar … He had remained thus encaged and chained more than twelve years.

Wakefield’s revelations, combined with earlier reports about patient maltreatment at the York Asylum, helped to prompt a renewed campaign for national lunacy reform and the establishment of an 1815 House of Commons Select Committee on Madhouses, which examined the conditions under which the insane were confined in county asylums, private madhouses, charitable asylums and in the lunatic wards of Poor-Law workhouses.

In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of ‘wanting in humanity’ towards his patients.

Dr T.B. Hyslop came to the hospital in 1888 and rose to be physician in charge, bringing the hospital into the 20th century and retiring in 1911.

1930 to the Present

In 1930, the hospital moved to the suburbs of Croydon, on the site of Monks Orchard House between Eden Park, Beckenham, West Wickham and Shirley. The old hospital and its grounds were bought by Lord Rothermere and presented to the London County Council for use as a park; the central part of the building was retained and became home to the Imperial War Museum in 1936. The hospital was absorbed into the National Health Service in 1948.

750th Anniversary and “Reclaim Bedlam” Campaign

In 1997 the hospital started planning celebrations of its 750th anniversary. The service user’s perspective was not to be included, however, and members of the psychiatric survivors movement saw nothing to celebrate in either the original Bedlam or in the current practices of mental health professionals towards those in need of care. A campaign called “Reclaim Bedlam” was launched by Pete Shaughnessy, supported by hundreds of patients and ex-patients and widely reported in the media. A sit-in was held outside the earlier Bedlam site at the Imperial War Museum. The historian Roy Porter called the Bethlem Hospital “a symbol for man’s inhumanity to man, for callousness and cruelty.”

Recent Developments

In 1997, the Bethlem Gallery was established to showcase the work of artists that have experienced mental distress.

In 1999, Bethlem Royal Hospital became part of the South London and Maudsley NHS Foundation Trust (“SLaM”), along with the Maudsley Hospital in Camberwell, and the merger of mental health services in Lambeth and Lewisham took place.

In 2001, SLaM sought planning permission for an expanded Medium Secure Unit and extensive works to improve security, much of which would be on Metropolitan Open Land. Local residents’ groups organised mass meetings to oppose the application, with accusations that it was unfair that most patients could be from inner London areas and were, therefore, not locals and that drug use was rife in and around the hospital. Bromley Council refused the application, with Croydon Council also objecting. However the Office of the Deputy Prime Minister overturned the decision in 2003 and development started. The 89-bed, £33.5m unit (River House) opened in February 2008. It is the most significant development on the site since the hospital opened in 1930.

Fatal Restraints

Olaseni Lewis (known as Seni; aged 23) died in 2010 at Bethlem Royal Hospital after police subjected him to prolonged restraint of a type known to be dangerous. Neither police nor medical staff intervened when Lewis became unresponsive. At coroner’s inquest, the jury found many failures by both police and medical staff which played a part in Lewis’s death. They said “The excessive force, pain compliance techniques and multiple mechanical restraints were disproportionate and unreasonable. On the balance of probability, this contributed to the cause of death.” Ajibola Lewis, Olaseni Lewis’s mother, claimed a nurse at Maudsley hospital where Lewis had been earlier warned against allowing his transfer to Bethlem. “She said to me, ‘Look, don’t let him go to the Bethlem, don’t let him go there’,” his mother said. A doctor later persuaded her to take her son to Bethlem hospital. She was concerned about the conditions there. “It was a mess,” she told the court, “It was very confused, a lot of activity, a lot of shouting. I was not happy; I was confused.”

Police were trained to view Lewis’s behaviour as a medical emergency, but the jury found police failed to act on this. The jury found that “The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and if necessary administer life support. On the balance of probability this also contributed to the cause of death.” A doctor did not act when Lewis became unresponsive while his heart rate dramatically slowed.

The Independent Police Complaints Commission first cleared officers over the death, but following pressure from the family, they scrapped the conclusions and started a new inquiry. The IPCC was planning disciplinary action against some of the police officers involved. Deborah Coles of the charity Inquest, who has supported the Lewis family throughout their campaign, said the jury had reached the most damning possible conclusions on the actions of police and medics. “This was a most horrific death. Eleven police officers were involved in holding down a terrified young man until his complete collapse, legs and hands bound in limb restraints, while mental health staff stood by. Officers knew the dangers of this restraint but chose to go against clear, unequivocal training. Evidence heard at this inquest begs the question of how racial stereotyping informed Seni’s brutal treatment.”

A disciplinary hearing conducted by the Metropolitan Police found the officers had not committed misconduct. The hearing was criticised by the family because it was held behind closed doors with neither press nor public scrutiny.

In 2014, Chris Brennan (aged 15) died of asphyxiation while at Bethlem hospital after repeated self-harming. The coroner found lack of proper risk assessment and lack of a care plan contributed to his death. The hospital claimed staffing problems and low morale were factors. Lessons were learned and the adolescent unit where Brennan died was assessed as good in 2016.

In November 2017, a bill was debated in the House of Commons that would require psychiatric hospitals to give more detailed information about how and when restraints are used. This bill is referred to as “Seni’s law”. In November 2018, the bill received Royal Assent as the Mental Health Units (Use of Force) Act 2018.

Facilities

The hospital includes specialist services such as the National Psychosis Unit.

Other services include the Bethlem Adolescent Unit, which provides care and treatment for young people aged 12-18 from across the UK.

The hospital has an occupational therapy department, which has its own art gallery, the Bethlem Gallery, displaying work of current and former patients.

The Bethlem Museum of the Mind features exhibits about the history of Bethlem Royal Hospital and the history of mental healthcare and treatment. It features a permanent collection of art created by some of its patients, as well as changing exhibitions.

Media

In 2013, the South London and Maudsley NHS Foundation Trust (SLaM) took part in a Channel 4 observational documentary, Bedlam. Staff and patients spent two years working with television company The Garden Productions. The four-part series started on 31 October.

The first programme, Anxiety, followed patients through the 18-bed Anxiety and Disorders Residential Unit. This national unit treats the most anxious people in the country – the top 1% – and claims a success rate of three in four patients.

The next programme was called Crisis; cameras were allowed in Lambeth Hospital’s Triage ward for the first time. In a postcode with the highest rates of psychosis in Europe, this is the Accident and Emergency of mental health, where patients are at their most unwell.

The third programme, Psychosis, films a community mental health team. South London and Maudsley NHS Foundation Trust provides support for more than 35,000 people with mental health problems.

The final programme, Breakdown, focuses on older adults, including the inpatient ward for people over 65 with mental health problems at Maudsley Hospital.

Notable Patients

  • Richard Dadd – artist.
  • John Frith – would-be assailant of King George III.
  • Mary Frith – also known as “Moll Cutpurse” or “The Roaring Girl”, released from Bedlam in 1644 according to Bridewell records.
  • Daniel M’Naghten – catalyst for the creation of the M’Naghten Rules (criteria for the defence of insanity in the British legal system) after the shooting of Edward Drummond.
  • Jonathan Martin – set fire to York Minster.
  • William Chester Minor – surgeon who was committed for murder; best known for being one of the largest contributors to the Oxford English Dictionary.
  • James Hadfield – would-be assassin of King George III.
  • Margaret Nicholson – would-be assassin of King George III.
  • Edward Oxford – tried for high treason after the attempted assassination of Queen Victoria and Prince Albert.
  • Augustus Welby Northmore Pugin (1812-1852) – English architect, best known for his work on the Houses of Parliament as well as many churches; in the last year of his life he suffered a breakdown, possibly due to hyperthyroidism, and was for a short period confined in Bethlem.
  • Hannah Snell (1723-1792) – a woman cross-dressing as a male soldier; spent the last six months of her life in Bethlem.
  • Bannister Truelock – conspirator who plotted to assassinate George III.
  • Louis Wain – artist.

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 a Mental Health Trust (UK)?

Introduction

A mental health trust provides health and social care services for people with mental health disorders in England.

There are 54 mental health trusts. They are commissioned and funded by clinical commissioning groups (CCG).

Patients usually access the services of mental health trusts through their general practitioner (GP; primary care medical doctor) or via a stay in hospital. Most of the services are for people who live in the region, although there may be specialist services for the whole of the UK or services that accept national referrals. Mental Health Trusts may or may not provide inpatient psychiatric hospital services themselves (they may form part of a general hospital run by a hospital trust). The various trusts work together and with local authorities and voluntary organisations to provide care.

Services

Services provided by mental health trusts vary but typically include:

  • Counselling sessions – one-to-one or in a group.
  • Courses – such as on how to deal with stress, anger, and bereavement. Courses may also be available for carers of those with mental health disorders.
  • Resources – such as leaflets and books on mental health issues.
  • Psychotherapy – treatment sessions with a therapist. Commonly cognitive behavioural therapy.
  • Family support – providing support to the family, friends, and carers of those with a mental health problem.
  • Community drug and alcohol clinics – helping people to cope with addiction.
  • Community mental health houses – supported housing to help people live in the community.
  • Day hospitals and day centres – short-term outpatient sessions with a psychiatrist, clinical psychologist or other mental health professional, and drop-in centres for peer support and therapeutic activities.

If more specialist hospital treatment is required, Mental Health Trusts will help with rehabilitation back into the community (social inclusion). Trusts may operate community mental health teams, which may include Crisis Resolution and Home Treatment, assertive outreach and early intervention services.

The Mental Health Act 1983, Mental Health Act 2007 and Mental Capacity Act 2005 cover the rights, assessment and treatment of people diagnosed with a mental disorder who are judged as requiring to be detained (“sectioned”) or treated against their will. A mental health trust will typically have a Mental Health Act team responsible for ensuring that the Act is administered correctly, including to protect the rights of inpatients, or of service users in the community who may now be under community treatment orders. The Care Quality Commission is the body with overall national responsibility for inspecting and regulating the operation of the mental health act by the regional trusts.

Capacity

According to the British Medical Association (BMA) the number of beds for psychiatric patients was reduced by 44% between 2001 and 2017. An average of 726 mental health patients were placed in institutions away from their home area in 2016.

Children of school age are normally treated through Child and Adolescent Mental Health Services (CAMHS), usually organised by local government area. Young people who become psychiatric in-patients frequently are treated in adult wards due to lack of beds in wards that are suitable for people of their ages. Young people frequently stay in hospital wards when they are fit for discharge because the mental health support facilities they need are not available where they live.

List of MHTs
These are the mental health trusts in the NHS in England in 2017 (note that many have NHS Foundation Trust status – a type of trust that has more independence from government):

  • 2gether NHS Foundation Trust.
  • 5 Boroughs Partnership NHS Foundation Trust.
  • Avon and Wiltshire Mental Health Partnership NHS Trust.
  • Barnet, Enfield and Haringey Mental Health NHS Trust.
  • Berkshire Healthcare NHS Foundation Trust.
  • Birmingham and Solihull Mental Health NHS Foundation Trust.
  • Bradford District Care Trust.
  • Cambridgeshire and Peterborough NHS Foundation Trust.
  • Camden and Islington NHS Foundation Trust.
  • Central and North West London NHS Foundation Trust.
  • Cheshire and Wirral Partnership NHS Foundation Trust.
  • Cornwall Partnership NHS Foundation Trust.
  • Coventry and Warwickshire Partnership NHS Trust.
  • Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
  • Derbyshire Healthcare NHS Foundation Trust.
  • Devon Partnership NHS Trust.
  • Dorset HealthCare University NHS Foundation Trust.
  • Dudley and Walsall Mental Health Partnership NHS Trust.
  • East London NHS Foundation Trust.
  • Greater Manchester Mental Health NHS Foundation Trust.
  • Humber NHS Foundation Trust.
  • Isle of Wight NHS Trust.
  • Kent and Medway NHS and Social Care Partnership Trust.
  • Lancashire Care NHS Foundation Trust.
  • Leeds and York Partnership NHS Foundation Trust.
  • Leicestershire Partnership NHS Trust.
  • Lincolnshire Partnership NHS Foundation Trust.
  • Mersey Care NHS Trust.
  • Norfolk and Suffolk NHS Foundation Trust.
  • North East London NHS Foundation Trust.
  • North Essex Partnership University NHS Foundation Trust.
  • North Staffordshire Combined Healthcare NHS Trust.
  • Northamptonshire Healthcare NHS Foundation Trust.
  • North Cumbria Integrated Care NHS Foundation Trust.
  • Nottinghamshire Healthcare NHS Trust.
  • Oxford Health NHS Foundation Trust.
  • Oxleas NHS Foundation Trust.
  • Pennine Care NHS Foundation Trust.
  • Rotherham Doncaster and South Humber NHS Foundation Trust.
  • Sheffield Health & Social Care NHS Foundation Trust.
  • Somerset Partnership NHS Foundation Trust.
  • South Essex Partnership University NHS Foundation Trust.
  • South London and Maudsley NHS Foundation Trust.
  • South Staffordshire and Shropshire Healthcare NHS Foundation Trust.
  • South West London and St George’s Mental Health NHS Trust.
  • South West Yorkshire Partnership NHS Foundation Trust.
  • Southern Health NHS Foundation Trust.
  • Surrey and Borders Partnership NHS Foundation Trust.
  • Sussex Partnership NHS Foundation Trust.
  • Tavistock and Portman NHS Foundation Trust.
  • Tees, Esk and Wear Valleys NHS Trust.
  • West London NHS Trust.
  • Worcestershire Health and Care NHS Trust.

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 Involuntary Commitment?

Introduction

Involuntary commitment, civil commitment, or involuntary hospitalisation (also known informally as sectioning or being sectioned in some jurisdictions, such as the UK) is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.

Refer to Voluntary Commitment.

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

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

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

Purpose

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

First Aid

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

Observation

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

Containment of Danger

Refer to Obligatory Dangerousness Criterion.

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

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

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

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

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

Deinstitutionalisation

Refer to Deinstitutionalisation.

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

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

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

Around the World

France

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, and, in 1839, he opened the first school for the intellectually disabled. His method of treatment was based on the idea that the intellectually disabled did not suffer from disease.

United Kingdom

In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many ‘pauper lunatics’. Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents – the Medico-Psychological Association – was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841.

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalisation was soon disappointed. Psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums kept on growing. Asylums were quickly becoming almost indistinguishable from custodial institutions, and the reputation of psychiatry in the medical world had hit an extreme low.

United States

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

In the United States and most other developed societies, severe restrictions have been placed on the circumstances under which a person may be committed or treated against their will as such actions have been ruled by the United States Supreme Court and other national legislative bodies as a violation of civil rights and/or human rights (e.g. O’Connor v. Donaldson). Thus a person is rarely committed against their will and it is illegal for a person to be committed for an indefinite period of time.

United Nations

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

Criticism

The dangers of institutions were chronicled and criticized by reformers almost since their foundation. Charles Dickens was an outspoken and high-profile early critic, and several of his novels, in particular Oliver Twist and Hard Times demonstrate his insight into the damage that institutions can do to human beings.

Enoch Powell, when Minister for Health in the early 1960s, was a later opponent who was appalled by what he witnessed on his visits to the asylums, and his famous “water tower” speech in 1961 called for the closure of all NHS asylums and their replacement by wards in general hospitals:

“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defenses which we have to storm.”

Scandal after scandal followed, with many high-profile public inquiries. These involved the exposure of abuses such as unscientific surgical techniques such as lobotomy and the widespread neglect and abuse of vulnerable patients in the US and Europe. The growing anti-psychiatry movement in the 1960s and 1970s led in Italy to the first successful legislative challenge to the authority of the mental institutions, culminating in their closure.

During the 1970s and 1990s the hospital population started to fall rapidly, mainly because of the deaths of long-term inmates. Significant efforts were made to re-house large numbers of former residents in a variety of suitable or otherwise alternative accommodation. The first 1,000+ bed hospital to close was Darenth Park Hospital in Kent, swiftly followed by many more across the UK. The haste of these closures, driven by the Conservative governments led by Margaret Thatcher and John Major, led to considerable criticism in the press, as some individuals slipped through the net into homelessness or were discharged to poor quality private sector mini-institutions.

Wrongful Involuntary Commitment

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

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

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

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

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

What is Obligatory Dangerousness Criterion?

Introduction

The obligatory dangerousness criterion is a principle present in the mental health law of many developed countries. It mandates evidence of dangerousness to oneself or to others before involuntary treatment for mental illness. The term “dangerousness” refers to one’s ability to hurt oneself or others physically or mentally within an imminent time frame, and the harm caused must have a long-term effect on the person(s).

Psychiatric hospitals and involuntary commitment have been around for hundreds and even thousands of years around the world, but the obligatory dangerousness criterion was created in the United States in the 1900s. The criterion is a controversial topic, with opponents claiming that it is unethical and potentially harmful. Supporters claim that the criterion is necessary to protect the mentally ill and those impacted by their involuntary treatment.

Background

If a court determines that a person may cause long-term harm to themselves or others, then the person can be hospitalised or be required to outpatient treatment and treated involuntarily. In order to be released, the court must determine whether the person is no longer dangerous. The length of time that a person is involuntarily hospitalised varies and is determined by the state.

An obligatory dangerousness criterion has two main parts:

  • First is the Latin phrase parens patriae, which translates to “parent of his or her nation,” which “assigns to the government a responsibility to intervene on behalf of citizens who cannot act in their own best interest”.
  • The second part “requires a state to protect the interests of its citizens,” meaning that the government must do what it can to care for greater society, which may involve limiting one individual’s rights to avoid harming the greater society.

Brief History

Psychiatric asylums and guardianship over the mentally ill have been present for centuries. In Greece, individuals, such as Hippocrates, believed that those with mental illnesses should be separated from others and maintained within a safe, healthy environment. Ancient Rome allowed guardianship over mentally ill individuals. In the US, psychiatric hospitals were not established until the late 18th and early 19th centuries. Before their establishment, individuals suffering with mental illnesses were imprisoned or kept from society. After their establishment, anyone could be admitted to a psychiatric hospital if a family member brought them and a physician agreed to provide a treatment. Individuals could be at the hospital indefinitely until a court ruled they could be released.

An obligatory dangerousness criterion was officially established in the United States in 1964 by the Ervin Act in Washington DC. It provided a more lenient interpretation of “dangerousness” as well as alternatives to involuntary hospitalisation. It is meant to protect individuals with mental health disorders on the basis of parens patria. In order to be involuntary hospitalised under the obligatory dangerousness criterion, one must have a mental illness, and most states also require that the individual is in need of medical treatment for the illness.

In 1964, Washington D.C. established that an individual may only be involuntarily hospitalised if the individual has a mental illness, may be threat to others or their self in the near future, or is unable to survive on their own. States followed suit and began implementing a dangerousness criteria, as well. In the 1975 Supreme Court case, O’Connor v. Donaldson, the Supreme Court ruled that the individual must have a mental illness, pose a known threat to the safety of their self or others, be unable to care for themselves, or need psychiatric care. States adjusted their rules so that a patient’s involuntary hospitalisation would be re-evaluated over the span of a short period of time, ranging from two days to two weeks before a patient could have a court hearing to potentially be released.

Controversy

The obligatory dangerousness criterion is controversial. Supporters claim that the criterion is necessary in order to ensure that those who are in vital need of psychiatric care will receive it, and to prevent the mentally ill individual from potentially harming themselves or others. They also note that mental health disorders can impair one’s judgement, for example, if an individual with depression does not think that they need help. They argue that psychiatric care often involves some form of hospitalisation or treatment, and as a result, “involuntary hospitalization, or civil commitment, has been a mainstay of psychiatric care” since the field first began. Some individuals who have been involuntarily hospitalised perceived their experience to be beneficial and fair. Lastly, they also note how many states require that the least invasive measures be taken before involuntary hospitalisation is considered.

Its opponents claim that an obligatory dangerousness criterion is unethical. Some believe it denies the individual of consent, is discriminatory based on mental health, and may increase the patient’s risk of suicide, psychotic symptoms, or other harmful behaviours. They worry an obligatory dangerousness criterion might lead individuals without a serious mental illness to be involuntarily hospitalised, or that individuals without a serious mental illness will be involuntarily hospitalised as a “preventative” means. Those who oppose an obligatory dangerousness criterion also argue that there are less restrictive alternatives to involuntary hospitalisation that can help those with a mental illness.

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.

What is Involuntary Commitment?

Introduction

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

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

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

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

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

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

Purpose

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

First Aid

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

Observation

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

Containment of Danger

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

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

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

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

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

Deinstitutionalisation

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

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

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

Around the World

Refer to Involuntary Commitment by Country.

United Nations

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

Wrongful Involuntary Commitment

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

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

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

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

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

Reference

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