Posted by: thealienist | July 7, 2015

A Little More About Involuntary Hospitalization

As I posted earlier, I am not a big fan of involuntary hospitalization.  I have done it when there were no other moral or ethical options left, but I have consented to it only after intense and prolonged consideration.  In my earlier post, I tried to comment on how to avoid (or achieve — your choice) involuntary hospitalization.  In this post, I want to comment on an important part of the decision that I omitted from my earlier post.  The quality of the institution one is committing a patient (or being committed as a patient) to. Let me start by saying that even if the institution one is dealing with is the most advanced, successful, caring, accommodating, and thoughtful place in the world, it is not a light matter to infringe upon a person’s rights and commit them.  Involuntary commitment, under any circumstances, is an infringement on a person’s rights.  Its only possible justification (to my mind) is to prevent a patient from taking an irreversible and harmful action that is conceived of and/or motivated by a demonstrably false view of the world or of one’s self, compelled by an overpowering emotion, and/or performed by a person who is unable to control his actions.

If such a person is to be committed, our mental health providers need to consider what kind of conditions are required to look after him.  (In fact, I think that our entire society should ask itself this question.)  Hospitals are not, nor should they be expected to function as, jails.  Merely confining those who are presumed to be mentally ill is unethical.  Patients in hospitals have the right to expect at least two things:  prompt evaluation and competent treatment.  Prompt evaluation is required because the patient is presumed to be mentally ill when involuntarily hospitalized and this must be confirmed.  Because a psychiatric hospital is no place for a non-mentally ill person to be, prompt evaluation of the patient’s condition needs to be carried out to confirm the presence of signs and symptoms of psychiatric illness and to rule out general medical illnesses and intoxications that can mimic psychiatric illness.  Ethically, this requires that the patient be evaluated by a person trained to make valid and reliable diagnoses based on accurate and complete observations and measurements.  Once this is done, the patient can be treated, released, or turned over to the legal system as appropriate to each case.

If the patient is found to be dangerous to himself or others and this dangerousness is due to a mental illness, then he should expect competent and compassionate care.  By competent care, I mean empirically supported care that is rationally related to the issues leading to hospitalization.  The patient should expect that the care given will be given at a frequency and dose that will result in improvement over a reasonable amount of time.  He should also expect to be treated with respect, be allowed (as far as he is able) to choose between available treatments, and be actively involved in his treatment.  Finally, he should be informed of the requirements for him to be released, his ongoing progress in meeting these requirements, and his plans for discharge.

Unfortunately, not all hospitals are equally good in all of these areas.  I have been fortunate to work in some hospitals that were excellent in all of these areas (shout out to University of Michigan Hospital in Ann Arbor).  I have heard from some of my patients about other hospitals that were not.  As a psychiatrist, I am more comfortable involuntarily hospitalizing a patient to a facility that I know will carefully and accurately diagnose them, work with them to make effective, efficient, and comprehensive treatment plans, treat them with respect, and help them find continuing care if they need it.  This ensures that patients are not hospitalized longer than necessary and are not abandoned to their illnesses upon discharge.  When such facilities are not available (because a facility is not staffed well, no beds are available in the better facilities, or there are simply too few beds available anywhere), it is much more difficult to justify involuntary hospitalization (except in the most extreme cases of suicidality or homicidality).

The moral of the story, I guess, is this:  If the mental health system is going to take on the burden of ethically and morally hospitalizing people against their will, they need to advocate for the kinds of facilities, physicians, nurses, and psychologists that these patients need.  These are the necessities for preserving human dignity in the face of dehumanizing illness.

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