Hospitalizing people against their will: 4 questions to ask

Involuntary commitment refers to hospitalizing people against their will for psychiatric reasons. It is a controversial topic because this is where medicine and civil liberties intersect: Physicians have the ability to take away the rights of fellow citizens. (I suspect that few people who become psychiatrists realize that making recommendations about involuntary commitment is part of the job. I certainly did not know this. I also did not appreciate the ramifications until I was well into my residency training. It is the worst part of my job.)

Involuntary commitment laws differ in each state. In general, there are three criteria to consider prior to hospitalizing someone against their will. In a just world, all three criteria must be met for involuntary commitment to occur.

1. Does this person want to harm himself or someone else? The legal language often refers to this as “danger to self” (often suicide) or “danger to others” (often homicide). The “danger” could also refer to inadvertent harm — not only purposeful intention to harm self or others. For example, consider a man who believes he is Superman and wants to fly off of a roof or someone who believes that he will prevent the next nuclear war by destroying a high traffic bridge.

There is also a concept of “grave disability,” which refers to individuals who cannot attend to basic needs. Consider a woman who refuses to eat because she believes that, if she eats, she is eating her internal organs.

2. How imminent is this risk of harm to self or others? If the risk of dangerousness is high and there are concerns that harm will come to self or others “soon,” this strengthens the argument to hospitalize someone against his will. (Note that the word “soon” is not defined. “Imminent” could refer to minutes or hours, though generally not days.)

No one, however, can predict the future, so no one knows for certain who will actually hurt themselves or other people. We can only assess risk of dangerousness. This includes evaluating known factors, such as past history of violence, current symptoms, demographics, etc.

3. Are these behaviors due to a psychiatric condition? If this person is a danger to self or others, is this due to a psychiatric condition? Or is it due to something else (such as a medical condition, drug use, etc.)? Depression, substance use, and psychotic disorders increase the risk of suicide; social support, cultural beliefs that discourage suicide, and a sense of hope decrease the risk of suicide. Some people argue that the wish to kill self or others is always due to a psychiatric condition (“there must be something mentally wrong”), though others (such as Thomas Szasz) argue that psychiatric conditions do not exist or that they are irrelevant.

To further complicate the issue, sometimes it’s not clear if behaviors are due to a psychiatric condition. For example, some people argue that substance use disorders are not psychiatric conditions.

Another question to consider: Will hospitalization help treat the underlying psychiatric condition that led to the imminent danger to self or others? This last point is often not considered as strongly as the others.

This explains why some people go to jail instead of to the hospital. We don’t have effective treatments for people with antisocial personality disorder (“sociopaths”) or pedophilia. If hospitalization doesn’t appear either indicated or helpful, then involuntary commitment may not be an option.

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • Suzi Q 38

    I would be difficult to hospitalize my sister, who needs psychiatric assistance. Just because she thinks that her mother got sick due to members of a Latin mafia, does not mean that she will harm anyone.
    She does other odd and troubling things, but that is all it adds up to.
    I would love to get her to voluntarily seek help but she thinks nothing is wrong with her and the doctors would be prescribing meds that were poison.

    • beautyis everywhere

      The problem with the concept of “protecting society” from certain “disturbed” persons …is that it is ultimately a POLITICAL issue. If you are disturbed, rich, protected and well-armed monetarily you will never be committed to an insane asylum. If you are poor you will be lucky in the same circumstances to avoid being imprisoned. And anti-female bigotry serves the same purpose even if the guy is also poor!!! As a result the insane asylums can be and many times are even WORSE than the prisons….and the most frightening result is this: Even a defenseless harmless woman who becomes a domestic violence victim can end up locked up instead of the perpetrator…IF it is more convenient and cheaper for the “system” to do it…and by “system” I mean DA’s, and law-enforcement personnel, the heads of psych. facilities, and state/county-supported “helping” personnel. The system is corrupt through and through and what happened to me myself…..is a prime example.The “system” thinks it is more important to “protect” and perpetuate itself and it own biased values…than the people it is charged with protecting, and this is corruption by consensus….And everyone, in spite of ALL rhetoric…. seems to think that’s the way it should be….at least it turned out that way in my situation. Thirty years later and I have still not recovered from the trauma of them doing that to me….and btw the perp killed himself 8 years later, probably from the guilt of perjuring himself to make it look like he was the good guy and seeing me get punished instead of him.

      • Suzi Q 38

        Thank you for your response, your heartfelt story, and the sad ending.
        At least Karma worked for him in a negative way.
        I hope that you are improving day by day.

        • beautyis everywhere

          Karma worked for him and me too. I never got one apology from any of the key players or anyone else for that matter; my own parents showed total contempt for me when I called them terrified from the nuthouse floor on the fifth day….. and never could sue anyone and never found any emotional improvement or any better housing/community situation, all hopes notwithstanding. Wish I just could have said thank you and yes you are right and I appreciate your pointing out the “positive”….cause nothing good came out of this. But I sure learned some stuff. I learned if you are not very well supported by family and friends and you are a woman and want to keep your pets from taking the brunt of any other abuse (and this WILL always happen!!) you will be stranded and have no one who cares what’s going on. Your own next door neighbors will turn on you too if it’s convenient. The number one crime in America is to be poor and female and a pet lover and trusting that some marginal person can move in with you and benefit from your kindness and love. The system will finish you for having the nerve to be in that category. Finish you. But thank you for your kind-spirited response. Email me if you like at kneesox at inbox dot com. I’m still in a lot of trouble trying to live in this world and almost d*ing from lack of friendship or support……..

  • medicontheedge

    Your last paragraph is the paradox: in my ED, we see just the opposite. Intoxicated and/or criminal behavior often results in the the police offering either jail or the ED…they claim that the person is “gravely disabled” and “commit” them. Which do YOU think most people chose?

    • guest

      However, there is still a significant number of people with psychiatric illnesses who end up in the criminal justice system (one of the most rapidly growing locations in the U.S. for the seriously mentally ill,) so if a few sociopaths end up getting committed, it all evens out.

  • Lemmethink101

    What happened when a psychiatrist with mental illness that requires involuntary admission evaluates patients that also have mental illness requiring involuntary admission?

    We are about to find out. Or not.