The Circumstances Behind Involuntary Hospitalization A Personal Ethics Narrative

Abstract

Would you rather your loved ones be treated effectively or taken to the hospital against their will? Involuntary hospitalization, a legal process by which the mentally ill are forced into treatment at hospitals, is highly contested. Some medical and legal scholars believe those with mental health disorders should not have their personal autonomy restricted or infringed. In contrast, other organizations such as the American Medical Association believe that although mentally ill individuals are often able to make their own decisions, involuntary hospitalization can be a very quintessential tool to stimulate recovery. Involuntary hospitalization should be executed when individuals pose harm to themselves or others, regardless of whether the cause is mental illness or substance abuse.

Imagine someone who you love is kicking, screaming, and threatening the lives of others or yourself. This was my reality before my brother was involuntarily hospitalized. My 16-year-old, younger brother, Declan, has bipolar two, ADHD, and nonverbal learning disorder. These mental health disorders cause my brother to be violent and impulsive, characteristic of hyper-mania. Occasionally, he also has hypomanic episodes at times because of bipolar two, regardless of his medications. In one incomprehensible situation, Declan violently burst into a rage after not a disagreement with our parents; he started throwing vases, punching holes in the walls, and cursing loudly. My single mom, younger sister, and I were endangered in the unstructured setting of my house because of my brother’s instability. In my brother’s case, hospitalization was necessary to ensure the safety of my brother and others surrounding him. Hospitalization allowed psychiatrists to stabilize or modify his medications and open new avenues of treatment. This included transfer to an out-of-state facility last summer. Without hospitalization, Declan would not have found the valuable resources he has today. Involuntary hospitalization was the clear solution to save Declan and my family from a dangerous situation.

My family and I view involuntary hospitalization through different lenses than my brother. Declan believes that his hospitalization was unnecessary and that his violent outburst was just a “one-time mistake.” However, all of Declan's peers and family members could see his emotional and physical improvements following his release from Alexian Brothers. For example, hospitalization taught Declan new coping skills and helped stabilize his medications in an effort to prevent another violent outbreak. Although difficult, Declan’s hospitalization was a necessary result of the violent situation he put my family and me through.

In contrast to Declan, other mentally ill individuals involuntarily placed in hospitals are grateful for their experiences. Patients, generally, have a positive view of involuntary hospitalization after being released, especially if “they experienced the hospital environment as warm, friendly, accommodating to their individual needs, [and feel] safe…” The hospital environment should be a comfortable place for individuals to be treated. I truly believe Declan, as he matures, will also be thankful for the intensive therapy and treatment he received.

The public’s general view of involuntary hospitalization is circumstantial and disorder-dependent as evidenced by the 1996 General Social Survey, conducted by the National Opinion Research Center at the University of Chicago. According to the social survey, the public agrees that troubled people have the capacity to make their own treatment decisions; however, they recommend that individuals who have severe mental disorders, like schizophrenia, should be involuntarily hospitalized. Additionally, “respondents were slightly more likely to condone coercion, if others, rather than the person himself or herself, are seen as in danger” because they can picture themselves in a dangerous situation. Coercion, performing an action against a patient’s free will or resistance, is the most serious consideration in involuntary hospitalization. It is comforting to realize most respondents shrug it off in severe, violent scenarios. The public’s view of involuntary hospitalization corresponds with my view: involuntary hospitalization is necessary under certain circumstances.

Involuntary hospitalization is warranted if mentally ill individuals are capable of harming those around them. As the Clinical Manual of Psychiatry and Law states, “the person must have a mental illness that causes his or her potential for violence” to be appropriately involuntarily hospitalized. Some may suggest that the offender should be managed by the police when violence is involved. When Declan hurt my family and me, police intervention made him more scared, angry, and upset. Although the police did their job to the best of their ability, healthcare professionals are better qualified to treat and regulate disorders. In the healthcare environment, mentally ill individuals who are capable of violence can receive the care they need. Involuntary hospitalization should be utilized whenever a mentally ill person poses a serious threat to his or her community.

Involuntary hospitalization is also necessary when individuals with mental health disorders express consistent suicidal thoughts. Although suicidal individuals may regard hospitalization as harmful to their well-being, this harm is minor in comparison to the outcome of self-harm. Although hospitalization may not prevent suicide, “a person’s right to be treated in the least restrictive environment must be balanced against his or her potential dangerousness to self or others.” The hospital provides a structured setting where suicidal individuals can express their feelings and engage in social support systems. Declan successfully worked through suicidal thoughts and emotions that appeared during his violent outbursts. Since involuntary means hospitalization is only performed with the patient’s best interest at heart, it should be implemented for suicidal individuals.

In addition, a frequent substance abuser who is at risk of posing imminent harm to themselves or others should be involuntarily hospitalized, since addiction to drugs or alcohol can change the brain in fundamental ways. Violence to self and others should be regarded on the same level of concern as substance abuse because both could lead to death or harm. However, a person who is simply intoxicating themselves with no harm to others does not always warrant violating their civil rights. It’s when they pose a harm to others, through an act like drunk driving, that involuntary hospitalization should be implemented. It is a personal choice to harm the body with alcohol or drugs, but if that action poses harm to others, it is justified to violate the abuser’s civil rights. For instance, involuntary hospitalization allowed Declan to be educated on the risks of drugs after he immersed himself into a group of peers that abused drugs. Involuntary hospitalization should not be implemented for every single person who suffers from substance abuse disorder, but it should be utilized for severe substance abusers who are at risk of causing harm to themselves or others.

There are some who believe that involuntary hospitalization is coercive, harmful, and diminishes the patient’s self-esteem, leading to mental instability because of its coercive nature. To suggest the benefits of voluntary hospitalization, the Northwestern University Law Review says, “making the patient responsible for his own treatment, rather than committing him forcibly to an institution, is said to increase his feelings of self-worth and his receptivity to treatment.” However, one must ask: How do feelings of self-worth and increasing one’s self-esteem compare to the fact that the individual could die without treatment? Increasing self-esteem is a benefit to voluntary hospitalization, but involuntary hospitalization has the potential to save lives.

Similarly, opponents to involuntary hospitalization believe that to eliminate coercion, less restrictive means such as outpatient centers should be utilized to treat the mentally ill. This line of reasoning ignores the importance of involuntary hospitalization. These opponents state, “there is little reason why the prescription of medication or the provision of convulsive, psychological, and social therapies also cannot be accomplished on an outpatient.” Although some of these therapies can be accomplished in an outpatient facility, the ease with which this can be done is overstated. The current lack of communication between courts and outpatient centers inhibits the use of outpatient resources. Additionally, community-based care will not be effective until there are more facilities and the public has more acknowledgment of the stigma surrounding mental illness. Therefore, hospitals need to intervene and provide the proper care to the mentally ill while more outpatient services develop. The more medical professionals address this healthcare resource issue, the less they must violate patient civil rights. Although outpatient systems are preferable, the current lack of resources in the mental healthcare system renders involuntary hospitalization necessary.

Involuntary hospitalization is indicated for those with the potential to commit violent acts, high-risk suicidal actions, and pose a risk to themselves or others as a result of substance abuse disorder. Although involuntary hospitalization can be coercive, it exists to treat the mentally ill who do not realize they need help or refuse to take the necessary treatment steps for their health. Other outpatient resources may be used, but with limited resources available involuntary hospitalization is the most feasible option. Hospitalization stabilized my brother and removed my family and I from a dangerous situation. For that, I am forever thankful.

References

Gilboy, Janet A., and John R. Schmidt. “Voluntary Hospitalization of the Mentally Ill.” Northwestern University Law Review 66, no. 4 (1971-1972): 429–53.

American Medical Association. “Patient-Physician Relationships.” In Code of Medical Ethics of the American Medical Association, 1st ed. American Medical Association, 2016.; Council on Psychiatry and Law. “APA Official Actions: Resource Document on Involutnary Outpatient Commitment and Related Programs of Assisted Outpatient Treatment,” 2015.

Danzer, Graham, and Asha Wilkus-Stone. "The Give and Take of Freedom: The Role of Involuntary Hospitalization and Treatment in Recovery from Mental Illness." Bulletin of the Menninger Clinic 79, no. 3 (2015): 255–80.

Pescosolido, B. A., J. Monahan, B. G. Link, A. Stueve, and S. Kikuzawa. "The Public’s View of the Competence, Dangerousness, and Need for Legal Coercion of Persons with Mental Health Problems." American Journal of Public Health 89, no. 9 (1999): 1339–345.

Simon, Robert I., and Daniel W. Shuman. Clinical Manual of Psychiatry and Law. Washington, DC: American Psychiatric Pub., 2007.

Glick, Rachel Lipson. Emergency Psychiatry: Principles and Practice. Philadelphia: Wolters Kluwer, 2008.

Gilboy, Janet A., and John R. Schmidt. "Voluntary Hospitalization of the Mentally Ill." Northwestern University Law Review 66, no. 4 (1971-1972): 429–53. Morse, Stephen J. "A Preference for Liberty: The Case against Involuntary Commitment of the Mentally Disordered." California Law Review 70, no. 1 (1982): 54–106.