Dr. Marett is Volunteer Assistant Professor, and Dr. Mossman is Professor of Clinical Psychiatry and Director, Division of Forensic Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Patients often view commitment as unjustified.16 They and their advocates object to what some view as the ultimate infringement on civil liberty.7,17 By its nature, involuntary commitment eliminates patients’ involvement in a major treatment decision,8 disempowers them,18 and influences their relationship with the treatment team.15
Some involuntary patients feel disrespected by staff members8 or experience inadvertent psychological harm, including “loss of self-esteem, identity, self-control, and self-efficacy, as well as diminished hope in the possibility of recovery.”15 Involuntary hospitalization also can have serious practical consequences. Commitment can lead to social stigma, loss of gun rights, increased risks of losing child custody, housing problems, and possible disqualification from some professions.19
Having seen many involuntary patients undergo a change of heart after treatment, psychiatrist Alan Stone proposed the “Thank You Theory” of civil commitment: involuntary hospitalization can be justified by showing that the patient is grateful after recovering.20 Studies show, however, that gratitude is far from universal.1
How coercion is experienced often depends on how it is communicated. The less coercion patients perceive, the better they feel about the treatment they received.21 Satisfaction is important because it leads to less compulsory readmission,22 and dissatisfaction makes malpractice lawsuits more likely.23
Commitment decision-making
States’ laws, judges’ attitudes, and court decisions establish each jurisdiction’s legal methods for instituting emergency holds and willingness to tolerate “false-positive” involuntary hospitalization,4,24 all of which create variation between and within states in how civil commitment laws are applied. As a result, clinicians’ decisions are influenced “by a range of social, political, and economic factors,”25 including patients’ sex, race, age, homelessness, employment status, living situation, diagnoses, previous involuntary treatment, and dissatisfaction with mental health treatment.22,26-32 Furthermore, the potential for coercion often blurs the line between an offer of voluntary admission and an involuntary hospitalization.18
Collateral information
Psychiatrists owe each patient a sound clinical assessment before deciding to initiate involuntarily hospitalization. During a psychiatric crisis, a patient might not be forthcoming or could have impaired memory or judgment. Information from friends or family can help fill in gaps in a patient’s self-report.33 As Dr. R’s question illustrates, adequate assessment often includes seeking information from persons familiar with the patient.1 A report on the Virginia Tech shootings by the Virginia Office of the Inspector General describes how collateral sources can provide otherwise missing evidence of dangerousness,34 and it often leads clinicians toward favoring admission.35
Yet clinicians should regard third-party reports with caution.36 As one attorney warns, “Psychiatrists should be cautious of the underlying motives of well-meaning family members and relatives.”37 If you make a decision to hospitalize a patient involuntarily based on collateral information that turns out to be flawed, are you at fault and potentially liable for harm to the patient?
