Author: piperrlinn

A new perspective on the risks of stealing a patient’s freedom to choose their own treatment and future.

By Piper Lin

Anna is your average college student. Like many students, she is heavily involved in her school work and extracurricular activities, both academic and leisure. One difference is that Anna suffers from severe mental illness. Her diagnoses range from major depressive disorder to borderline personality disorder. Despite this, she still manages her various responsibilities as a student, friend, and active community member. Like all those plagued with these disorders, she has moments where her disease takes control. Anna experiences suicidal thoughts but has no plans to carry through with them. Although, she does experience episodes of mild self-mutilation as a form of stress relief. For Anna, this coping mechanism converts her psychological pain to physical pain as a momentary distraction from reality. She takes her illness seriously by regularly attending therapy and taking several medications to cope. She is constantly trying to manage her disorders, so she can move ahead with her life and future plans.

The growing severity of the mental health crisis is taking the United States by storm, especially after the COVID-19 pandemic. In 2021, an estimated 22.8% of Americans experienced some kind of mental illness (6). Every day, the talk discussion around mental illness is becoming more and more prevalent, whether it be in regard to suicide rates, substance abuse, or other mental health-related issues. Along with the increased focus on mental health, discussions about treatment options, wellness, and self-care for sufferers are all the rage right now. However, one particular form of mental illness, “treatment,” has been identified to potentially cause more harm than good because it borders on the infringement of basic human rights: Involuntary hospitalization.

Significantly, the phrase constantly associated with all psychiatric treatment is: “Your privacy is protected unless your therapist or doctor believes you are a threat to yourself or another person.” What many do not think about or know is what occurs once those threat criteria are met, and the person’s privacy is revoked.

Sometimes Anna’s disease gets the upper hand.

One particularly hard evening, Anna’s disease got the best of her, and she cut her arms while under the influence of alcohol. She quickly realized she needed medical assistance and rushed herself to the hospital for sutures. At the hospital emergency room, she was given stitches, and all seemed to be well. She had no idea about the experiences that awaited her. Soon after her stitches were finished, a nurse came in, handed her inpatient hospital attire, and instructed her to change. Anna was then stripped of all her belongings, including her phone. She was confused. No one was giving her information about what was going on, and no one would answer her questions. She was forced into a room and watched over by a hospital staff member and a police officer for her own “protection.” She was not permitted to contact anyone or talk directly to her parents, who were only given information by the hospital staff. After being told by hospital staff she would be released after talking to a therapist, she spent 12 grueling hours in that small room, alone, with little to no interaction with doctors or medical staff. After those 12 hours, she was not released. Instead, she was informed that she was being transferred via ambulance to a behavioral health hospital four hours away from her university.

The term “involuntary hospitalization” of a patient, or “civil commitment,” is defined by the United States Health and Human Services as the legal process by which a person is confined in a psychiatric hospital against his or her wishes because of a treatable mental disorder (1). In this process, a patient is stripped of their right to refuse treatment. Involuntary hospitalization often occurs as the result of a medical professional deeming a person a threat to themselves, a threat to others, or of grave disability to provide themselves with necessities such as food and housing due to mental illness (1).

Anna knew her actions were worrisome, but she believed she had the right to know what was going on and to explain her case. She especially believed she had the right to contact her own parents and a doctor to decide on a plan to move forward. She did not feel that she needed to be hospitalized.

Anna became a victim of the involuntary hospitalization process.

The idea of psychiatric commitment dates back to the 4th century B.C. when Hippocrates, known as the father of medicine, believed that sufferers of mental illness should be secluded in a comforting environment (1). The first official psychiatric commitments did not occur until 1752 and, at that time, were characterized by long stays in psychiatric institutions. In colonial America, treatments for mental illness were barbaric, including physical pain, social isolation, and emotional torment (7). In the 1950s, deinstitutionalization began with the discovery of the first antipsychotic medicine, chlorpromazine, and the Civil Rights Movement. Deinstitutionalization reduced these long stays in institutions and promoted the alternative of less isolated, community-based treatment plans for the mentally ill (1).

In the United States, there are several variations of an involuntary hold that are defined in the Welfare and Institution Code. A 5150, more commonly known as the 72-hour hold, allows a mentally ill patient to be hospitalized in a psychiatric institution against their will for 72 hours. If, after 72 hours, the doctor or therapist decides the patient continues to show one or more of the three criteria previously stated, then the patient is subjected to a 5250 code, which extends the involuntary hold up to 14 days, a time determined by a Certification Review Hearing or Probable Cause Hearing (2).

The involuntary hold is meant to protect patients suffering from mental illness, but the legally mandatory nature of it warrants a discussion about an involuntary hold’s infringement upon human rights. In reality, it pits patient autonomy versus beneficence. Patient autonomy is about personhood, about the right of a patient to make decisions about their medical care without being influenced by a healthcare provider. Beneficence is the intention of doing good. In the case of mental health sufferers, beneficence is not only about the good of the patient but also relates to the concept of parens patriae, Latin for the “parent of the country.” The concept of parens patriae holds that the state or court has an obligation to protect its citizens, even from themselves). So, in this case, beneficence is also about the good of the community.

With these factors in mind, when does the involuntary hold do more harm than good for patients plagued with mental illness?

Entombment of Christ, 1672, in Saint-Martin Church in Arc-en-Barrois (Haute-Marne, France) by Vassil

Once admitted to the behavioral hospital, Anna was finally given a chance to speak with a therapist, who would have complete control over her release. She begged and pleaded about how she was missing classes and that being locked up was putting her academic standing in jeopardy. Anna’s concerns were not prioritized in any way, although she tried time and time again to explain her case. One hour a day, Anna was given access to a phone that she had to share with several other patients. With almost no contact with the outside world, Anna felt she had completely lost control over her own life. She did not trust the physicians or anyone around her. She fell into a deeply depressed state that she was forced to hide in order to get into good standing with the staff so that they would release her quickly.

The final negative impact of an involuntary hold is that it also can contribute to the future pursuit of care. Traumatized patients may have difficulty admitting suicidal thoughts because they worry that sharing this information may result in future unwanted treatment and more involuntary hospitalization. This contributes to a disconnect between patients and caregivers. Dainius Pūras, a professor of psychiatry who was recently appointed by the United Nations as an independent expert on the right to mental health, stated, “Forced treatment is ineffective and perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services.” (5)

Anna became even more distressed than she had been before going to the hospital. She wished she had never reached out for help.

After four days, Anna convinced the therapist that she was well enough to leave. In reality, Anna had never felt worse. She had been stripped of her right to choose, missed several days of classes, and lost many aspects of her identity. She was robbed of her voice and ability to communicate with the outside world. Worst of all, Anna lost all trust in the healthcare system. She now believed they cared not for her well-being but only about protecting themselves and following overgeneralized codes and regulations put in place by organizations that did not understand their impact. Anna left the behavioral health hospital riddled with confusion, stress, and a worse mental state than what sent her to the hospital. Still, Anna was glad to return to her own life, and she focused on getting better. But now, she was instilled with the belief that from then on, avoiding a repeat of this nightmare was the number one thing she would care about, even over reaching out for help again. She would get better on her own.

In sum, the practice of involuntary holds raises many ethical concerns because it interferes with patients’ right to choose a care option for themselves, and it can cause more harm than benefit. While involuntary holds can be a short-term solution for the potential protection of the patient from themselves, they should be imposed with great caution and care. The benefits and disadvantages of this course of treatment should always be called into question first to determine which truly outweighs the other.

References

1. Fariba K, Gupta V. Involuntary commitment – statpearls – NCBI bookshelf. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK557377/. Published April 28, 2022. Accessed October 9, 2022. 
2. 7. Hickman D. Mental health in colonial America. The Hospitalist. December 19, 2021. Accessed September 10, 2023. https://www.the-hospitalist.org/hospitalist/article/123117/mental-health-colonial-america#:~:text=Insanity%20in%20colonial%20America%20was,them%20were%20fueled%20by%20cruelty. 
3. Involuntary holds . Family Education and Resource Center. https://ferc.org/uploads/docs/resources/5150_5250.pdf. Accessed October 9, 2022. 
4. Mental illness. National Institute of Mental Health. March 2023. Accessed September 10, 2023.https://www.nimh.nih.gov/health/statistics/mental-illness#:~:text=Prevalence%20of%20Any%20Mental%20Illness%20(AMI),-Figure%201%20shows&text=In%202021%2C%20there%20were%20an,%25)%20than%20males%20(18.1%25). 
5. Morris NP, Kleinman RA. Involuntary commitments: Billing patients for forced Psychiatric Care. American Journal of Psychiatry. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20030319. Published December 1, 2020. Accessed October 9, 2022. 
6. Rüsch N, Müller M, Lay B, et al. Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness. Eur Arch Psychiatry Clin Neurosci. 2014;264(1):35-43. doi:10.1007/s00406-013-0412-5x
7. Simons P, By, -. Involuntary hospitalization increases risk of suicide. Mad In America. https://www.madinamerica.com/2019/06/involuntary-hospitalization-increases-risk-suicide-study-finds/. Published May 7, 2022. Accessed October 9, 2022.

Image References

1. “Prisoner of the Heart” by qthomasbower is licensed under CC BY-SA 2.0.
2. Entombment of Christ, 1672, in Saint-Martin Church in Arc-en-Barrois (Haute-Marne, France) by Vassil is licensed under CC BY 3.0 DEED.