Demystifying Psychiatry

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Can the Mentally Ill Be Hospitalized Against Their Will?

Involuntary Hospitalization

Can people with mental disorders be hospitalized against their will? The short answer is "yes," but only under specific circumstances.

Some psychiatric disorders result in severe behavioral changes that necessitate rapid and dramatic action, including restricting a person's freedom. Such action may be necessary in order to protect the person either from self harm or from harming others.

Involuntary psychiatric hospitalization involves an appropriate interaction between the medical and legal systems. Although the exact policies governing involuntary hospitalization vary among states, certain health care providers can be certified to hospitalize a patient against his or her will if specific conditions are met. These conditions almost always involve dangerousness to self or others. This authority is taken very seriously by psychiatrists and other certified health care providers, and important checks and balances exist to minimize inappropriate decisions.

What are the issues involved in such a decision and what are some of the checks and balances that protect individuals from having their rights taken away inappropriately?

If a patient with an active psychiatric disorder is exhibiting behaviors that a certified health care professional believes could lead to imminent harm to that person or another person, then that health care provider can initiate the process of involuntary hospitalization. In most jurisdictions, the initial period of involuntary hospitalization is typically brief, up to 96 hours excluding weekends. The conditions that prompt such interventions can be quite varied. For example, such action might be taken when a severely depressed person has made a suicide attempt and continues to express suicidal intent but refuses hospitalization. Another example would be a person with schizophrenia who demonstrates agitated behavior and attacks a family member with a knife, believing that he is being commanded to do so by an external agent appearing in the form of auditory hallucinations (hearing "voices").

The initial brief period of involuntary confinement is often used for direct observation and evaluation. At the time of the involuntary admission, substantial documentation is gathered, including statements from witnesses who have observed dangerous behaviors. Naturally, this is awkward for many involved. Many people feel uncomfortable filing legal documents that lead to the loss of freedom for their family member or friend. Nevertheless, family and friends are concerned about the individual and often do whatever is necessary to help him or her receive care.

Once hospitalized, the detained individual is provided with information about the legal process and access to a lawyer. Many psychiatrists hesitate to prescribe medications during this initial 96-hour period unless it is necessary to prevent a patient from harming himself or others. Even in a hospital setting with substantial supervision, agitated patients can inflict harm, and certain psychiatric medications may be the most effective way of minimizing that harm.

During the initial period of hospitalization, it is hoped that the patient will develop sufficient understanding and insight to become a voluntary patient and comply with treatment recommendations. If this occurs, the legal proceedings are terminated and voluntary treatments can be initiated.

If the patient does not want to stay in the hospital as a voluntary patient, the clinical team, led by the psychiatrist, determines whether the patient continues to demonstrate behaviors indicating dangerousness as the result of a psychiatric illness. If not, the patient may be discharged even if still exhibiting symptoms of illness. It is imminent dangerousness and not the presence of psychiatric symptoms that drives the need for involuntary hospitalization. If the person's behaviors continue to suggest significant danger to self or others, then a court hearing occurs shortly after the initial 96-hour period of involuntary hospitalization.

The patient is present at this court hearing and is represented by an attorney. Witnesses may be called; these are often family members, friends, and mental health professionals. Mental health professionals, particularly psychiatrists, testify about the nature of the patient's illness and the reasons they believe the person is an imminent danger to self or others. An impartial judge decides whether the evidence supports continued denial of the person's freedom. If the judge does not find that the evidence is sufficient, the patient is released immediately. If the judge believes there is sufficient evidence that a psychiatric illness is likely to result in imminent harm to the patient or others, the judge authorizes a longer period of involuntary hospitalization, for example, an additional 21 days in the State of Missouri. During this time, treatment of the psychiatric disorder is initiated. This treatment often involves psychiatric medications and group or individual therapy. Electroconvulsive therapy (ECT) is not an option without a specific order from the judge; use of involuntary ECT requires demonstration that reasonable attempts at other treatments have failed and that the patient is likely to respond to ECT.

During the longer period of involuntary commitment, it is hoped that the person will respond to treatment. Often, as treatment progresses, the patient develops enough insight to realize that he or she is ill and that treatment can help. During a several week commitment, it would be unusual for a person to "recover" completely, but it would not be unusual for a person to improve to the point of being discharged from the hospital and referred for voluntary treatment in a less restrictive environment. This may be a day hospital or an outpatient setting.

If a person remains ill after the court mandated treatment period but is no longer considered to be dangerous to self or others, the treatment team will encourage the patient to follow-up with outpatient treatment and will discharge him or her. If the person remains ill and dangerous, and refuses further care, then another court hearing will occur and the judge will be asked to determine whether a longer period of involuntary confinement is warranted.

It is important to emphasize that the vast majority of patients with psychiatric illnesses never require involuntary hospitalization. The purpose of this post is to explain that formal legal procedures are in place so that the medical and legal systems can work together in a manner that balances the need to safeguard patients and society while also protecting individual rights.

This posting was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.

Eugene Rubin, M.D., Ph.D., is Professor and Vice-Chair for Education in the Department of Psychiatry at Washington University in St. Louis - School of Medicine.

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