Thanks for sharing this study. I've worked extensively as both a crisis evaluator and on inpatient psychiatric units and you're assessment is spot on. Involuntary inpatient psychiatric hospitalization is so disruptive to people's lives, and, particularly in smaller communities, very stigmatizing. Not only is the person getting the message that they are "dangerous" but now they have also come to the attention of law enforcement.
I have watched people who have never had any contact with the legal system be handcuffed in order to be placed in the police car for transport to the psychiatric placement. When I would ask the police officer, "are the handcuffs really necessary," they would cite policy and safety.
Many people refuse voluntary psychiatric admission to inpatient units for precisely the reasons you mention. They have jobs, children, pets, other responsibilities that prohibit them from being away for days at a time. When those crisis moments hit, although they are suffering, they are very cognizant of these responsibilities. Wouldn't it be wonderful if we had a system that was designed to give a person a "time out?" Where they could stay for a few hours/days, receive psychiatric care, move through the initial hours of the crisis with support and in a safe place, and then return to their responsibilities.
For many people, suicidal ideation is a fleeting event. Something has occurred that has so overwhelmed their ability to cope, that taking their own life feels like a viable option. For many people, these moments pass, and with support, they stabilize and move forward with their lives. We need to set up less intrusive systems, that invite people to use them voluntarily, so that we don't have to resort to involuntary hospitalization in our effort to "keep someone safe," and do more harm than good.
I keep wondering to what extent the experience of NOT being committed could boost people's sense of agency and internal commitment to "pushing through" the crisis, even socially validate their belief they are not such a completely hopeless case? Obviously not applicable in acute psychosis but eg suicide attempts or similar crises.
Suicide is not a psychological problem but a social symptom and locking people up over it is a direct affront to their autonomy. It's literally making them existential slaves.
upends “our” understanding… this, I guess, being an exclusive “our”. this does not upend my understanding! I’m glad the authors were able to develop an empirical method to demonstrate what any involuntarily committed person already knows. I hope more studies like this can be done so that the scientific consensus can be shifted, and then, hopefully, normative clinical practice can be shifted as well.
I've unfortunately been in the unique position of a psychiatrist who involuntarily hospitalizes people and was involuntarily hospitalized myself for a suicide attempt. The experience opened my eyes to how dehumanising it can be, and how easy my experience could have been changed if anyone had a kind word to say to me. The fellow patients were much nicer to me than the psychiatrist and the psychologist whom I perceived to be judgemental and critical. I think there is a role for a true "place of safety" where people in a crisis can heal, but the way we do it is seriously wrong.
It is so telling that you need to use a pseudonym to write about your experiences, I can imagine the fear you live in of being exposed or shunned by your colleagues.
As always thank you SO MUCH doctor for speaking about this. I was hospitalized for "suicidal thoughts" as a teen and it felt like I had to tell them what they wanted to hear (which was ALWAYS the opposite of what I actually felt) upon being discharged I avoided mental health "help" because to me it WASN'T healing it was TRAUMATIZING but so many people get in the mindset of "OH THEY MUST HAVE BEEN DOING THEIR BEST" or "YOU DIDN"T DIE DID YOU?" just because I didn't go on to successfully kill myself doesn't mean that they "helped" me. I have been told that the goal of hospitalization isn't to make you better, but to "stabilize" you.... I call bullshit. I am just a good actress so I played the role until my insurance ran out and I was discharged...... That experience has fundamentally changed the way that I interact with healthcare as an adult some 20-something years later.... I won't ever forgive nor will I forget....
Prior to this study, every time a patient who had been considered for, but not voluntarily admitted got into trouble, the evaluator who did not involuntarily admit them might think "Oh, I should lower my bar for admission. If only I'd admitted this one..." and when one who had been involuntarily admitted had a bad outcome, it would be "in spite of" the admission. "We did everything we could."
As a primary care doc, I've desperately wished that patients would get admitted, usually because I was sure something medical was going on that I just couldn't diagnose for whatever reason, and seldom have had my wish granted.
Such a good point, thank you. I hadn’t even considered how there could be a natural ratcheting up of willingness to commit over time, and how this paper might counteract that
Encouraging to see this empirical data confirming what patients already know. I’m curious: do physicians know what their admit rate is relative to other physicians? And do physicians even know when other physicians would judge a case differently? The 100% admit rates for those 46 physicians make me wonder how much self-awareness and clinical experience they have.
I would be curious about that as well. I trained in a program with a heavy psych-ER component, where each of us might have to make 20+ admit/discharge decisions in a single day. We knew there were certain attending supervisors who would not allow anyone to be discharged without an ironclad plan, whereas other attendings would basically "open the door" and anyone who could walk and talk would be given a bus ticket and well wishes.
Thanks for sharing this data, it is so critical. Involuntary hospitalization is also a re-enactment of the psychological injuries that caused the person to be in extreme emotional distress in the first place. When what is supposed to be a place of safety and healing, becomes a place of assault and incarceration, no wonder people lose hope and suicide shortly afterward. I have clients who were so traumatized by the psych ward of the local hospital, that they have instructed their loved ones to take them to another city if they need medical care.
Absolutely. Ask almost any person held on a ward involuntarily and they will describe it as an incarceration, a kidnapping. It engenders distrust in the very people best placed to help.
When they speak of "safety" it always seems to be for the perceived "safety" of literally everyone but the actual patient themselves. They are treated like another "problem" instead of a person. They're clearly already in a state of crisis - treating them as just another day at work is dehumanizing, devastating, humiliating. They need kindness, and to be recognized as the individual they are. Truly one kind word or even just a simple smile can be the act that saves someone.
Yes! As I said elsewhere - "help" doesn't cause pain or fear. Help is helpful. If you say you're providing "safety" for an individual but their experience is one of visceral danger, distress, and fear - you are not making them safer. You are not helping, you are not providing care. And from my experience, I can say that every traumatic experience I have with psychiatry makes me less and less likely to engage with psychiatric services in the future.
Is it also possible that the stress of non-agency in itself is a catalyst for negative outcomes?
Recent research into vengeance suggests an extreme neurological response to mistreatment (being cheated, harmed), and certainly detention is experienced as harm. Perhaps it is not simply that someone misses a rent check or doesn’t show up for their job, but instead that they have been traumatized by being incarcerated.
Whoops … I wanted to say that I worked for a long stretch on a reservation that did not have authorizing legislation for holds. The practical result of that reality was that we worked harder and longer to connect with family and the patient’s social network, explored more alternative supports, and spent more time directly with patients. I’ve since worked in communities where holds occur in part to speed up dispositions and reduce liability not just for the determining clinicians but also police and ems services. Even ‘voluntary’ patients in these settings get held because 1) it is more efficient for overworked systems, 2) it essentially cedes agency and decision making to the system (much simpler than working with ‘messy’ patient agency) and 3) in psychiatric settings rare is the suit for doing something over not doing. The not doing creates so much inefficiency (time with patient, exhaustive documentation, dealing with anxious/angry/demanding family members) that committing someone becomes the default position. It has always been my position that we do involuntary holds more for ourselves and some part of the community than in the best interests of the patient.
…alternate forms of monitoring (eg. a relative keeping tabs on a family member from a tolerated distance), more time with patients, less aggressive law enforcement involvement, more of a focus on the family unit with somewhat more loosely held notions re confidentiality…and I suspect setting plays a role - large open rural environments mean the possibility of less direct conflict with others
Super interesting perspective and one I’ve often wondered about. Psychiatric care in a social context where families/deep community are the authority looks very different from what most Americans can expect.
I want to say first, I think this is a very neat analysis that does give us lots to think about; I think its conclusions are almost certainly correct: those that could be managed in the community should be, as they will have better outcomes.
However, I thought when reading that the idea that this ‘upends’ many people’s view is slightly exaggerated.
I wonder if this is from living in the UK, where a principle of the Mental Health Act (which deals with involuntary detention) is using “the least restrictive option”. This seems to be addressing the exact situation you highlight: “where a person undergoing an evaluation for involuntary psychiatric admission can reasonably be discharged rather than involuntarily admitted, [ ] it is better to discharge the person than commit them.”
Involuntary detention in the UK requires two doctors (one of whom must have training in psychiatry) and something called an Approved Mental Health Professional (normally as social worker) to agree to an admission. The doctors must be independent of each other so can’t work in the same service or department; historically this meant dragging a local general practitioner out of bed. I would hope this somewhat reduces the wild variation dependent on individual doctors seen in the data presented here. (It is good for the soul of British Psychiatry and its psychiatrists, whatever the many other sins, that psychiatrists have to spend so much time trying to reach consensus in huddled meetings in corridors or cupboards having just completed an assessment.)
This by the way is not to say that there are not unnecessary hospitalisations in the UK, (there are) that some people are not harmed by admission, (they certainly are) or that the Mental Health Act doesn’t have issues (oh the issues it has). What I do think though is this would mostly be greeted with a “well that’s good to know” rather than ‘upending’ anyones understanding.
( I also have a half formed thought that doctors who complete an assessment and manage to come, by the end, to a point where more of their patients feel supported, safe, and able to engage in the community, therefore do not 'need' an admission to manage risks, are just better doctors and these assessments should be thought of more as interventions with higher rates of involuntary commitment indicating the intervention is just being done very poorly with poor outcomes following but I am not quite sure the statistics allows for that interpretation)
This is a hard pill for me to swallow, but I am happy I am reading it. I used to work in the psychiatric portion of an ED and do the evals and place holds/admit patients. From what I've seen, the patients who may more often need psychiatric involuntary hospitalization than the law allows are those with psychosis. I find that those with suicidal ideation as the primary concern are often over-hospitalized, but those with psychosis but that aren't imminently a danger to themselves or others are under-hospitalized. While all humans are often irrational, the trait of anosognosia and the disorganized thought process that characterizes psychosis makes involuntary hospitalization often feel like the compassionate decision. Did they do any work trying to identify differences like these in patient presentations?
I have similar thoughts. I feel severe psychosis and mania where a person has lost insight or is very impaired are situations where involuntary admission is most warranted, and these are likely situations where there is less disagreement among clinicians too, so they may be less well-represented in the judgment-call cases discussed here. Researchers did try to look at differences that may be associated with reasons for admission (suicidality/violence/grave disability) but nothing stood out. Judgment-call cases were less likely to have a prior hx of serious mental illness but they also defined SMI very broadly, and included things like depression and borderline personality.
I am really glad you included this comment; it was difficult reading the post without screaming about psychosis+anosognosia+GD. Yes, psychiatric inpatient is traumatic, but I have to imagine outcomes are better for this specific population.
Do you want other peoples imagination to be grounds for depriving you of your liberty? I guess not. So maybe don't stick to your imagination when talking about the liberty of others, and stick to the science.
It is good to hear I am not alone. While I am veering away from my knowledge or experience, I wonder if things like capacity assessments have ever been considered as part of the hold or commitment process instead of just measures of harm. That might be a way to hold those with florid psychosis but questionable dangerousness while holding less patients with suicidal thoughts. It also makes me wonder how the world of dementia and memory care works. I have never worked with that population outside of consult/liaison work. My assumption is that they often have legal guardians and aren't civilly committed under mental health laws, but are capacity assessments a part of that? I do think when guardianship is one of the better (although imperfect) ways of going about involuntary mental healthcare.
Manic psychosis and ostensible suicidal ideation are the two reasons I've been hospitalized and I wholly agree with this. I was very much (eventually, on the third try) helped by a hospitalization for mania. The others inflicted lasting psychological harm that still impacts my ability to have a functional relationship with the medical system, with no benefit save meeting other patients who would be kind to me.
I'm glad to see this study and really appreciate the commentary here. As you note near the end, "alternatives [to hospitalization] remain woefully underfunded and underdeveloped." I'd love to see a future post on what research we do have--and what remains to be done--on the full spectrum of existing and potential alternatives in the United States.
Having been sectioned twice (both times to a hospital that is supposed to be pretty good, relatively speaking) I can’t say that these results are surprising. I was probably never worse than I was for the few weeks after release.
I’m glad the authors of this study understood how important it was to do it well. Changing impressions and practices is difficult to do, and mediocre science is easy to dismiss.
Thanks for sharing this study. I've worked extensively as both a crisis evaluator and on inpatient psychiatric units and you're assessment is spot on. Involuntary inpatient psychiatric hospitalization is so disruptive to people's lives, and, particularly in smaller communities, very stigmatizing. Not only is the person getting the message that they are "dangerous" but now they have also come to the attention of law enforcement.
I have watched people who have never had any contact with the legal system be handcuffed in order to be placed in the police car for transport to the psychiatric placement. When I would ask the police officer, "are the handcuffs really necessary," they would cite policy and safety.
Many people refuse voluntary psychiatric admission to inpatient units for precisely the reasons you mention. They have jobs, children, pets, other responsibilities that prohibit them from being away for days at a time. When those crisis moments hit, although they are suffering, they are very cognizant of these responsibilities. Wouldn't it be wonderful if we had a system that was designed to give a person a "time out?" Where they could stay for a few hours/days, receive psychiatric care, move through the initial hours of the crisis with support and in a safe place, and then return to their responsibilities.
For many people, suicidal ideation is a fleeting event. Something has occurred that has so overwhelmed their ability to cope, that taking their own life feels like a viable option. For many people, these moments pass, and with support, they stabilize and move forward with their lives. We need to set up less intrusive systems, that invite people to use them voluntarily, so that we don't have to resort to involuntary hospitalization in our effort to "keep someone safe," and do more harm than good.
I keep wondering to what extent the experience of NOT being committed could boost people's sense of agency and internal commitment to "pushing through" the crisis, even socially validate their belief they are not such a completely hopeless case? Obviously not applicable in acute psychosis but eg suicide attempts or similar crises.
Suicide is not a psychological problem but a social symptom and locking people up over it is a direct affront to their autonomy. It's literally making them existential slaves.
upends “our” understanding… this, I guess, being an exclusive “our”. this does not upend my understanding! I’m glad the authors were able to develop an empirical method to demonstrate what any involuntarily committed person already knows. I hope more studies like this can be done so that the scientific consensus can be shifted, and then, hopefully, normative clinical practice can be shifted as well.
Yes, that's a fair point
I've unfortunately been in the unique position of a psychiatrist who involuntarily hospitalizes people and was involuntarily hospitalized myself for a suicide attempt. The experience opened my eyes to how dehumanising it can be, and how easy my experience could have been changed if anyone had a kind word to say to me. The fellow patients were much nicer to me than the psychiatrist and the psychologist whom I perceived to be judgemental and critical. I think there is a role for a true "place of safety" where people in a crisis can heal, but the way we do it is seriously wrong.
It is so telling that you need to use a pseudonym to write about your experiences, I can imagine the fear you live in of being exposed or shunned by your colleagues.
As always thank you SO MUCH doctor for speaking about this. I was hospitalized for "suicidal thoughts" as a teen and it felt like I had to tell them what they wanted to hear (which was ALWAYS the opposite of what I actually felt) upon being discharged I avoided mental health "help" because to me it WASN'T healing it was TRAUMATIZING but so many people get in the mindset of "OH THEY MUST HAVE BEEN DOING THEIR BEST" or "YOU DIDN"T DIE DID YOU?" just because I didn't go on to successfully kill myself doesn't mean that they "helped" me. I have been told that the goal of hospitalization isn't to make you better, but to "stabilize" you.... I call bullshit. I am just a good actress so I played the role until my insurance ran out and I was discharged...... That experience has fundamentally changed the way that I interact with healthcare as an adult some 20-something years later.... I won't ever forgive nor will I forget....
Prior to this study, every time a patient who had been considered for, but not voluntarily admitted got into trouble, the evaluator who did not involuntarily admit them might think "Oh, I should lower my bar for admission. If only I'd admitted this one..." and when one who had been involuntarily admitted had a bad outcome, it would be "in spite of" the admission. "We did everything we could."
As a primary care doc, I've desperately wished that patients would get admitted, usually because I was sure something medical was going on that I just couldn't diagnose for whatever reason, and seldom have had my wish granted.
Such a good point, thank you. I hadn’t even considered how there could be a natural ratcheting up of willingness to commit over time, and how this paper might counteract that
Encouraging to see this empirical data confirming what patients already know. I’m curious: do physicians know what their admit rate is relative to other physicians? And do physicians even know when other physicians would judge a case differently? The 100% admit rates for those 46 physicians make me wonder how much self-awareness and clinical experience they have.
I would be curious about that as well. I trained in a program with a heavy psych-ER component, where each of us might have to make 20+ admit/discharge decisions in a single day. We knew there were certain attending supervisors who would not allow anyone to be discharged without an ironclad plan, whereas other attendings would basically "open the door" and anyone who could walk and talk would be given a bus ticket and well wishes.
Thanks for sharing this data, it is so critical. Involuntary hospitalization is also a re-enactment of the psychological injuries that caused the person to be in extreme emotional distress in the first place. When what is supposed to be a place of safety and healing, becomes a place of assault and incarceration, no wonder people lose hope and suicide shortly afterward. I have clients who were so traumatized by the psych ward of the local hospital, that they have instructed their loved ones to take them to another city if they need medical care.
Absolutely. Ask almost any person held on a ward involuntarily and they will describe it as an incarceration, a kidnapping. It engenders distrust in the very people best placed to help.
Yeah, involuntary hospitalizations are traumatizing experiences of violence.
They increase risk of suicide just like any other such experience (war, violent crimes, etc.).
It's not rocket surgery.
When they speak of "safety" it always seems to be for the perceived "safety" of literally everyone but the actual patient themselves. They are treated like another "problem" instead of a person. They're clearly already in a state of crisis - treating them as just another day at work is dehumanizing, devastating, humiliating. They need kindness, and to be recognized as the individual they are. Truly one kind word or even just a simple smile can be the act that saves someone.
Yes! As I said elsewhere - "help" doesn't cause pain or fear. Help is helpful. If you say you're providing "safety" for an individual but their experience is one of visceral danger, distress, and fear - you are not making them safer. You are not helping, you are not providing care. And from my experience, I can say that every traumatic experience I have with psychiatry makes me less and less likely to engage with psychiatric services in the future.
What a fantastic article!
Is it also possible that the stress of non-agency in itself is a catalyst for negative outcomes?
Recent research into vengeance suggests an extreme neurological response to mistreatment (being cheated, harmed), and certainly detention is experienced as harm. Perhaps it is not simply that someone misses a rent check or doesn’t show up for their job, but instead that they have been traumatized by being incarcerated.
Whoops … I wanted to say that I worked for a long stretch on a reservation that did not have authorizing legislation for holds. The practical result of that reality was that we worked harder and longer to connect with family and the patient’s social network, explored more alternative supports, and spent more time directly with patients. I’ve since worked in communities where holds occur in part to speed up dispositions and reduce liability not just for the determining clinicians but also police and ems services. Even ‘voluntary’ patients in these settings get held because 1) it is more efficient for overworked systems, 2) it essentially cedes agency and decision making to the system (much simpler than working with ‘messy’ patient agency) and 3) in psychiatric settings rare is the suit for doing something over not doing. The not doing creates so much inefficiency (time with patient, exhaustive documentation, dealing with anxious/angry/demanding family members) that committing someone becomes the default position. It has always been my position that we do involuntary holds more for ourselves and some part of the community than in the best interests of the patient.
I worked for a long stretch on a Native American reservation that, due to the absence of tribal law supporting involuntary holds
I’m curious, what was the custom there for managing disabling and disruptive states of psychosis and mania?
Space, a broader tolerance for what other communities would consider aberrant behavior,
…alternate forms of monitoring (eg. a relative keeping tabs on a family member from a tolerated distance), more time with patients, less aggressive law enforcement involvement, more of a focus on the family unit with somewhat more loosely held notions re confidentiality…and I suspect setting plays a role - large open rural environments mean the possibility of less direct conflict with others
Super interesting perspective and one I’ve often wondered about. Psychiatric care in a social context where families/deep community are the authority looks very different from what most Americans can expect.
I want to say first, I think this is a very neat analysis that does give us lots to think about; I think its conclusions are almost certainly correct: those that could be managed in the community should be, as they will have better outcomes.
However, I thought when reading that the idea that this ‘upends’ many people’s view is slightly exaggerated.
I wonder if this is from living in the UK, where a principle of the Mental Health Act (which deals with involuntary detention) is using “the least restrictive option”. This seems to be addressing the exact situation you highlight: “where a person undergoing an evaluation for involuntary psychiatric admission can reasonably be discharged rather than involuntarily admitted, [ ] it is better to discharge the person than commit them.”
Involuntary detention in the UK requires two doctors (one of whom must have training in psychiatry) and something called an Approved Mental Health Professional (normally as social worker) to agree to an admission. The doctors must be independent of each other so can’t work in the same service or department; historically this meant dragging a local general practitioner out of bed. I would hope this somewhat reduces the wild variation dependent on individual doctors seen in the data presented here. (It is good for the soul of British Psychiatry and its psychiatrists, whatever the many other sins, that psychiatrists have to spend so much time trying to reach consensus in huddled meetings in corridors or cupboards having just completed an assessment.)
This by the way is not to say that there are not unnecessary hospitalisations in the UK, (there are) that some people are not harmed by admission, (they certainly are) or that the Mental Health Act doesn’t have issues (oh the issues it has). What I do think though is this would mostly be greeted with a “well that’s good to know” rather than ‘upending’ anyones understanding.
( I also have a half formed thought that doctors who complete an assessment and manage to come, by the end, to a point where more of their patients feel supported, safe, and able to engage in the community, therefore do not 'need' an admission to manage risks, are just better doctors and these assessments should be thought of more as interventions with higher rates of involuntary commitment indicating the intervention is just being done very poorly with poor outcomes following but I am not quite sure the statistics allows for that interpretation)
The UK process does seem to have better safeguards than what happens in the US!
And yes, I'll admit, "upend" was an exaggeration on my part :)
I was going to make the same point about the UK, only less well
This is a hard pill for me to swallow, but I am happy I am reading it. I used to work in the psychiatric portion of an ED and do the evals and place holds/admit patients. From what I've seen, the patients who may more often need psychiatric involuntary hospitalization than the law allows are those with psychosis. I find that those with suicidal ideation as the primary concern are often over-hospitalized, but those with psychosis but that aren't imminently a danger to themselves or others are under-hospitalized. While all humans are often irrational, the trait of anosognosia and the disorganized thought process that characterizes psychosis makes involuntary hospitalization often feel like the compassionate decision. Did they do any work trying to identify differences like these in patient presentations?
I have similar thoughts. I feel severe psychosis and mania where a person has lost insight or is very impaired are situations where involuntary admission is most warranted, and these are likely situations where there is less disagreement among clinicians too, so they may be less well-represented in the judgment-call cases discussed here. Researchers did try to look at differences that may be associated with reasons for admission (suicidality/violence/grave disability) but nothing stood out. Judgment-call cases were less likely to have a prior hx of serious mental illness but they also defined SMI very broadly, and included things like depression and borderline personality.
I am really glad you included this comment; it was difficult reading the post without screaming about psychosis+anosognosia+GD. Yes, psychiatric inpatient is traumatic, but I have to imagine outcomes are better for this specific population.
Do you want other peoples imagination to be grounds for depriving you of your liberty? I guess not. So maybe don't stick to your imagination when talking about the liberty of others, and stick to the science.
It is good to hear I am not alone. While I am veering away from my knowledge or experience, I wonder if things like capacity assessments have ever been considered as part of the hold or commitment process instead of just measures of harm. That might be a way to hold those with florid psychosis but questionable dangerousness while holding less patients with suicidal thoughts. It also makes me wonder how the world of dementia and memory care works. I have never worked with that population outside of consult/liaison work. My assumption is that they often have legal guardians and aren't civilly committed under mental health laws, but are capacity assessments a part of that? I do think when guardianship is one of the better (although imperfect) ways of going about involuntary mental healthcare.
Manic psychosis and ostensible suicidal ideation are the two reasons I've been hospitalized and I wholly agree with this. I was very much (eventually, on the third try) helped by a hospitalization for mania. The others inflicted lasting psychological harm that still impacts my ability to have a functional relationship with the medical system, with no benefit save meeting other patients who would be kind to me.
Ha. My apologies. This post does what all good posts should do. It challenges my preconceptions.
I'm glad to see this study and really appreciate the commentary here. As you note near the end, "alternatives [to hospitalization] remain woefully underfunded and underdeveloped." I'd love to see a future post on what research we do have--and what remains to be done--on the full spectrum of existing and potential alternatives in the United States.
Having been sectioned twice (both times to a hospital that is supposed to be pretty good, relatively speaking) I can’t say that these results are surprising. I was probably never worse than I was for the few weeks after release.
I’m glad the authors of this study understood how important it was to do it well. Changing impressions and practices is difficult to do, and mediocre science is easy to dismiss.