Does involuntary treatment work?

Current debates about reforming LPS are mostly based on the aggregation of anecdotes, clinical intuitions, and moral/legal arguments about the ethics of involuntary treatment. As a qualitative researcher, I see all of these as valuable. But it’s also worth asking: what is the evidence that involuntary treatment actually works?

What follows is not a comprehensive meta-analysis of research on involuntary care—of which I could find no recent examples—but a review of all the relatively recent articles I have found in major sociology and psychiatric journals (there was more research on these topics in the 1970s and ‘80s shortly after commitment laws changed, and I cite some of it below, even though the overall structure of the mental health system has changed substantially). I’m largely leaving out articles on forensic treatment (like mental health courts) and involuntary outpatient treatment (like AOT), because both are not a core part of proposed reforms to LPS.

To preview: involuntary hospitalization “works” for some people, insofar as they show clinical improvement afterwards. It also can lead to trauma and suicide. It’s less clear whether it drives people away from seeking treatment in the future. On the other hand, there’s almost no research base establishing that long-term guardianship, of the sort that reformers are promoting, will lead to positive outcomes.

Involuntary hospitalization is followed by clinical improvement in most cases, but there are methodological limitations.

People who are involuntarily committed consistently (but not universally) show improvements in symptoms and functioning over the course of and at follow-up to hospitalization.1–3 These studies don’t tell us much about whether people show greater improvement than they would have had they received community treatment or nothing at all, because it would be ethically indefensible to design a study where you randomly assigned some people meeting criteria for involuntary commitment to an alternative approach.

Another key comparison would be between the improvement we see in involuntary hospitalization versus voluntary hospitalization. Surprisingly, most studies find that there is no difference in outcomes based on patients’ legal status or perceptions of coercion,4–7 although one study found that involuntary patients were more likely to be readmitted8 and have subsequent involuntary hospitalizations.9 These populations likely differ in significant ways, so it is difficult to isolate the impact of legal status on its own.

Coerced treatment is a source of trauma and may increase suicide attempts.

Forcing people to be in an inpatient setting is frequently traumatic. 69% of respondents in one study reported that their hospitalization was “traumatic”10; in another, 40% recalled “experiencing panic, flashbacks, and nightmares about events that occurred during the transfer and admission process, including persistent thoughts about their experience or nightmares regarding being physically restrained or coerced in their own homes.”11(p1129)

People forced into psychiatric settings are vulnerable to a range of abuses, although research into patient safety is limited.12 In a longer-term study of public mental health consumers, 59% reported being placed in seclusion, 34% put in restraints, 31% assaulted, 24% strip-searched, 20% medicated as a form of punishment, 14% insulted or bullied by staff, and 8% sexually assaulted at some point in a psychiatric facility.13

Most strikingly, coercive hospitalization is associated with an elevated risk of a suicide attempt in the following year, although the effect size is small (the consequences for the individual, of course, are quite large).14,15

It’s unclear if involuntary treatment drives people away from seeking treatment in the future.

When asked, people subject to involuntary treatment state that it deters them from seeking treatment. One recent study with forty young people in Florida found that 70% reported their hospitalization made them less trustful of the mental health system.16 In two studies, one-third of people with schizophrenia said that past experiences created barriers to accessing treatment in the future.17,18 Coercion may also have indirect effects: people who hear about others’ experiences with involuntary treatment may be deterred from seeking care.19

Studies that look at “objective” measures of treatment adherence paint a different picture. A range of studies have found that people subject to involuntary hospitalization or coercion were no less likely to be medication compliant or attend follow-up care afterwards than those who had been hospitalized voluntarily.4,20,14,21,22,10,23,6 However, because the individuals least adherent to treatment are probably those most likely to drop out of studies, this research may underestimate the negative effects of involuntary treatment on later compliance. And showing up for treatment is also not the same as having a working therapeutic alliance.

Respecting and listening to patients seems to matter more for their experiences and outcomes than their official legal status.

Most studies find that over half of people subject to coercive measures or forced hospitalization ultimately state that it was helpful or justified.19,3,24–27 This may be inflated, again, by the fact that the people least satisfied with treatment are the hardest to find for follow up. It could also be biased by peoples’ tendency to tell clinician-interviewers what they want to hear.

This might also reflect that many people who are on an involuntary legal status do not actually perceive themselves as being coerced. On the other hand, as much as half of formally voluntary patients in hospitals do not believe they could leave if they wanted to.4,28 Studies have concluded that, surprising, “the correlation between subjectively experienced coercion and formal legal status is modest at best.”24(p254),29

These results point to the fact that ensuring minimizing subjectively-experienced coercion can play a crucial role in ensuring positive outcomes even for involuntary patients. In interviews, servicer users are clear in their demand for “procedural justice”—that processes are transparent, that staff treat them with respect and listen, and that rights restrictions are minimized to the greatest extent possible.16,21,7 While we should never “underestimate the subjective suffering of patients who experience involuntary treatment,”6(p790) there is clearly much more that could be done to mitigate it even among people facing rights restrictions.

There’s almost nothing on outcomes for conservatorship for mental illness.

Conservatorship is different from the civil commitments usually evaluated in the studies above. Most commitments last for days or weeks, while conservatorships last months or years. Conservatees generally leave acute-cate settings for locked sub-acute facilities or unlocked Board and Care homes.30 And conservatees have an additional form of “treatment”: the oversight of a conservator.

A handful of studies in the 1980s and ‘90s evaluated conservatorships in California. Generally, they showed that conservatees had schizophrenia and long histories of repeated hospitalizations. The studies did not show that conservatees helped people become more autonomous or less impaired, but did demonstrate that conservatorship helped provide shelter, food, and stability.31–35 I could find only one study on the impacts of the sub-acute facilities where most conservatees go, which showed that even after an average stay of 196 days only a third were able to stay in the community for the following year without returning to a structured setting.36

Although a huge amount has been written on the legal and ethical aspects of guardianship more broadly, there is less available on its impacts. A recent review, for example, concluded that “reformers did not generally address in any depth is the underlying question of whether guardianship, when it functions exactly as designed, actually meets the goal of increasing the well-being of wards.”37(p353) Two national reports on guardianship both found little evidence for positive impacts of guardianship and concluded that institutionalization, in particular, was harmful.38,39(p102)

Most studies on guardianship are focused on the elderly or people with developmental disabilities, however, and tell us little about what expanding conservatorship would mean for people living with mental illness.

We desperately need more research and attention to civil commitments from regulators and policymakers

Research on and attention to civil commitments has dropped off over time. An eminent psychiatric researcher involved in a host of earlier studies told me to choose another dissertation topic, because the key questions had been answered and people moved out.

Yet civil commitments still affect hundreds of thousands of people per year in the U.S. and we know little about what happens to them afterward.40 There is no national database providing even the most basic information about civil commitments, like the number per year.41 The last major national report on reforming the U.S. mental health system didn’t mention involuntary treatment at all,42 while a recent report on the topic from SAMHSA, while welcome, provided no new data.43 It focused on involuntary outpatient treatment, which has been the object of more recent research but which affects an order of magnitude fewer people.44

More research probably won’t resolve the debates over civil commitments. Commitments help some people improve, can cause trauma and increased risk of suicide, and have mixed effects on peoples’ long-term engagement with treatment. We know almost nothing about the impact of conservatorship. The most uncontested finding in the literature is that even people subject to involuntary treatment want dignity and respect. They deserve it.

Literature Cited

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2.         Kallert TW, Katsakou C, Adamowski T, et al. Coerced Hospital Admission and Symptom Change—A Prospective Observational Multi-Centre Study. PLOS ONE. 2011;6(11):e28191. doi:10.1371/journal.pone.0028191

3.         Katsakou C, Priebe S. Outcomes of involuntary hospital admission – a review. Acta Psychiatr Scand. 2006;114(4):232-241. doi:10.1111/j.1600-0447.2006.00823.x

4.         Bindman J, Reid Y, Szmukler G, Tiller J, Thornicroft G, Leese M. Perceived coercion at admission to psychiatric hospital and engagement with follow-up. Soc Psychiatry Psychiatr Epidemiol. 2005;40(2):160-166. doi:10.1007/s00127-005-0861-x

5.         Nicholson RA, Ekenstam C, Norwood S. Coercion and the outcome of psychiatric hospitalization. Int J Law Psychiatry. 1996;19(2):201-217. doi:10.1016/0160-2527(96)00005-2

6.         Steinert T, Schmid P. Effect of Voluntariness of Participation in Treatment on Short-Term Outcome of Inpatients With Schizophrenia. Psychiatr Serv. 2004;55(7):786-791. doi:10.1176/appi.ps.55.7.786

7.         Wallsten T, Kjellin L, Lindström L. Short-term outcome of inpatient psychiatric care—impact of coercion and treatment characteristics. Soc Psychiatry Psychiatr Epidemiol. 2006;41(12):975-980.

8.         Houston KG, Mariotto M, Hays JR. Outcomes for Psychiatric Patients following First Admission: Relationships with Voluntary and Involuntary Treatment and Ethnicity. Psychol Rep. 2001;88:1012-1014.

9.         Fennig S, Rabinowitz J, Fennig S. Involuntary First Admission of Patients With Schizophrenia as a Predictor of Future Admissions. Psychiatr Serv. 1999;50(8):1049-1052. doi:10.1176/ps.50.8.1049

10.       Paksarian D, Mojtabai R, Kotov R, Cullen B, Nugent KL, Bromet EJ. Perceived Trauma During Hospitalization and Treatment Participation Among Individuals With Psychotic Disorders. Psychiatr Serv. 2014;65(2):266-269. doi:10.1176/appi.ps.201200556

11.       Murphy R, McGuinness D, Bainbridge E, et al. Service Users’ Experiences of Involuntary Hospital Admission Under the Mental Health Act 2001 in the Republic of Ireland. Psychiatr Serv. 2017;68(11):1127-1135. doi:10.1176/appi.ps.201700008

12.       Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.2018.0718

13.       Frueh BC, Knapp RG, Cusack KJ, et al. Patients’ Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting. Psychiatr Serv. 2005;56(9):1123-1133. doi:10.1176/appi.ps.56.9.1123

14.       Jordan JT, McNiel DE. Perceived Coercion During Admission Into Psychiatric Hospitalization Increases Risk of Suicide Attempts After Discharge. Suicide Life Threat Behav. 2020;50(1):180-188. doi:10.1111/sltb.12560

15.       Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand. 2011;124(1):18-19. doi:10.1111/j.1600-0447.2010.01672.x

16.       Jones N, Gius BK, Shields M, Collings S, Rosen C, Munson M. Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care. Soc Psychiatry Psychiatr Epidemiol. 2021;56:2017-2027. doi:10.1007/s00127-021-02048-2

17.       Lucksted A, Coursey RD. Consumer perceptions of pressure and force in psychiatric treatments. Psychiatr Serv. 1995;46(2):146-152. doi:10.1176/ps.46.2.146

18.       Swartz MS, Swanson JW, Hannon MJ. Does fear of coercion keep people away from mental health treatment? Evidence from a survey of persons with schizophrenia and mental health professionals. Behav Sci Law. 2003;21(4):459-472. doi:10.1002/bsl.539

19.       Hotzy F, Jaeger M. Clinical Relevance of Informal Coercion in Psychiatric Treatment—A Systematic Review. Front Psychiatry. 2016;7:197. doi:10.3389/fpsyt.2016.00197

20.       Jaeger S, Pfiffner C, Weiser P, et al. Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion. Soc Psychiatry Psychiatr Epidemiol. 2013;48(11):1787-1796. doi:10.1007/s00127-013-0687-x

21.       O’Donoghue B, Lyne J, Hill M, Larkin C, Feeney L, O’Callaghan E. Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services. Eur Psychiatry. 2011;26(4):208-214. doi:10.1016/j.eurpsy.2010.01.014

22.       Opjordsmoen S, Friis S, Melle I, et al. A 2-year follow-up of involuntary admission’s influence upon adherence and outcome in first-episode psychosis. Acta Psychiatr Scand. 2010;121(5):371-376. doi:10.1111/j.1600-0447.2009.01536.x

23.       Rain SD, Williams VF, Robbins PC, Monahan J, Steadman HJ, Vesselinov R. Perceived Coercion at Hospital Admission and Adherence to Mental Health Treatment After Discharge. Psychiatr Serv. 2003;54(1):103-105. doi:10.1176/appi.ps.54.1.103

24.       Monahan J, Hoge SK, Lidz C, et al. Coercion and commitment: understanding involuntary mental hospital admission. Int J Law Psychiatry. 1995;18(3):249-263.

25.       Owen GS, David AS, Hayward P, Richardson G, Szmukler G, Hotopf M. Retrospective views of psychiatric in-patients regaining mental capacity. Br J Psychiatry. 2009;195(5):403-407.

26.       van Baars A, Wierdsma A, Hengeveld M, Mulder N. Predictors of Perceived Benefit Among Patients Committed by Court Order in the Netherlands: One-Year Follow-Up. Psychiatr Serv. 2010;61(10):1024-1027. doi:10.1176/ps.2010.61.10.1024

27.       Wyder M, Bland R, Herriot A, Crompton D. The Experiences of the Legal Processes of Involuntary Treatment Orders: Tension Between the Legal and Medical Frameworks. Int J Law Psychiatry. 2015;38:44-50. doi:10.1016/j.ijlp.2015.01.006

28.       Hoge SK, Lidz CW, Eisenberg M, et al. Perceptions of coercion in the admission of voluntary and involuntary psychiatric patients. Int J Law Psychiatry. 1997;20(2):167-181. doi:10.1016/S0160-2527(97)00001-0

29.       Hiday VA, Swartz MS, Swanson J, Wagner HR. Patient perceptions of coercion in mental hospital admission. Int J Law Psychiatry. 1997;20(2):227-241. doi:10.1016/S0160-2527(97)00004-6

30.       Choi KR, Castillo EG, Seamans MJ, et al. Mental Health Conservatorship Among Homeless People With Serious Mental Illness. Psychiatr Serv. Published online October 27, 2021:appi.ps.202100254. doi:10.1176/appi.ps.202100254

31.       Frank JB, Degan D. Conservatorship for the chronically mentally ill: Review and case series. Int J Law Psychiatry. 1997;20(1):97-111. doi:10.1016/S0160-2527(96)00025-8

32.       Lamb RH, Weinberger LE. Conservatorship for Gravely Disabled Psychiatric Patients: A Four-Year Follow-Up Study. Am J Psychiatry. 1992;(149):909-913.

33.       Lamb RH, Weinberger LE. Therapeutic Use of Conservatorship in the Treatment of Gravely Disabled Psychiatric Patients. Psychiatr Serv. 1993;44:147-150.

34.       Reynolds SL, Wilber KH. Protecting persons with severe cognitive and mental disorders: An analysis of public conservatorship in Los Angeles County, California. Aging Ment Health. 1997;1(1):87-98. doi:10.1080/13607869757425

35.       Young JL, Mills MJ, Sack RL. Civil commitment by conservatorship: the workings of California’s law. Bull Am Acad Psychiatry Law. 1987;15(2):127-139.

36.       Lamb RH, Weinberger LE. One-Year Follow-Up of Persons Discharged From a Locked Intermediate Care Facility. Psychiatr Serv. 2005;56(2):198-201. doi:10.1176/appi.ps.56.2.198

37.       Wright JL. Guardianship for your own good: Improving the well-being of respondents and wards in the USA. Int J Law Psychiatry. 2010;33(5):350-368. doi:10.1016/j.ijlp.2010.09.007

38.       Teaster P, Wood E, Karp N, Lawrence S, Schmidt W, Mendiono M. Wards of the State: A National Study of Public Guardianship. Retirement Research Foundation; 2005.

39.       National Council on Disability. Beyond Guardianship: Toward Alternatives That Promote Greater Self-Determination.; 2018. Accessed October 14, 2021. https://ncd.gov/publications/2018/beyond-guardianship-toward-alternatives

40.       Lee G, Cohen D. Incidences of Involuntary Psychiatric Detentions in 25 U.S. States. Psychiatr Serv. 2021;71(1):61-68. doi:10.1176/appi.ps.201900477

41.       Morris NP. Detention Without Data: Public Tracking of Civil Commitment. Psychiatr Serv. 2020;71(7):741-744. doi:10.1176/appi.ps.202000212

42.       President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America.; 2003.

43.       Substance Abuse and Mental Health Services Administration. Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice. Department of Health and Human Services; 2019.

44.       Meldrum ML, Kelly EL, Calderon R, Brekke JS, Braslow JT. Implementation Status of Assisted Outpatient Treatment Programs: A National Survey. Psychiatr Serv. 2016;67(6):630-635. doi:10.1176/appi.ps.201500073

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