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Involuntary Treatment Meeting Summary

Meeting Objective One:
Specify Issues, Concerns, and Questions
about Involuntary Interventions and Coercion

When people generally are aware of a problem, it can be said to have entered the public consciousness. But when people get on their hind legs and holler, the problem has not only entered the public consciousness, it has also become a part of the public conscience; and at that point, things in our democracy begin to hum.

- Hubert Humphrey, quoted by Dr. Bernie Arons in convening the meeting

One of three purposes of the meeting was to provide new input to CMHS on current issues, concerns, and questions concerning involuntary interventions from diverse perspectives. This broad assignment led to a far-ranging discussion and a considerable amount of disagreement. As Dr. Arons stated in his opening remarks, involuntary intervention is clearly a topic about which people do, in Humphrey's words "get up on their hind legs and holler." There are many different paths to take to mitigate these practices. Some of the major comments and suggestions mentioned at the meeting are featured below.

• Involuntary commitment is the most frequently mentioned example of coercion in mental health practice. However, consumers may experience coercion in many other situations, such as:
  • seclusion,
  • restraints,
  • involuntary medication,
  • outpatient commitment
  • persuasion by family members, friends, or practitioners to enter the hospital,
  • inducements if one agrees to enter the hospital,
  • threats of loss of services or other supports (e.g., housing, income) by family members, friends, or practitioners unless one enters the hospital,
  • pressure to give informed consent without viable alternatives,
  • highly assertive community case management,
  • lack of alternatives to psychopharmacological treatment, and
  • being told that one has a mental illness and should give up hopes of being employed or fulfilling other major life roles.
• Studies indicate that consumers report experiencing coercion in voluntary -- as well as involuntary -- hospitalizations. However, some consumers involuntarily committed report that they had not been coerced into being hospitalized. Consumers' perceptions of being treated with respect and having their views taken into account seem to relate to perceptions of fair and non-coercive practices.
• Research was presented regarding the opinions of individuals who have been involuntarily committed regarding their admission. Some individuals who believe they need to be hospitalized at the time of admission later regret having done so. However, it is more often the case that individuals who reject inpatient treatment and are involuntarily committed, later change their minds and are supportive of having received treatment.
• The Well-Being Project found that 48% of consumers interviewed had avoided mental health treatment on one or more occasions because they feared being involuntarily committed. The figure was even higher (55%) among consumers who had the personal experience of being involuntarily committed.
• There is a growing awareness that involuntary commitment, seclusion, and restraints can trigger re-traumatization of individuals who have been physically or sexually abused or traumatized in other ways. Consumer/ex-patient/survivors may need help to overcome the traumatization of involuntary interventions and coercion.
• Interest was expressed in learning more about the possible harmful effects of coercion not only for the identified patient, but also for family members, friends, and practitioners who participate in it.
• Some participants stated that the initiation of involuntary commitment is not undertaken lightly, but rather that practitioners and family members feel compelled to act when they witness the distress of a patient or loved one, or the danger that individual is to him/herself or others. Examples were given of family members intervening to aid homeless individuals living in unsafe or unsanitary conditions, and securing medical care for individuals with maggots in open wounds.
• It was suggested that researchers and policymakers too often assume coercive practices are necessary rather than questioning their use. For instance, the Professional and Technical Advisory Committee of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently developed new standards for seclusion and restraints; some participants, however, would like JCAHO standards to preclude the use of seclusion and restraints in health care facilities.
• A participant denied the existence of mental illness, describing it as a culturally biased concept that devalues significant human and spiritual experiences. He asserted that in some cultures, people who hear voices and see visions are revered as healers. However, it was also noted that all cultures recognize the difference between mystics and people with mental illness.
• The need for involuntary treatment is generally linked to behavior on the part of the person with mental illness. However, availability of services may also be a relevant factor. For example, depending on staff resources, a particular behavior may lead to a staff person sitting next to a patient for a few hours or to seclusion and restraints.
• It was proposed that coercive practices could be reduced if crisis services were more responsive to consumer preferences. Peer supported crisis services may be more appealing.
• Some participants stated their belief that a significant proportion of federal funds seem to be devoted to research and demonstration projects on community services rather than state hospital treatment, and were concerned that coercion and involuntary interventions are more likely to occur in state hospitals.
• It was the view of some that since advocacy efforts have been focused on public institutions, people do not have the same opportunity to exercise their civil rights in private psychiatric hospitals.
• The Supreme Court's Hendricks decision is an example of how public mental health agencies may be mandated to assume custody or social control functions. This decision allows states to detain convicted sex offenders in psychiatric institutions after they have served their prison sentences if they have a "mental abnormality" or personality disorder and are considered likely to engage in predatory behavior again. Concern was expressed that this precedent, could draw limited public resources away from other forms of mental health care or make institutions more dangerous for people with mental illness.
• It was suggested that research on involuntary interventions should measure the cost of lost autonomy, loss of trust in relationships with family members or care providers, damaged sense of self, or learned helplessness, in addition to more traditional outcome measures relating to treatment, functioning and symptom levels.
• Some participants were concerned that current legal protections and procedures are insufficient to protect patients' rights. Suggestions for improving the implementation of patients' rights included increased access to legal representation and independent psychiatric consultation prior to court hearings.
• One proposal for reducing the incidence of involuntary interventions is to make practitioners liable for the long-term effects of their clinical decisions (e.g., tardive dyskinesia), including unwanted psychotropic medications.
• While some advocates emphasize the ill effects of coercion, others are concerned about the harm that may come to individuals who do not get help during a crisis. They may die, suffer unabated psychiatric symptoms, experience a decline in physical well-being and safety, or end up in coercive systems such as jails.
• There were anecdotal reports that, under managed care, practitioners are more likely to use involuntary commitment to ensure access to and payment for care. It was suggested that the relationship between managed care principles and coercion needs to be examined.
• The National Opinion Research Center at the University of Chicago has found that the overwhelming majority of Americans favor the use of coercion when people with mental illness do not accept treatment voluntarily and are a danger to themselves (90% in favor) or others (95% in favor).
• It was suggested that anti-stigma campaigns aimed at reducing the beliefs that people with mental illness are dangerous or don't know what's in their best interest might make coercion less acceptable in the public's eyes.
• The need for health care consistently exceeds the resources available. The concern was expressed that if steps are taken to make it easier for people to refuse mental health treatment, this could provide an opening for public and private mental health agencies to provide less mental health care overall.
• Participants called for a wider forum to discuss these issues -- one that includes not only some consumers, family members, and practitioners, but also the public, the press and more consumers, family members, and practitioners.