Involuntary Commitment: Opinions Regarding Patient Autonomy, Legal Parameters, and Behavioral Services Care Delivery

The Controversies in Psychiatric Services column aims to highlight differing viewpoints on topics relevant to psychiatric services that have generated a debate or a divide in opinion. For this column, the editorial team chose to focus on the practice of involuntary commitment, asking authors to respond to the following statement:

With growing concern by local and state officials that individuals with mental disorders are underserved and lack access to hospital-based services, changes to involuntary commitment rules to enhance access to care are being assessed. Currently, there is controversy about criteria for involuntary commitment, authority to commit patients, and how both factors affect patient autonomy.

Clinical, legal, and ethical dilemmas regarding involuntary commitment in the delivery of mental health care services are addressed in three opinions. First, Zhong and Wasser argue that involuntary commitment in its current form does not preserve patient autonomy or provide an opportunity for recovery-oriented treatment. Worse, involuntary psychiatric hospitalizations and outpatient commitment practices are typically ineffective for many with an extensive history of prior commitment, resulting in repeated hospital admissions and poor community tenure. The authors propose decreasing the practice and focusing instead on palliative psychiatry and community-based supports, noting that liability laws also need to be updated to accommodate the new approach. Taking a contrary view, Sullivan et al. acknowledge that involuntary commitment is problematic, but they advocate for maintaining the practice to ensure that patients receive lifesaving treatments (as well as care that may benefit caregivers and the community as a whole). The authors note that involuntary treatment is ethically and clinically warranted for humanitarian reasons when it protects vulnerable individuals from harm. Finally, Minkoff describes the new laws in some states that authorize involuntary treatment for substance use disorders, which may be a catalyst for rethinking involuntary interventions in behavioral health. Specifically, the involuntary commitment process may be improved by a targeted approach that is supported by enhanced guidelines delineating criteria, settings, outcomes, and length of time for involuntary treatment.