Ethical Considerations of Involuntary Psychiatric Treatment

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COMMENTARY

In the United States and many other countries around the world, individuals with mental illness may be involuntarily hospitalized in an acute psychiatric unit when they pose an imminent risk to themselves or others. This can often pose an ethical dilemma for clinicians, who must attempt to balance a patient’s right to autonomy with beneficence. When it comes to severe mental illnesses such as schizophrenia, the concept of anosognosia, which is the lack of awareness of illness, is often used as a justification for involuntary treatment. This article seeks to analyze the different ethical considerations when it comes to mandated psychiatric treatment and ultimately find a middle ground to providing safe and ethical treatment to individuals with severe mental illnesses.

Schizophrenia and Insight

According to the American Psychiatric Association, schizophrenia is a chronic brain disorder with symptoms including delusions, hallucinations, disorganized speech, trouble with thinking, and lack of motivation.¹ Schizophrenia affects less than 1% of the US population but is one of the top 15 causes of disability worldwide.² Many patients with schizophrenia experience a lack of insight, meaning they do not acknowledge the medical disease in oneself or the need for treatment. Estimates of the prevalence of lack of insight in schizophrenia vary greatly, ranging anywhere from 30% to 50% of patients.³

Insight is a concept with various definitions in psychiatry. Most widely accepted definitions of insight include awareness that one has a mental illness that requires treatment, as well as awareness of one’s symptoms and their consequences.³ Greater insight in patients with schizophrenia has been linked to various outcomes, including less overall symptom burden and improvements in functioning over time.⁴ Those who lack insight may believe that the signs and symptoms of the disease are an authentic part of who they are.³ Given its subjective nature, insight can be difficult to measure. Perhaps the first scale designed to measure insight in psychiatric subjects was The Insight and Treatment Attitudes Questionnaire (ITAQ), which asks questions about awareness of illness and attitudes regarding treatment. Since then, prominent schizophrenia researcher Xavier Amador has developed the Scale to Assess Unawareness of Mental Disorder (SUMD), which views insight as a multidimensional concept on a continuum.⁵

Attitudes towards lack of insight have also varied in psychiatry over time. Some psychiatrists believe that lack of insight is a psychological defense or coping mechanism used by patients to protect themselves from the difficult reality of having a disorder such as schizophrenia. However, one new theory that has gained more recognition in the field is the neurobiological model, which argues that poor insight is a result of neurological deficits in the brain, similar to the deficits seen in stroke and other neurological disorders.⁶

Anosognosia

Anosognosia is a term that derives itself from the Greek roots of a (without), noso (disease), and gnosia (knowledge). This term was first coined by French neurologist Joseph Babinski in 1914 to describe the awareness of deficit or illness that many patients with brain lesions lack. For example, some stroke survivors with hemiplegia may be completely unaware of their inability to use 1 side of their body. The term anosognosia has evolved to refer to a phenomenon of denial or unawareness of illness that is neurologically based.⁶ Even before Babinski coined this term, scientists have pointed out the incidence of anosognosia in patients with schizophrenia. For example, in 1896, Kraepelin noted that patients with dementia praecox (now known as schizophrenia) were unaware of their disorder.⁷

The prefrontal cortex, which is affected by schizophrenia, is crucial in developing one’s awareness and understanding of one’s needs. Damage to the prefrontal cortex, which is seen in neurological disorders such as Alzheimer disease and some cerebrovascular accidents, can result in a loss of self-awareness.⁸ Anosognosia has been shown to be caused by lesions of the frontal lobes and the nondominant hemisphere temporal parietal system, which are seen in many patients with schizophrenia.⁷ Some of the widely accepted signature pathologies of schizophrenia include prefrontal neuropil loss, gray matter volume reduction, and functional "hypofrontality.”⁶ Young et al has found that poor insight as assessed by the SUMD has been associated with poor performance on tests that are also sensitive for frontal lobe dysfunction.⁷

If a person does not understand that they have a mental disorder, then how do they have the capability to make decisions regarding treatment for said disorder?⁹ E. Fuller Torrey is an American psychiatrist who founded the Treatment Advocacy Center (TAC), a nonprofit organization that advocates for outpatient civil commitment laws for individuals with severe mental illness. According to Torrey, anosognosia is the reason why forced psychiatric treatment is a biological issue rather than a civil rights one.¹⁰ Torrey has written and advocated extensively on behalf of involuntary treatment for those with severe mental illness. He even argued that some individuals with severe mental illness should be required to get psychiatric treatment even if they are not dangerous, as this may decrease the number of patients who end up homeless, incarcerated, or committing suicide.¹⁰

Deinstitutionalization

Torrey has written about how deinstitutionalization in the United States greatly exacerbated the mental health crisis by discharging individuals from psychiatric hospitals without ensuring that they had access to the services that would allow them to thrive in the community.¹¹ Deinstitutionalization, which is defined by the World Health Organization as the "process of shifting mental health care and support from long-stay psychiatric institutions to community mental health services,” has dramatically changed the trajectory of psychiatric treatment in the United States over the past 70 years.¹² In 1955, 559,000 individuals were institutionalized in state mental health hospitals in the United States. In 1998, this number had decreased significantly to around 57,151.¹³ By 2020, the number of individuals in state psychiatric hospitals around the US was less than 40,000.¹⁴ The rationale behind deinstitutionalization was that community-based care would be more humane, therapeutic, and cost-effective than hospital-based care. While the number of persons residing in psychiatric hospitals has reduced greatly since the 1950s, the development of community-based services for the care of those with mental illnesses has not been as rapid.¹³ Some would argue that rather than deinstitutionalization, we should be using the term transinstitutionalization, as many patients were discharged from state hospitals to other facilities such as nursing homes.¹⁵

Outpatient Civil Commitment

In the aftermath of deinstitutionalization, there has been an emergence in the United States of outpatient civil commitment, also known as assisted outpatient treatment (AOT), which involves a court order that mandates a person to follow a specific treatment plan. If they do not comply, there is a risk for potential involuntary hospitalization and treatment. Studies in several US states have shown that outpatient commitment has at least doubled rates of treatment compliance and reduced the need for psychiatric hospitalization by anywhere from 50% to 80%.⁸ Up until this year, there were only 3 states (Connecticut, Maryland, and Massachusetts) without outpatient commitment statutes in place. In early 2024, legislation entitled Mental Health - Assisted Outpatient Treatment Programs was approved in the Maryland General Assembly, authorizing each county to establish an assisted outpatient treatment program by July 2026. The responses to this decision have been strong and emphatic. Many have called this legislation “draconian” or “dystopian” and have argued that it has set back civil rights in this country by decades.¹⁶

Autonomy

One of the main arguments against involuntary commitment, whether it be in the inpatient or outpatient setting, is that it is a violation of one’s civil liberties and bodily autonomy. Some also argue that involuntary treatment is ineffective, expensive, and takes away resources from those individuals who agree to voluntary care. The Bazelon Center for Mental Health Law, a legal and advocacy organization that aims to protect and advance the civil rights of individuals with mental illnesses and developmental disabilities, has been at the opposite end of the spectrum from Torrey and TAC. While the 2 groups seem to agree that one of the primary problems with the mental health system today is the severe shortage of community-based outpatient treatment centers, this is perhaps where the similarities between the 2 groups end. While Torrey argued in his book The Insanity Offense that deinstitutionalization was the direct cause for the increase in individuals who have mental illnesses and are homeless or incarcerated, Ira Burnim, senior counsel of the Bazelon Center, has voiced his disagreement. When interviewed for the book Committed, he expressed his belief that this argument does not “conform to the actual chronology” as homelessness in the United States “developed when the Reagan administration slashed federal housing programs.”¹⁰ He also stated that housing first programs are essential for the well-being of individuals with severe mental illnesses, as are mobile crisis services, supported housing, supported employment, and assertive community treatment, and that these programs should be voluntary.

Does Involuntary Treatment Lead to Future Reluctance to Seek Care?

Another argument made by those on the side of the Bazelon Center is that the threat of outpatient commitment will drive away individuals who need treatment. A similar argument has been made for involuntary hospitalization, as there is concern that the fear of being involuntarily committed will keep individuals who are in a mental health crisis from coming to the emergency department or seeking help. Unfortunately, patients’ perceptions on forced psychiatric treatment is a topic that has been understudied, particularly in the United States. Research has shown that patients typically have mixed views when looking back on their experience with forced treatment. These views vary based on factors such as country, diagnosis, gender, and type of coercive care that was experienced. Although most of the data is from Europe, where the commitment process often differs from that in the United States, it is still worthwhile to look at some of this research while keeping in mind that views may vary based on country.

A literature review conducted on outcomes of involuntary admission in various countries across Europe and North America found that between 33% to 81% of patients believed that their involuntary admission was justified and that coercive treatment was beneficial. Positive views were found to improve over time.¹⁷ A 2018 prospective cohort study with participants who were involuntarily admitted across 11 European nations corroborated this finding that positive retrospective views on forced treatment improve over time. At 1 month, 55% of patients believed that their admission was right while 63% believed so at 3 months.¹⁸ A 2016 study examined the association between various types of coercive measures used in involuntary psychiatric admissions and retrospective views of patients towards their admission about 3 months after the index admission. This study looked at 1353 involuntary patients across 10 European countries. When interviewed 3 months later, 62.6% approved of their admission while 37.4% disapproved.¹⁹

A 10-year follow-up study was completed assessing the perceptions of 395 individuals who had been hospitalized for psychosis for the first time between 1989 and 1995 in Suffolk County, New York. Approximately 69% of participants reported that at least 1 of their hospitalizations had been traumatic or extremely distressing. Additionally, 23% reported that they had forwent necessary treatment at least once during the past year, though this rate did not differ between those who had or had not reported perceived trauma.²⁰

Civil Liberties vs Forced Treatment

One argument against mandated psychiatric treatment is that it is a form of coercive care that is an infringement on a person's civil liberties. Coercive measures, which are defined as any measure “against the patient’s will or in spite of his or her opposition,”²¹ are not unique to mental health. If an individual arrives to the emergency department having a seizure, clinicians do not withhold antiepileptic medications until the patient can provide consent.²² One of the most infamous examples of coercive care is the story of Mary Mallon, more commonly known as Typhoid Mary, who was forcibly quarantined for 30 years after she knowingly continued to work as a cook and infect others with Salmonella typhi. Coercive care exists on a continuum and can take many different forms. There is formal coercion, which includes measures such as restraint, seclusion, involuntary hospitalization, and forced medication. There is also informal coercion, which includes persuasion or manipulation of the patient and their decisions.²³

Coercive care infringes on one’s fundamental right to autonomy, which is defined as an individual’s right to make his or her own choices.²⁴ There are several ethical principles that can be used to justify this infringement on a person’s right to autonomy, including beneficence, nonmaleficence, and justice/equity. Ensuring the safety of others (including other citizens, relatives, caregivers, patients, and staff members) can also be used as a moral argument to justify coercion.²³ When a patient enters forced psychiatric treatment, his autonomy is temporarily restricted. Coercion is used with the ultimate goal of restoring the patient’s capacity, thus promoting his autonomy in the long run.²⁵

One question that arises is whether individuals with severe mental illness are in fact free if they are ill. Is it true liberty if one’s "thoughts and behavior are driven by delusions and hallucinations because of a disease process of the brain over which the person has no control?”⁸ There is also clinical evidence that the longer schizophrenia goes untreated, the lower the possibility of future recovery. Medication can free one from his illness and allow him to live a meaningful life free from psychosis. Are clinicians doing patients a disservice by unnecessarily prolonging the amount of time schizophrenia goes untreated, thus reducing the chances that autonomy can be restored in the long run? This then brings up the question of who gets to decide what a meaningful life is—the patient or the doctor? Is the disruption to one’s prefrontal cortex in schizophrenia so severe that it prevents the patient from living his life in a way that he, if not ill, would consider meaningful? These are gray areas that psychiatry has yet to fully explore.

The Logistics of Outpatient Civil Commitment

As a psychiatry resident, I recently spent a year providing care to patients in an outpatient community mental health center in Baltimore. I had a firsthand look into how the outpatient mental health system is overburdened. There are not enough clinicians to meet the demand of patients who need and/or want care. Two-thirds of Maryland counties have a shortage of mental health professionals currently.²⁶ There is a real concern that outpatient commitment will overwhelm an already strained system.²⁷ Some have also questioned whether outpatient civil commitment in Maryland will prevent the equitable distribution of care to individuals who both need and want it. Without more resources devoted to community mental health centers, this is a real possibility.

While the jury is still out on how the implementation of outpatient commitment will impact Maryland’s mental health system, we can look at other states around the country. New York State is often considered to be the gold standard of outpatient civil commitment since the enactment of Kendra’s Law in 1999 and has devoted increased funding to its outpatient civil commitment program. However, a recent audit found significant deficits in the program with delays in providing care that have resulted in fatal consequences. These deficits can be linked to a lack of funding that has resulted in treatment teams with unmanageable caseloads.²⁸

Concluding Thoughts

The topic of forced psychiatric treatment is one that evokes strong beliefs in those on either side of the debate. Although schizophrenia is a disabling and life-altering disease, the field of psychiatry has come a long way in advances in treatment. Nowadays, many individuals with schizophrenia can go on to live healthy and fulfilling lives despite their illness. But first, they must agree to treatment. Research on anosognosia has showed us that a lack of awareness of one’s illness is common in schizophrenia and will often lead one to refuse treatment. As clinicians, how can we balance doing what is in the best interest of the patient while respecting the patient’s right to autonomy?

Most psychiatrists agree that involuntary treatment is necessary in certain scenarios. However, there must be strict criteria in place to ensure that involuntary treatment is not inappropriately overused. Clinicians should not make the decision to involuntarily hospitalize someone lightly. We must be constantly aware that when we make the decision to hospitalize someone against her will, we are temporarily taking away her autonomy. Involuntary treatment should be restricted to scenarios where it is clinically essential to ensure the imminent safety of the patient and/or others, there are no other less restrictive options, and the patient lacks the capacity to make her own decisions.²²

The availability of less restrictive options for treatment is certainly lacking in the United States. Deinstitutionalization came with the promise of the expansion of community-based services, but this has not yet come to fruition. Patients are stabilized in the hospital, released without proper support or adequate resources, and then end up right back in the hospital weeks later. In an ideal society, there would be a range of different services with varying degrees of restriction available to patients.²² Individuals would not spend more time in an inpatient unit than is necessary to acutely stabilize them and could then be discharged to less restrictive options that would continue to provide them with adequate support. We cannot expect individuals with mental illness to be able to live safely in the community without proper access to housing, food, and outpatient treatment.

As clinicians, we also need to acknowledge the role that social determinants of health and our own personal biases play when determining who is involuntarily hospitalized. Persons of color are more likely to be involuntarily committed in this country.²⁹ As the group Social Work Advocates for Social Change noted in their testimony in opposition to Maryland Senate Bill 453, Black residents of Maryland are disproportionately emergency petitioned.²⁶

We should also acknowledge when repeated involuntary hospitalization is likely to do more harm than good. Many individuals with treatment-resistant mental illness are repeatedly hospitalized not because they are actively suicidal or homicidal but rather because they have a “grave disability,” meaning they are unable to meet their own basic needs due to their mental illness. Those with grave disability who have been repeatedly hospitalized with no improvement in their medical condition are unlikely to benefit from continued short-term hospitalizations, as these hospitalizations are meant to focus on crisis stabilization rather than addressing chronic and systemic issues. While outpatient civil commitment may improve the situation for these individuals, this will not be effective unless it is paired with supportive housing, access to food and medications, and the appropriate support that these individuals need.³⁰

Involuntary commitment has a place in psychiatry. The presence of anosognosia in individuals with severe mental illness, such as schizophrenia, is an example of why involuntary treatment can sometimes be essential to ensuring the safety and health of a person with severe mental illness. However, as clinicians, we must also be aware of the limitations of the system we are working in and recognize when forcing treatment is likely to do more harm than good. Ultimately, there are many structural changes that are needed to improve support for those with chronic mental illnesses, so that these individuals can live meaningful and safe lives in the community.

Dr Quayum is a fourth-year psychiatry resident at the University of Maryland and Sheppard Pratt.

Acknowledgments

This paper was written as part of a Mental Health Policy course taught by Steven Sharfstein, MD. Thank you to Dr Sharfstein for his assistance and feedback while writing this paper. Thank you also to Dinah Miller, MD, author of Committed: The Battle over Involuntary Psychiatric Care, for her comments and feedback on this paper.

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