What We Don't Talk About With Involuntary Hospitalization

Currently, several states including New York and California are considering legislation that would greatly expand involuntary hospitalization. Perhaps no topic has been more divisive among mental health advocates than this.

On one side of the debate, advocates argue for individuals' civil liberties and express fears of abuses of this power. Psychiatric survivors share tales of coercion and fight for self-determination. Whenever a person's civil rights and liberties are mitigated, tangled ethical issues appear.

Other advocates discuss the reality that many living with serious mental illness do not realize their need for help due to the nature of the illness. Rather than a hospital, many find themselves on the street or in a jail cell due to challenges related to a treatable illness. The reality is that when a person can not orient to consensus reality, they may be making decisions of pretenses. Is a person wading through florid psychosis able to give consent for hospitalization?

For example, say a person living with schizophrenia does not want treatment because they do not believe they are ill but that they are in truth an alien awaiting their call back to another planet. As that person shows deteriorating ability to care for themself as they lay on a pile of trash on the side of the road, is their "no" to treatment still a "no"? By accepting their disinterest, are we truly advancing their civil liberties? Are they in a position to exercise those liberties?

In most states, a stand of "risk of harm to self or others" is used for psychiatric hospitalization. Yet, research on the benefits of psychiatric hospitalization for individuals experiencing thoughts of suicide is shaky (Ward-Ciesielski and Rizvi, 2021). There may potentially be more value in hospitalization for individuals experiencing ongoing and severe psychosis; however, laws are often written in a way that accessing involuntary hospitalization for these individuals is difficult. Still, each day people die of causes related to experiencing homelessness, or reach contact with the justice system for reasons related to a mental illness.

An Under-discussed Element

Still, there is an important element that is often left out of this debate: The experience of psychiatric hospitalization can be traumatic, and the quality of treatment is often poor. Sessions with a psychiatrist in the hospital are typically short, with little room for assessment, and group interventions are rarely provided by licensed psychotherapists, but more often by psychiatric techs who have limited training in psychotherapy. The focus is primarily on stabilization.

After a hospitalization, discharge planning is often incomplete. Follow-up appointments may or may not be arranged with an outpatient psychiatrist and transportation to these appointments is often a barrier. Families rarely are allowed to participate in treatment and may be unaware that their loved one is hospitalized. In addition, the core housing and social difficulties that often complicate the clinical picture are seldom addressed in inpatient psychiatric units leading to a revolving door of repeated hospitalizations (Loch, 2014).

Overall, the number of available "beds" in psychiatric units is often low, stays are short, and staff are left to handle the impossible task of treating complex, multidimensional conditions with limited resources and time.

Unnecessary Restriction?

There is also a reality of coercion within the hospital.

In America, psychiatric hospitals are traditionally quite restrictive with double-locked doors, close monitoring often through "checks" every 15 minutes, strict limitations on which belongings are allowed, and narrow visiting hours (Kuosmanen et al., 2007). It's assumed that these measures are necessary for the patients' "own good," yet research shows that incidents of violence are no greater (and sometimes slightly less) in unlocked psychiatric units than in locked ones (Schneeberger et al., 2017; Indregard et al., 2024).

Research has shown that perceived coercion during a psychiatric hospitalization correlates with suicide attempts upon discharge (Jordan and McNeil, 2020). There is no evidence that these paternalistic practices improve outcomes in any way. Rather, these add a punitive element to the hospital stay.

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There is a strong need for improvement in the quality of care that individuals experience when admitted to inpatient psychiatric care. We might do well also to revisit paternalistic practices such as unnecessarily limiting access to phone calls or one's belongings. In addition, aspects such as the need for the creation of realistic aftercare plans and the inclusion of family in treatment and discharge planning must be addressed, as well as the community mental health resources to support this work once the hospital is no longer indicated.

A psychiatric hospital stay should not feel like an incarceration.

It is not uncommon for spaces within a psychiatric hospital to be bare, and intimidating. What if we created environments that encouraged creativity, compassion, and wellness? What if instead of the ultra-heavy but plastic jail-style chairs we had comfortable furniture akin to other areas in a hospital? What if staff were trained to assume the best and utilize force at an extreme minimum? What if groups were led by licensed therapists, and patients received short-term individual therapy during their stay? What if visits with a psychiatrist were kept at a minimum of 15-30 minutes and time given at the beginning for a comprehensive initial assessment? What if the only rules applied were ones that were absolutely necessary?

Access to care is important. Consideration that some individuals who are gravely ill may not be able to recognize their need for care and exercise their right to treatment on their own must be considered as well as the relevant self-determination issues.

Still, humane care within the hospital, the maximum right to self-determination during the stay, and a plan for wellness afterward are just as important. Perhaps, these are a few things mental health advocates can agree on.