Involuntary Commitment for Substance Use Disorder?

The calls to invoke civil involuntary commitment laws for people with Substance Use Disorders (SUDs) are getting louder in communities with a marked increase of overdose deaths. In the past year, there have been more than 140,000 deaths related to excessive alcohol consumption. Perhaps springing from the best intentions to keep people safe, these laws are seen as a last resort for individuals and communities being decimated by addiction. Parents who have lost children, children who have lost parents, people who have lost spouses, and many others often speak passionately and persuasively of the need to help people begin to help themselves.

Civil commitment is a legal mechanism that allows family members, healthcare practitioners, police, or others to go to court asking for legally mandated substance abuse treatment for an individual who poses a significant threat of harm to self or others. While this is a legal mechanism, it is not a criminal one. The process often involves assessment by professionals of the harm an individual poses. These assessments may result in mandates for hospitalization, in- or out-patient treatment, or participation in other community-based resources for specified periods of time. At present, 35 states and the District of Columbia have laws that allow for a civil commitment of an individual for a SUD.

I’ll focus on three troubling dimensions of these laws, including their relationship to laws about mental illnesses or disorders, a lack of clarity of efficacy of involuntary treatment, and the familiar ways that individuals are made to bear the burdens of broader structural realities.

Are SUDs mental illnesses?

While SUDs are included in the Diagnostic Statistical Manual of Mental Disorders 5^th edition (DSM-5), some of these states’ laws exclude SUDs from their legal definition of mental illness or disorder. It is an important and long-fought achievement that mental illness is no longer seen as a moral failing but rather a medical condition. There is still much work to be done to remove the stigma of mental illness and educate police and legal professionals on the ways mental illnesses may present themselves. The exclusion of SUDs from this category in legal statutes may be a consequence of the overlap of two considerations.

The first is the vestiges of the view that addiction is, on some level, a moral failure. Moral failings, in general, are not taken to absolve a person of responsibility. To the contrary, people tend to think we are most responsible for our moral failings and the acts that issue from them. Moral failings most certainly can lead to illegal activity, which is the second consideration.

Some addictions are to illegal substances or to legal substances used illegally, such as prescription medications used not as prescribed, or alcohol consumption by minors, for example. Put another way, these laws enshrine the view that mental illnesses may involve a diminished capacity that is different in kind from the diminished capacity from a SUD. The former may mitigate legal responsibility but the latter does not.

Does mandated treatment work? What counts as success?

There are few studies about the efficacy of mandated treatment for SUDs. One reason for this is the significant variation between states in what may be mandated or what is even possible to mandate. Rural areas, for example, are treatment deserts for both in- and out-patient services. Some areas have no in-patient treatment facilities but may be richer in other community-based programs. How can one compare an experience where medication-assisted therapies are available from those that are not, for example? How does mandated treatment in an unused building at a correctional facility affect outcome, as is the case in Massachusetts? This points to the deeper and even more troubling question of efficacy. There is no shared standard or benchmark for successful treatment in general.

What is a successful outcome of treatment? The answer may be the always unsatisfying, “It depends.” Treatment centers that primarily use the 12 Step Model see abstinence as the success. But how long after the completion of treatment must one remain abstinent in order to count as a success? That is never specified. Treatment centers that use medication-assisted therapies aim at harm reduction by using medications that may reduce cravings or replace an illegal drug with one medically prescribed, such as methadone or naltrexone. While a more rigid 12 Stepper might say this isn’t true abstinence, a person who drastically reduces their cravings lowers the chances of overdosing, which is a significant reduction of harm. Should the reduction of harm, as opposed to abstinence, be the guiding consideration in judging efficacy?

Does involuntary commitment shift all the blame to individuals?

A final concern is that the increase of laws for civil commitment continues a long-established practice of making individuals bear the responsibility for problems that have systemic or structural dimensions. Addiction is a condition of an individual most surely; it is individuals who are addicted. But that is not all it is; addiction has social, political, and economic dimensions. The production and aggressive marketing of oxycontin to targeted communities, for example, shows some of these dimensions. Communities that had high disability claims were singled out; these were people in physical and psychological distress. These considerations made people especially vulnerable to developing addictions. That vulnerability is linked to the absence of accessible and affordable healthcare, treatment options, other forms of social services, and viable employment opportunities. The drug companies were apex predators.

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The sharp increase in overdose deaths is driven by a multitude of causal factors—some of which are deeply personal and others of which are social, political, and economic. No amount of focus on the personal will ever be enough to counteract the power of the broader considerations. Involuntary commitment laws keep the focus on individuals who are seen as hopeless, intractable, or utterly defiant. To reduce the great harms of addiction, we need better healthcare, treatment options, social services, and employment options.

A version of this post also appeared on HeraldNet.