Ending Involuntary Commitment for People With Treatment-Resistant Mental Illness and Grave Disability

In the United States, people may be involuntarily hospitalized in acute psychiatric units when, as a result of mental illness, they pose an acute safety risk and refuse voluntary care (1). Such people may be deemed a danger to others by exhibiting homicidal or violent behavior, a danger to themselves by exhibiting suicidal or self-harming behavior, or “gravely disabled”—appearing so sick that they cannot meet their own basic needs, such as those for food, clothing, and shelter. Unlike homicidal or suicidal behaviors, grave disability tends to involve safety concerns that are nebulous and chronic. When the mental illness at issue is also persistently resistant to treatment, short-term involuntary hospitalization may not protect persons with grave disability from harm, improve their well-being, or restore their capacity to make informed decisions. In other words, a subset of individuals with grave disability have exhausted all reasonable treatments and have been hospitalized multiple times, yet those hospitalizations did not meaningfully improve outcomes. Involuntary hospitalization is an important tool when acute safety risks are present, but is it justifiable for this subset of people with grave disability who have chronic problems and treatment-resistant illness and who may not recover? We argue that involuntary commitment is not helpful for this group of patients, highlight the problems stemming from this practice, and advocate for a shift in focus to palliative psychiatry and reinforcement of voluntary community-based supports.

Involuntary treatment is imposed to protect patients’ safety and restore their autonomy, but it does not achieve either outcome for those who do not present an imminent risk of harm to themselves or others and whose illness has not improved despite repeated hospitalizations. Instead, such persons experience a cycle of emergency care, short-term hospitalizations, incarceration, and inadequate outpatient services resulting from an overtaxed mental health system and incomplete legislative and policy solutions (2). Repeated involuntary hospitalizations do not meet the needs of this group. Admissions are typically short, efforts are narrowly focused on crisis stabilization rather than on chronic problems, and clinicians are limited in their ability either to ensure that patients engage in outpatient follow-up treatment or to address social determinants of health.

In addition, forcing nondangerous individuals with chronic mental illness to receive treatment has societal costs. First, psychiatric beds are scarce and valuable. Public beds have declined from 300 to 14 per 100,000 people over the last 70 years, with the COVID-19 pandemic further exacerbating shortages (3). Beds occupied by involuntarily held patients who pose no acute risks are unavailable to patients who want to use them but who must instead wait in emergency departments for an opening. Lengthy emergency department boarding is associated with poor outcomes and may damage patients’ faith in the mental health care system. Second, social justice concerns permeate involuntary treatment. People belonging to minority groups are overrepresented among individuals who are involuntarily committed. Forcing ineffective interventions on already marginalized groups compounds existing inequities in health care and may be influenced by the same biases that affect these groups throughout the health care continuum. Overusing involuntary commitment may reinforce patients’ mistrust in psychiatry, inhibiting their engagement in appropriate services in the future.

Some policy makers have seen that repeated short-term acute hospitalizations are ineffective for people with treatment-resistant illness and grave disability and have thus turned to involuntary outpatient commitment (IOC). IOC is built on the assumption that the cycle of repeated hospitalizations or incarcerations, followed by nonadherence to prescribed outpatient treatment, can be broken by forcibly treating people in the outpatient setting (4). However, IOC is untenable in the short to medium term because of its ineffective implementation in most states (4). Effective IOC requires not only statutory authority but also an infrastructure of courts, first responders, community agencies, and mechanisms for forced treatment, which all require time to build.

We join the call for greater investment in inpatient and outpatient psychiatric services, but such changes will likely be slow in coming. Meanwhile, a person with treatment-resistant mental illness who poses no imminent, intentional risk of harm should not be forcibly hospitalized repeatedly when such hospitalizations provide only marginal short-term benefits and do not alter the person’s illness trajectory. If a person returns each time to their prehospitalization state after multiple similar hospitalizations, the utility of these efforts must be questioned and their futility considered. Although members of this group may represent only a small fraction of people with serious mental illness (e.g., schizophrenia or bipolar disorder), they nevertheless deserve just and compassionate care. While awaiting broader reforms, clinicians can achieve this aim by moving away from using involuntary commitment with patients from this group and toward applying a palliative approach.

Psychiatric futility and palliative psychiatry are emerging and important concepts. Coulter and colleagues (5) propose that psychiatric treatment may be futile when the proposed intervention has historically yielded minimal benefit and, at the same time, the patient’s disease has a poor prognosis with apparent inexorable progression, has been resistant to multiple competent (i.e., effective and evidence-based) treatments, and is burdensome and has led to a substantial deterioration in health. These authors and other proponents of palliative psychiatry recommend a reorientation toward treatments aimed at minimizing pain, distress, and iatrogenic harms when standard treatment approaches are futile (5).

Although the precise contours of palliative psychiatry have yet to be fully determined, one clear and actionable implication of this new theory that has not been previously articulated is the cessation of forcible treatment for people who are exceedingly unlikely to benefit from it. Involuntary treatment is an extraordinary and risky measure. People are detained in locked facilities and receive unwanted interventions, which may include physical restraints and medications. No bright line distinguishes people who could benefit from involuntary care from those who would not, but clinicians routinely navigate complex scenarios that require individualized assessments. Such assessments are critical to ensuring that nondangerous people whose mental illness seems impervious to treatment are not subjected to unwanted, burdensome psychiatric care of uncertain benefit.

Previous calls to reduce involuntary treatment have been met with objections that heeding those calls would lead to patients “dying with their rights on.” Critics protest that not treating patients when they do not consent to hospitalization would give the semblance of liberty while effectively abandoning patients to their illnesses (1). We agree that patients should not be left to languish. On the contrary, robust outreach and engagement are vital to person-centered, recovery-oriented treatments. Such efforts must continue, but the receipt of treatment must be voluntary. Nondangerous patients with treatment-resistant illness who decline psychiatric services should not be mandated to undergo treatments that offer little to no benefit. Even when refusals involve impaired decisional abilities—and it may be unfair to presume that patients with extensive lived experience of the mental health system lack an appreciation of the interventions—clinicians should not insist on providing treatments with potential benefits that do not outweigh their risks.

Systemic reforms are not inevitably doomed. However, clinicians must recognize their limitations so that people who cannot succeed in the current system are not subjected to unnecessary deprivations of liberty. Reforms will require not only structural and policy changes but also shifts in frameworks and attitudes about what constitutes mental health, recovery, and appropriate interventions. Also needed are modifications to legal standards that address clinicians’ concerns about their liability risks when they allow people with treatment-resistant illness to remain in the community.

Nondangerous individuals with grave disability stemming from treatment-resistant mental illness should not be involuntarily hospitalized repeatedly when such interventions are ineffective. Involuntary care is highly restrictive, and its execution carries associated harms. Yet, people with illnesses that are not responsive to these interventions are often involuntarily committed to psychiatric hospitals despite bed shortages and other individuals’ lack of access to such care. Instead, palliative psychiatry and person-centered recovery approaches that allow nondangerous individuals to live in the community represent more humane, ethical, and equitable options. At the same time, the hard work of reforming the mental health system must continue.