Involuntary Commitment as an Intervention
Let us define certain concepts more precisely. Voluntary hospitalization is hospitalization to which the patient consents and with which he cooperates, being thoroughly informed and capable of understanding what is going on and the consequences. Involuntary or compulsory hospitalization means that commitment is ordered by a court in spite of the patient’s clear and explicit refusal to be hospitalized.
When the concepts are defined thus, a more or less clearly demarcated interim area remains. This concerns patients who do not or cannot make their wishes known clearly; who are confused and disoriented, apparently not understanding what is going on; who refuse to speak; and who say no to whatever is said (no to going to the hospital and no to not going to the hospital). Jongmans calls these cases virtually voluntary hospitalization. Van der Esch adopts the term “non-opposing” patients from English language literature . Sipsma points out the danger of such hospitalizations regarding the elderly, which are arranged more or less without involvement of the person in question. He posits that hundreds of hospitalizations are arranged for elderly people this way every year in psychiatric hospitals and nursing homes for the psychiatrically disordered elderly. This is all the more serious as in this category of patients the process is usually irreversible as hospitalization itself quickly leads to permanent changes in condition. This is less so for totally confused, stuporous, or negativistic patients. My impression is that the inclination to request involuntary commitment for the latter category of patients is stronger than for the elderly. So for the powerless, extremely vulnerable elderly, legal procedures are considered unnecessary, while they are in fact very much necessary for the protection of these elderly people. The legal procedures are invoked for “non-opposing” adults even though the consequences for this group may be less serious.
It is most important to realize that every involuntary commitment involves a conflict between the person involved and the authorities who effectuate the involuntary commitment: the psychiatrist or physician who signs the medical statement, the judge who rules, and the state that actualizes the hospitalization. The reason this is so important is that the conviction that hospitalization serves people’s best interests can create the illusion that the parties are acting benevolently to the exclusion of all other motives. This is not so. Coercion is being used to compel people to do things they do not want to do. Recognizing this conflict can safeguard against carelessness regarding the law and human rights. Furthermore, there should be awareness of the extreme difference in power between the authorities ordering involuntary commitment and the person involved. Not only are committed people forced to comply but to a certain point they are denied pronouncing an assessment of themselves and their situation, as though they were dangerous and disordered. They are feared and avoided by their fellow citizens.
In general, involuntary commitment should be considered a serious intervention in people’s lives. De Smit describes involuntary hospitalization as a sudden, more or less unpredictable event which drastically disrupts people’s social networks. Social reality is reconstructed in the direction of the stigmatizing stereotype of potential danger, that is to say, behaviorally unpredictable, destructive mental illness. De Smit concludes that involuntary hospitalization is always a more negative than positive experience. Stone mentions “considerable harms” and lists stigmatization, collapse of self-regard, separation of the patient from his family and community, loss of employment, grave restriction of prospects for future employment, and – considering current treatment of patients in Mental Hospitals – a not trivial risk of being brutalized or physically harmed. Such a commitment adheres to a person for a very long time as a handicap when applying for a driver’s license or other privileges. In the Netherlands it is only since 1979 that people who are hospitalized by court order do not automatically become legally incompetent (European Council ruling in the Winterwerp case). Ellis and Robitscher also underline the serious impact of involuntary commitment on people’s lives.
A peculiar and at the same time alarming aspect of involuntary commitment is that when, for instance, a mistake has been made, restoration is not really possible. Someone who is accused of a crime may be acquitted and thus his status of innocence restored. In current Dutch commitment laws there need only be suspicion that there is a disorder of mental functioning. But if this disorder should turn out not to exist, or not to be relevant to the dangerous behavior, the court order is simply terminated. As far as I know descriptions of unjustified involuntary commitment are extremely rare. When they do occur it is not uncommonly thanks to intervention by the media. Yet, in addition to judgmental mistakes made in good faith, incorrect information based on prejudice, or even malicious attempts of the family to remove another family member from society and have him declared incompetent, cannot be ruled out. Ellis relates that groups dedicated to assisting ex-mental patients claim that many Americans have been derailed this way. He quotes a publication by Redlich et al in which appears the statement, “In some cases, there is evidence that psychiatrists and other involved persons are motivated, in part, by counter-aggression toward very provocative patients.”
In addition it is generally impossible for those who advise and order involuntary commitment to receive meaningful feedback. The first reason for that is the complexity of the issue. It has at least three aspects. First: is a psychiatric disorder present, and if so, how severe is it? Secondly: if there is danger, what constitutes it and how serious is the threat? Thirdly: Is there a relationship between the psychiatric disorder and the danger? If so, what is it? The first aspect was thoroughly discussed in Chapter V, 3.3. Some people have proposed dropping the concept of psychiatric disorder as a legal term because what is meant by it is too vague for legal procedures, can have too many meanings, and generates too many misunderstandings. The second aspect was discussed in 3.2. The third aspect (see 3.2.1) is also problematic. Offerhaus describes the position of the psychiatrist who must advise about involuntary hospitalization as follows: “He makes his choice on the axis from ‘safety’ to ‘freedom’ first and foremost on the basis of personal insight and experience which is scarcely supported by scientifically obtained knowledge. He thereby finds himself in a situation that in no way satisfies the requirements of a careful and responsible decision process.”
Secondly, meaningful feedback is usually impossible for the reasons mentioned in 3.2.1: when during hospitalization the patient does well, the involuntary commitment is credited, if he does poorly it is seen as confirmation of the necessity for involuntary commitment. This state of affairs predisposes to an augmentation of the number of involuntary commitments as well as Scheff’s medical decisional rule quoted by Giel, that “when no clear choice is possible, the physician considers the patient more benefited by presuming illness than denying it and risking having overlooked a disorder.”
Thirdly, meaningful feedback is very difficult because the dilemma of psychiatrists advising involuntary commitment cannot be formulated by the question “is it permissible to involuntarily commit this patient?” but by the question “is it permissible to allow this patient to continue on his own?” This is generated by the nature of involuntary hospitalization as an ultimate refuge. It means that psychiatrists feel morally responsible not for the serious intervention that they advocate but for all the things that might go wrong if they do not commit the patient. It has been amply demonstrated in different places and under different political regimes that such procedures are easily politically abused and form an urgent, grave problem, as a motion against such practices in the [former] USSR by the World Psychiatric Association in 1977 attests.
When feedback on decisions is not meaningfully possible there is no opportunity to learn from experience, correct policy according to newly gained insights, and develop better procedures accordingly. This means that as involuntary commitment as a social intervention exists several centuries already, a process of self-confirming experience has led to such a deeply rooted tradition that we can no longer imagine what to do without such intervention. But it also means that the moral judgment of the necessity of involuntary commitment is still largely devoid of empirical support. And it means that the enormous social changes since the eighteenth century do reflect the number and percentage of involuntary commitments, but hardly any fundamental discussion of this intervention, while the improvement and intensification of the network of helping professionals since then should have given rise to this discussion.
We can conclude from the above that unless consistently discouraged involuntary commitments will continue to proliferate and the rate will even rise. Without it we fear that all sorts of people who neglect themselves, who apparently cannot care for themselves, who take to a life of vagrancy and squalor, or who cause themselves serious suffering, will be left to their own devices and succumb. Compassion seems to dictate intervention even against people’s wishes. This also holds true for people who harm themselves or others due to voices they hear or who harm themselves when in a deep depression. Increasingly we fear disruption of society by psychiatrically disordered people who cannot be held accountable for their behaviors. Time and again the dilemma is whether such people can be left alone and whether it is admissible for society to deprive itself of the power to intervene. Here I should add that strictly speaking, the danger criterion does not justify involuntary commitment for most of the people in need mentioned in this paragraph, so they cannot be protected by the existence of involuntary commitment laws.
Robitscher quotes two relevant investigations in this respect, both carried out in the United States after a change in local law. Hiday determined in her research that in 20% of involuntary commitments the legal criteria for involuntary commitment were not met. Lelos found that of 109 hearings 58% of involuntarily committed people met the criteria and 42% did not. We would be justified in suspecting that judges either at the instigation of psychiatric reports order more people to be committed than the law strictly speaking permits, or have to drastically change the target population of commitment laws. Neither the systematic violation of the laws nor the inability to apply them to those who need them most are a pleasant prospect.
In summary, the decision to involuntarily commit someone is a decision with serious risks and disadvantages for that person. Any advantages should be weighed against these disadvantages. The consideration that the person is ill and must be hospitalized for his own benefit should be strongly questioned in light of these other considerations. Good intentions often eclipse the serious consequences for the person’s social future.
Thought on this problem is rendered more difficult by the moral burden. The near impossibility of meaningful feedback on decisions taken impairs learning from experience. Due to the long historical tradition involuntary commitment is deeply rooted in our culture which also renders a critical view and the search for alternatives difficult. This alone makes the abolition of involuntary commitment unlikely. Moreover, even after the most stringent selection, there will always be people left who are either so deeply demented, oligophrenic, or floridly psychotic that it would be inhumane to abandon them to their own devices. From this point of view I will examine the prospects of abolishing involuntary commitment.
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