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.
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.
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.
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
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.
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.
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.
…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.
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....
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.
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.
Why can we not conclude that patients exposed to a physician willing to hospitalise less frequently are better off, rather than the hospitalisation itself being harmful ?
This relates to the exclusion restriction assumption of their analysis, that physician assignment impacts outcomes only through hospitalization. This is what they say about that in the paper:
"Exclusion Restriction. The exclusion restriction requires that physician assignment only impacts outcomes via their decision about whether to hospitalize a patient or not. This is impossible to test empirically. However, several institutional features help give confidence that the exclusion restriction holds in our context. First, the emergency department physician who performs the involuntary hospitalization evaluation is not the physician who provides care on the mental health inpatient floor. Rather, inpatient physicians provide care while the patient is in the hospital. This means that the exact care provided is divorced from the decision of whether to hospitalize or not. This mitigates concerns about omitted treatment bias (Mueller-Smith, 2015).
Second, the emergency department physician does not decide the duration of hospitalization; inpatient physicians decide whether or not to file for an extension of involuntary hospitalization with a magistrate in the CCP and it is that magistrate who decides whether a patient should remain hospitalized for longer than 5 days.
Consistent with the exclusion restriction, we find that conditional upon hospitalization, the physician’s tendency to hospitalize is unrelated to further downstream outcomes (Table 6). Specifically, it is unrelated to whether an individual is prescribed antipsychotic medications, has a hearing with the Court of Common Pleas to extend their hospitalization based on the recommendation of the inpatient team or whether the magistrate extends their hospitalization.
If our exclusion restriction is violated, then the reduced form estimates can still be interpreted as the causal effect of being assigned to a physician more or less inclined to hospitalize. Our reduced form estimates are reported in our tables and tend to be fairly similar to the estimates arrived at via two stage least squares. This makes sense given that we have a very strong first stage. The similarity of the reduced form and two stage least squares estimates provides confidence that we may be capturing the causal effect of hospitalization."
The effect the first psychiatric encounter has on patients is enormous in my experience
Those are interesting findings, but there is no way to seperate convincingly the effect from that encounter and the following hospitalisation; and psychiatrists who are willing to take the risk not to hospitalise people are very, very different than those who do it 100% of the time
I didn't even know such practices existed tbh so I still learned a thing or two from that paper, thank you
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.
When providers initiate involuntary holds, regardless of their intention, they’re effectively communicating to the patient that they cannot handle the human condition.
This very question –Is the juice worth the squeeze? Can I adapt from this experience? Can I exploit these dynamic states of consciousness to carve out a new self? – have always for years been on the minds of those placed on holds and/or labeled with SMI.
The viability of an identity (substantial soul) depends not merely on answering such questions semantically via “beliefs” or cut-scores on a scale, but by living through them. That is, by living through a crisis without internalizing that “You cannot handle the human condition anymore”, a person is upgraded to the status of substance according to Aristotle.
Unlike the fields of counseling psychology and psychoanalysis, psychiatry is ignorant to this claim. Psychiatry knows everything about biochemistry, bureaucracy, and legalese, but few of them implicitly (via first-personal lived experience) know the limits of persons.
I have never found this alleged limit, and I wonder if it’s socially constructed. I wonder if those from a millennia ago knew more about the human condition than modernity. I wonder what it was like to be Plato or Heraclitus, when there was no such thing as mental health holds.
Of the 7 individuals so far I’ve known to take their lives, 5 of them were at one point told by mainstream psychiatry they *shall not* exist without being anesthetized and/or “held”.
Notice, in the latter, they're making a prescriptive claim. Whereas I’m making an epistemic and metaphysical claim about the persistence of identities and souls. A soul cannot know the limits of something unless they live it. And if a soul is prevented from being and adapting by way of a “hold”, then according to Nassim Taleb, it is downgraded from anti-fragile to fragile. It is nerfed.
I don't think we need a construct of a soul here, but I entirely agree that the very experience of being sectioned/being "spared" will likely influence the "edge case"; whether enough to generate such outcome difference hard to tell. But being told they are not too dysfunctional to retain autonomy might be more helpful than we imagine.
In some ways it is painful to have this suspicion validated. It would be easier to forgive the people in my life who are most responsible for my fruitless involuntary hospitalizations, believing they would help me over my maximally strenuous objections, if I hadn't been right about it. It's been many years since these incidents but being repeatedly kidnapped and confined against your will by the people who are supposed to be taking care of you (family, doctors) changes how you think about the whole world. These traumatizing experiences also made me extremely reluctant to return to the hospital when I did wind up needing it. Little could (and still does!) make me panic like the threat of putting me back in the hospital. I've never been able to set that injury and regain that tacit sense of trust and safety in the world around me, and I doubt I ever will.
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.
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.
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.
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.
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
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.
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.
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.
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.
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....
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.
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.
Why can we not conclude that patients exposed to a physician willing to hospitalise less frequently are better off, rather than the hospitalisation itself being harmful ?
This relates to the exclusion restriction assumption of their analysis, that physician assignment impacts outcomes only through hospitalization. This is what they say about that in the paper:
"Exclusion Restriction. The exclusion restriction requires that physician assignment only impacts outcomes via their decision about whether to hospitalize a patient or not. This is impossible to test empirically. However, several institutional features help give confidence that the exclusion restriction holds in our context. First, the emergency department physician who performs the involuntary hospitalization evaluation is not the physician who provides care on the mental health inpatient floor. Rather, inpatient physicians provide care while the patient is in the hospital. This means that the exact care provided is divorced from the decision of whether to hospitalize or not. This mitigates concerns about omitted treatment bias (Mueller-Smith, 2015).
Second, the emergency department physician does not decide the duration of hospitalization; inpatient physicians decide whether or not to file for an extension of involuntary hospitalization with a magistrate in the CCP and it is that magistrate who decides whether a patient should remain hospitalized for longer than 5 days.
Consistent with the exclusion restriction, we find that conditional upon hospitalization, the physician’s tendency to hospitalize is unrelated to further downstream outcomes (Table 6). Specifically, it is unrelated to whether an individual is prescribed antipsychotic medications, has a hearing with the Court of Common Pleas to extend their hospitalization based on the recommendation of the inpatient team or whether the magistrate extends their hospitalization.
If our exclusion restriction is violated, then the reduced form estimates can still be interpreted as the causal effect of being assigned to a physician more or less inclined to hospitalize. Our reduced form estimates are reported in our tables and tend to be fairly similar to the estimates arrived at via two stage least squares. This makes sense given that we have a very strong first stage. The similarity of the reduced form and two stage least squares estimates provides confidence that we may be capturing the causal effect of hospitalization."
Thank you
The effect the first psychiatric encounter has on patients is enormous in my experience
Those are interesting findings, but there is no way to seperate convincingly the effect from that encounter and the following hospitalisation; and psychiatrists who are willing to take the risk not to hospitalise people are very, very different than those who do it 100% of the time
I didn't even know such practices existed tbh so I still learned a thing or two from that paper, thank you
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.
When providers initiate involuntary holds, regardless of their intention, they’re effectively communicating to the patient that they cannot handle the human condition.
This very question –Is the juice worth the squeeze? Can I adapt from this experience? Can I exploit these dynamic states of consciousness to carve out a new self? – have always for years been on the minds of those placed on holds and/or labeled with SMI.
The viability of an identity (substantial soul) depends not merely on answering such questions semantically via “beliefs” or cut-scores on a scale, but by living through them. That is, by living through a crisis without internalizing that “You cannot handle the human condition anymore”, a person is upgraded to the status of substance according to Aristotle.
Unlike the fields of counseling psychology and psychoanalysis, psychiatry is ignorant to this claim. Psychiatry knows everything about biochemistry, bureaucracy, and legalese, but few of them implicitly (via first-personal lived experience) know the limits of persons.
I have never found this alleged limit, and I wonder if it’s socially constructed. I wonder if those from a millennia ago knew more about the human condition than modernity. I wonder what it was like to be Plato or Heraclitus, when there was no such thing as mental health holds.
Of the 7 individuals so far I’ve known to take their lives, 5 of them were at one point told by mainstream psychiatry they *shall not* exist without being anesthetized and/or “held”.
Notice, in the latter, they're making a prescriptive claim. Whereas I’m making an epistemic and metaphysical claim about the persistence of identities and souls. A soul cannot know the limits of something unless they live it. And if a soul is prevented from being and adapting by way of a “hold”, then according to Nassim Taleb, it is downgraded from anti-fragile to fragile. It is nerfed.
I don't think we need a construct of a soul here, but I entirely agree that the very experience of being sectioned/being "spared" will likely influence the "edge case"; whether enough to generate such outcome difference hard to tell. But being told they are not too dysfunctional to retain autonomy might be more helpful than we imagine.
In some ways it is painful to have this suspicion validated. It would be easier to forgive the people in my life who are most responsible for my fruitless involuntary hospitalizations, believing they would help me over my maximally strenuous objections, if I hadn't been right about it. It's been many years since these incidents but being repeatedly kidnapped and confined against your will by the people who are supposed to be taking care of you (family, doctors) changes how you think about the whole world. These traumatizing experiences also made me extremely reluctant to return to the hospital when I did wind up needing it. Little could (and still does!) make me panic like the threat of putting me back in the hospital. I've never been able to set that injury and regain that tacit sense of trust and safety in the world around me, and I doubt I ever will.
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.