Hello my Zebras and Spoonies! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about the way that we handle severely ill mental health cases. Specifically, I want to talk about involuntary commitment. I want to start by giving context to my opinion, for those of you that don’t already know. First, I am a psych nurse. I have worked in both long term care psych and acute care psych for about 10 years. But, I am also a mental health patient who has struggled with depression and even suicidal thoughts. I have family that has mental health diagnoses. Lastly, I am also someone who has lost someone very dear to me due to suicide. What this means is that I have seen this issue from various perspectives over the years. And it is those different angles that has informed my opinion on this.
For the most part, I am against involuntary commitment. The only context in which I think that it should be considered is within the realm of a criminal case. If someone with a mental illness has committed a crime, I think it makes sense to consider committing them to a mental health facility rather then sending them to jail for their crime. Outside that context, I am against those with mental illness being committed against their will.
The idea behind involuntary commitment is to prevent harm. If the system is working in the manner that it should, a person is only committed involuntarily when they are presenting an imminent risk of harming themselves or others.
The first problem that I have with this is the ease with which this system can be abused, even by well meaning mental health care providers. We are leaving this life altering decision to the personal judgement of a handful of individuals who have been pressured to air on the side of caution in order to protect their license. When a person is released from a facility and then causes harm, there is a degree of liability for the providers that released them. This creates an environment where the providers are going to be more inclined to maintain hospitalization not because they believe that the patient is a risk, but because they want to protect their license.
The second major problem is that we aren’t very good at predicting imminent risk. We do not have assessment tools that will clearly and easily determine who is likely to commit suicide or murder. This means that there isn’t a simple test that can be performed to determine who should be confined and who is safe to release. Assessing imminent risk is largely a game of guessing. This is not an appropriate manner in which to be basing this magnitude of decision upon.
One of the largest issues I have with involuntary commitment of the mentally ill is that there has been no crime committed. This is the biggest issue for me. If we are looking to maintain equity in our society then we need to be treating all people in a fair manner. Locking people into a hospital and forcing them to accept treatment that they are refusing when they have not committed a crime is not fair treatment. We do not do this with any other group of people. Consider the man that threatens to kill his wife who has left him and is actively seeking divorce. He has expressed homicidal ideation, having thoughts and desires to kill his wife. It is also well known that over 90% of women who are murdered are killed by their intimate partners. It is fair to say that this is imminent risk and yet that man will not be locked away on the basis that he has not yet committed a crime. Why then, are we locking away those who have a mental illness when they actually represent a much smaller portion of violent crimes then those without mental illness?
I value the medical right of body autonomy very highly. I believe that it is important that we maintain the right for each of us to choose what is done to our bodies. This is essential in maintaining the trust within the healthcare setting. Not everyone shares the same believes and values. Thus, not everyone will make the same choices regarding their treatment for their illnesses. That needs to be allowed. When we begin forcing medical treatments onto our patients, we break the trust that is essential in health care. Someone who is forced to receive care they don’t want is highly unlikely to seek medical help in the future. This means, that in the long run, we are making their mental and physical health worse by putting them in a situation of fear towards healthcare. And who are we to decide or to say what is best of a single individual? None of us nurses or doctors are in a position to know what treatments are actually going to result in good outcomes without causing unwanted side effects. Nor are we in a position to evaluate which side effects are acceptable to an individual.
Lastly, it doesn’t work.
We involuntarily commit someone for a time and force them to receive treatment until they reach the point of no longer being a risk to themselves or others. Then what? Then we discharge them into a system that has inadequate support where they are unlikely to receive follow up care even if they were to desire it after the trauma of having care forced upon them. They are discharged back into the social and economic situation that lead to them having severe mental instability. This means that they are returning to the very circumstances that led them to being involuntarily committed in the first place. So, it is pretty likely that they are going to return to that mental instability.
All of this fosters an environment of distrust where patients are trained to know what to say and what to with hold in order to maintain their freedom while receiving the level of care that they do desire. But this is an ineffective relationship that leaves providers trying to treat a person when they don’t fully understand what is going on with that person. This only increases the risk that patients will reach instability.
All of that being said, there are those that will die if they do not receive care and many claim that we have a duty to force treatment upon them in order to save their lives. But do we? A patient has the right to refuse care, even if it will result in them dying, when we are talking about physical illnesses. Why is this not also the case with mental illness? A person can refuse to receive a blood transfusion that they need in order to survive. So why can’t a suicidal person refuse a medication that might prevent their suicide. What’s the difference?
When affording medical autonomy we must respect the decisions that our patients make even when those decisions are not the ones that we would make for ourselves or ones that we can understand. Respecting medical autonomy is also respecting that a patient has the right to refuse life preserving care. This level of medical autonomy is essential for high quality health care and for good ethical practice. So, why does it not exist within the mental health care arena?
Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!