Involuntary Commitment Part 2
The Right to Choose
Involuntary Commitment is such a complex topic. My opinions and thoughts on the matter have changed a lot in the last 3 years since I have been working in acute psych. I’ve seen so many cases that have challenged my assumptions and have brought to light problems with the system. I don’t have any amazing suggestions or answers for all the complex problems. But I do think that it is important that the community, providers and patients are talking about these issues. I wrote a long post about what involuntary commitment is and how the legal process works, so I won’t be covering any of that here.
I think the biggest thing about a person being Involuntary Committed is the barrier it creates. When a person is Involuntary Committed, they are angry. And I can’t blame them for that. How would I feel? How would you? Imagine being put into a hospital and being told that you have to receive care that you don’t want or that you have to take medications that you believe will harm your body. How scary is that? There is no trust there. Helping people is all about trust. There is little or no way to build a bridge of trust when the relationship starts on the foundation of Involuntary Commitment.
So, they get care. They get better. But it isn’t built on trust and it isn’t built on cooperation. There is no bridge. There is no working towards something that the person can work with on the long term. When they leave the hospital they are still angry. They still don’t trust. How likely is it that they are going to continue to take their medications or to continue their other treatments or to follow up with out patient providers? Without those things in place, chances are that they will decline and return to the same status that led them to the hospital in the first place.
Giant circles. Is that what we want to do to these people? That’s not helping anyone. It’s not healing their minds. It’s not making our communities any safer. So, what is the benefit of taking away their rights? Why invest resources when those getting the resources don’t want them, aren’t benefiting and the community they are in is not benefiting?
Because we are forcing these people to get care, they are in hospital beds that voluntary patients would love to have. These are people that are more likely to gain from the services being provided. If these acute voluntary patients move into inpatient services it would make more outpatient services available. This would have a multi level benefit. This doesn’t mean that there would suddenly be a flood gate opening of available of services. But there is such a shortage that each small trickle is needed.
On the other hand, where would these people go? If they are not being Involuntary Committed, where are they going? The answer is either to jail or the grave. I’m not sure that I’m alright with them being in jail and I’m really not alright with them being in the grave. Most people with mental illness are NOT committing crimes. In fact, the vast majority of crimes are committed by the sane folks. 1 in 7 have mental illness, but it is mostly the other 6 that are the criminals. One more time: most criminals are not mentally ill.
There are times that I think Involuntary Commitment is more clearly right then others. Someone that is homicidal doesn’t have the right to kill another person. Treating them gives them the chance to live a free life, something better then jail and protects the other person. I agreed they need Involuntary Commitment, even if it is only a short term solution. It gives that other person a chance to live.
But there are cases that hit some serious grey. Suicidal thoughts requiring Involuntary Commitment is more difficult for me. What if they are suicidal because they are dying a long, slow and miserable death that has no good treatments and no cure? Yeah, suicide causes emotional harm to others. But so does divorce and choosing to put a child up for adoption. We humans emotionally dig each other deep all the time. It sucks, but it is part of living. We’re suppose to have the right to choose for ourselves. Why not in this? Yet, I am selfish in this too and would guard against this completely with my loved ones. I would want them to live.
Defining risk for self harm is complex and sorting out when they are no longer at risk is even more complex. In my previous post I gave an example of a person laying naked in the snow and reporting that they would stay there until the aliens came to get them. Clearly, they are at risk of death. So, we treat them. They reach a point when they no longer talk about aliens but are other wise still symptomatic. Are they safe now? How does all of that get sorted out? It is so complex. Because keeping them Involuntary isn’t about them being without symptoms, it’s about them reaching a point that they are no longer a danger to themselves.
What do we do? Involuntary Commitment is such a complex thing. Giving up on them seems cruel. But forcing them to accept care seems harsh and in some ways pointless. But there don’t seem to be any good alternatives. How do we fix this system? I’d like to see a culture that doesn’t rely so heavily on medications and that can be more accepting of behaviors that differ from our own. But we are a long ways from both of those.