Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without the consent of the person being treated. Involuntary treatment is permitted by law in some countries when overseen by the judiciary through court orders; other countries defer directly to the medical opinions of doctors.
Involuntary psychiatric treatment of individuals who have been diagnosed with a mental disorder and are deemed by some form of clinical practitioner, or in some cases law enforcement or others, to be a danger to themselves or to others is permitted in some jurisdictions, while other jurisdictions have more recently allowed for forced treatment for persons deemed to be "gravely disabled" or asserted to be at risk of psychological deterioration. Such treatment normally happens in a psychiatric hospital after some form of involuntary commitment, though individuals may be compelled to undergo treatment outside of hospitals via outpatient commitment.
A 2014 Cochrane systematic review of the literature found that compulsory outpatient treatment "results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care."
A 2006 review found that as many as 48% of respondents did not agree with their treatment, though a majority of people retrospectively agreed that involuntary medication had been in their best interest.
A review in 2011 looked at people's experience of coercion. It found common themes of feelings violated, disrespected, and not being heard, commonly conceptualized as being dehumanized through isolation. A minority of narratives from people who had been treated involuntarily talked about the necessity of treatment in retrospect.[a]
A systematic review and meta synthesis from 2020, that combined the experiences of stakeholders (service-users, informal carers such as family members, and mental health professionals), identified experiences of power imbalances among the stakeholders. The review found that these power imbalances hindered the respect for the service users' rights, will, and preferences.
Coercion of people in voluntary treatment
Individuals may be forced to undergo treatment voluntarily under the threat of involuntary treatment. Many individuals who legally would be viewed as receiving treatment voluntarily believe that they have no choice in the matter.[b]
Once voluntarily within a hospital setting rules, process and information-asymmetry, can be used to achieve compliance from a person in voluntary treatment. To prevent someone from leaving voluntarily, staff may use stalling tactics made possible by the fact that all doors are locked. For example, the person may be referred to a member of staff who is rarely on the ward, or made to wait until after lunch or a meeting, behaving as if a person in voluntary treatment does not have the right to leave without permission. When the person is able to talk about leaving, the staff may use vague language to imply that the person is required to stay, relying on the fact that people in voluntary treatment do not understand their legal status.[c]
Szmukler and Appelbaum constructed a hierarchy of types of coercion in mental health care, ranging from persuasion to interpersonal leverage, inducements, threats and compulsory treatment. Here persuasion refers to argument through reason. Interpersonal leverage may arise from the desire to please health workers with whom a relationship has formed. Threats may revolve around a health worker helping or hindering the receipt of government benefits.
The examples and perspective in this section deal primarily with the United States and do not represent a worldwide view of the subject. (July 2020) (Learn how and when to remove this template message)
All states in the U.S. allow for some form of involuntary treatment for mental illness or erratic behavior for short periods of time under emergency conditions, although criteria vary. Further involuntary treatment outside clear and pressing emergencies where there is asserted to be a threat to public safety usually requires a court order, and all states currently have some process in place to allow this. Since the late 1990s, a growing number of states have adopted Assisted Outpatient Commitment (AOC) laws.
Under assisted outpatient commitment, people committed involuntarily can live outside the psychiatric hospital, sometimes under strict conditions including reporting to mandatory psychiatric appointments, taking psychiatric drugs in the presence of a nursing team, and testing medication blood levels. Forty-five states presently allow for outpatient commitment.
In 1975, the U.S. Supreme Court ruled in O'Connor v. Donaldson that involuntary hospitalization and/or treatment violates an individual's civil rights. The individual must be exhibiting behavior that is a danger to themselves or others and a court order must be received for more than a short (e.g. 72-hour) detention. The treatment must take place in the least restrictive setting possible. This ruling has since been watered down through jurisprudence in some respects and strengthened in other respects. Long term "warehousing", through de-institutionalization, declined in the following years, though the number of people receiving involuntary treatment has increased more recently.[when?] The statutes vary somewhat from state to state.
In 1979, the United States Court of Appeals for the First Circuit established in Rogers v. Okin that a competent person committed to a psychiatric hospital has the right to refuse treatment in non-emergency situations. The case of Rennie v. Klein established that an involuntarily committed individual has a constitutional right to refuse psychotropic medication without a court order. Rogers v. Okin established the person's right to make treatment decisions so long as they are still presumed competent.
Additional U.S. Supreme Court decisions have added more restraints, and some expansions or effective sanctioning, to involuntary commitment and treatment. Foucha v. Louisiana established the unconstitutionality of the continued commitment of an insanity acquittee who was not suffering from a mental illness. In Jackson v. Indiana the court ruled that a person adjudicated incompetent could not be indefinitely committed. In Perry v. Louisiana the court struck down the forcible medication of a prisoner for the purposes of rendering him competent to be executed. In Riggins v. Nevada the court ruled that a defendant had the right to refuse psychiatric medication while he was on trial, given to mitigate his psychiatric symptoms. Sell v. United States imposed stringent limits on the right of a lower court to order the forcible administration of antipsychotic medication to a criminal defendant who had been determined to be incompetent to stand trial for the sole purpose of making them competent and able to be tried. In Washington v. Harper the Supreme Court upheld the involuntary medication of correctional facility inmates only under certain conditions as determined by established policy and procedures.
However, the involuntary treatment of minors remains legally permitted in most states, usually with the consent of a parent or guardian. The use or purported overuse of psychotropic drugs on minors has exploded in recent years, and this fact has received some increased attention from the public, legal experts, people who have received treatment, as well as medical researchers concerned over long-term effects on development.
Proponents and detractors
Supporters of involuntary treatment include organizations such as the National Alliance on Mental Illness (NAMI), the American Psychiatric Association, and the Treatment Advocacy Center.
A number of civil and human rights activists, Anti-psychiatry groups, medical and academic organizations, researchers, and members of the psychiatric survivors movement vigorously oppose involuntary treatment on human rights grounds or on grounds of effectiveness and medical appropriateness, particularly with respect to involuntary administration of mind altering substances, ECT, and psycho-surgery. Some criticism has been made regarding cost, as well as of conflicts of interest with the pharmaceutical industry. Critics, such as the New York Civil Liberties Union, have denounced the strong racial and socioeconomic biases in forced treatment orders.
- Coerced abstinence
- Obligatory Dangerousness Criterion
- Political abuse of psychiatry (also known as "political psychiatry" and as "punitive psychiatry")
- Social control
- Specific jurisdictions' provisions for a temporary detention order for the purpose of mental-health evaluation and possible further voluntary or involuntary commitment:
- United States of America:
- Giorgio Antonucci (elimination)
- Thomas Szasz (elimination)
- Robert Whitaker (reduction)
- E. Fuller Torrey (expansion)
- DJ Jaffe (expansion)
- Mental Health America (reduction/modification)
- Mad in America (reduction/elimination)
- PsychRights (reduction/elimination)
- Anti-psychiatry, also known as the "anti-psychiatric movement" (reduction/elimination)
- Citizens Commission on Human Rights (reduction/elimination; founded as a joint effort of the anti-psychiatric Church of Scientology and libertarian mental-health-rights advocate Thomas Szasz)
- MindFreedom International (reduction/elimination)
- Treatment Advocacy Center (expansion)
- Mental Illness Policy (expansion)
- NAMI (expansion)
- See table 1 of: "The aspects of care leading to the experience of coercion were broad, but all involved the forcing of “treatment” onto patients against their will. The themes from these articles highlight feelings of violation, disrespect, and not being heard by their clinicians. The most common conceptualization was that of being dehumanized through a loss of normal human interaction and isolation. Using a wide range of thematic analyses, we found that these themes emerged in each article for a range of treatment interventions; this finding was robust. Positive themes were mentioned in three of the five articles from a minority of patients. These tended to emerge in retrospect, well after a patient's hospitalization, and focused on the need or rationale for treatment. These positive themes tended to reflect the social norms and explanations for compulsory care's leading to coercion, rather than the emotive or subjective responses elicited by such care."
- "A significant proportion of voluntarily admitted service userscan experience the same level of perceived coercion as that experienced by involuntarily admitted service users. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion, that there is sufficient oversight of the practice to ensure that individual's rights are respected."
- See section 6.1 entitled "stalling" in. From this section: "[T]he patient’s mistaken belief that she cannot leave the hospital facilitates the staff’s efforts to stall her. Most importantly, uncertainties regarding formal status make it possible for clinicians to phrase persuasive statements in strategic ways. At times, they might use words that connote coercion where coercion is not formally used. At other times, they might use words of cooperation when formal coercion is in fact applied. Similarly, particular symptoms of the patient, such as a temporary inability to concentrate, might serve as a resource for the staff in managing information in order to accomplish compliance."
- Kisely, Steve R; Campbell, Leslie A; O'Reilly, Richard (17 March 2017). "Compulsory community and involuntary outpatient treatment for people with severe mental disorders". Cochrane Database of Systematic Reviews. 3: CD004408. doi:10.1002/14651858.CD004408.pub5. PMC 6464695. PMID 28303578. Lay summary.
- Katsakou C, Priebe S (October 2006). "Outcomes of involuntary hospital admission—a review". Acta Psychiatr Scand. 114 (4): 232–41. doi:10.1111/j.1600-0447.2006.00823.x. PMID 16968360. S2CID 20677644.
- Newton-Howes, Giles; Mullen, Richard (May 2011). "Coercion in Psychiatric Care: Systematic Review of Correlates and Themes". Psychiatric Services. 62 (5): 465–470. doi:10.1176/ps.62.5.pss6205_0465. PMID 21532070.
- Sugiura, Kanna; Pertega, Elvira; Holmberg, Christopher (24 November 2020). "Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals". Int J Law Psychiatry. 73: 101645. doi:10.1016/j.ijlp.2020.101645. PMID 33246221 Check
|pmid=value (help). Lay summary.
- O'Donoghue, Brian; Roche, Eric; Shannon, Stephen; Lyne, John; Madigan, Kevin; Feeney, Larkin (January 2014). "Perceived coercion in voluntary hospital admission". Psychiatry Research. 215 (1): 120–126. doi:10.1016/j.psychres.2013.10.016. PMID 24210740. S2CID 42451989.
- Sjöström, Stefan (January 2006). "Invocation of coercion context in compliance communication — power dynamics in psychiatric care". International Journal of Law and Psychiatry. 29 (1): 36–47. doi:10.1016/j.ijlp.2005.06.001. PMID 16309742.
- Szmukler, George; Appelbaum, Paul S. (January 2008). "Treatment pressures, leverage, coercion, and compulsion in mental health care". Journal of Mental Health. 17 (3): 233–244. doi:10.1080/09638230802052203. S2CID 144254330.
- "The right to refuse treatment: a model act". American Journal of Public Health. 73 (8): 918–921. August 1983. doi:10.2105/AJPH.73.8.918. PMC 1651109. PMID 6869647.
- Kanaboshi, Naoki (1 July 2006). "Competent Persons' Constitutional Right to Refuse Medical Treatment in the U.S. and Japan: Application to Japanese Law". Penn State International Law Review. 25 (1): 5.
- "Browse by State".
- "Washington et al., Petitioners v. Walter Harper". Retrieved 10 October 2007.
- New York Lawyers for the Public Interest, Inc., "Implementation of Kendra's Law is Severely Biased" (April 7, 2005) http://nylpi.org/pub/Kendras_Law_04-07-05.pdf Archived 28 June 2007 at the Wayback Machine (PDF)
- [ NYCLU Testimony On Extending Kendra's La NYCLU Testimony On Extending Kendra's Law]
- National Mental Health Consumers' Self-Help Clearinghouse
- Psychlaws.org — 'Keys to Commitment' (a guide for family members), Robert J. Kaplan, JD
- Rogers Law, concerning involuntary treatment/commitment in Massachusetts