International mental health standards call for mental health services that are person-centered, recovery-oriented, and adhere to human rights standards.
International mental health standards have been shifting in recent years away from involuntary mental health treatment and towards mental healthcare provided only to those consenting to receive it, as a growing number of research studies indicate the ineffectiveness and harm for many people from forced treatment.
Involuntary mental health treatment includes detention against one’s will in psychiatric facilities, psychiatric drugs forcibly administered, the use of restraints and seclusion, and the administration of electroconvulsive therapy (ECT, or electroshock) without the consent of the individual.
The exact number of individuals held against their will in psychiatric facilities in the U.S. is not known, as many states do not require providers to report it. A 2021 study found there were more than 590,000 involuntary psychiatric holds in 2014 in 24 states that, at the time, accounted for 52% of the U.S. population. It also found that from 2011 to 2018, the average state rate of psychiatric detention increased three times as much as the average increase in state population. Estimates suggest that as much as 54% of U.S. admissions to psychiatric inpatient settings are involuntary.
State laws allow individuals in the U.S. to be detained in psychiatric facilities and treated against their will if they are a danger to themselves or others or are unable to care for themselves. State laws also provide for the protection of certain rights during psychiatric confinement.
But media investigations suggest, and lawsuits allege, that mental health service providers have ignored the laws, wrongly admitting, holding and treating individuals against their will in psychiatric facilities, then charging them and their insurance companies for the stays. The recent National Health Care Fraud Takedown by the U.S. Department of Justice included allegations of over $220 million in fraud by behavioral and mental health providers.
Many concerns over involuntary mental health treatment
The decision of whether to involuntarily commit a person can be influenced by factors unrelated to their actual mental health condition. Research indicates the likelihood of being detained in a psychiatric facility is increased by an individual’s male gender, single marital status, lower level of education, homelessness, lower income, unemployment, and geographic region of the country, as well as the personal attitudes and beliefs of the psychiatrist involved in the decision.
Racial disparities exist in psychiatric confinement and treatment. Compared with White patients, Black patients are not only more likely to be admitted against their will, but are also 85% more likely to be restrained with a physical or mechanical hold or with medication than White patients, and often for longer periods.
There is little research supportive of the use of involuntary psychiatric hospitalization, but many studies have found it harmful.
Research suggests the shame and self-contempt felt by many in reaction to being involuntarily committed to a psychiatric hospital, along with the stress experienced, may lead to self-stigma, reduced empowerment, and poor quality of life.
Many patients perceive involuntary psychiatric hospitalization and treatment as more punitive than therapeutic, staff as more judgmental than empathetic, and the hospitalization overall failing to meet their needs.
People whose admission to a psychiatric facility was coerced were more likely to attempt suicide after being released than those whose admission was not, according to a 2020 study. Another study found that compared to those who had not received any psychiatric treatment, those who had been admitted to a psychiatric hospital were at a 44 times greater risk of suicide, even after taking their worse mental health conditions into account.
The use of psychiatric drugs as the primary treatment for individuals deemed to be a danger to themselves has also been called in question. A 2019 reanalysis of FDA data on the safety of antidepressants found evidence that the rate of (attempted) suicide was 2.5 times higher in those using antidepressants compared to those not taking the drugs. Antidepressants are first-line treatment in the U.S. for depressed individuals.
As for danger to others, “psychiatric drugs cannot protect against violence unless the patients are drugged into a zombie-like state,” according to physician and medical researcher Peter Gøtzsche, M.D., director of the Institute for Scientific Freedom.
What’s more, many psychiatric drugs have been linked to an increased risk of violence. A 2010 analysis of the FDA’s Adverse Event Reporting System found that 31 out of 484 prescription drugs were disproportionately associated with violence, and 25 of those 31 were psychiatric drugs. The most recent documentary from the Citizens Commission on Human Rights, Prescription for Violence, details a deadly link between psychiatric drugs and acts of mass violence.
The use of restraints and seclusion in involuntary psychiatric hospitalizations is another area of serious concern. Legally, these practices can only be used in emergency safety situations and only when all less restrictive interventions have been attempted.
However, restraints and seclusion still carry the risks of psychological distress, physical injury to the patient or staff, and even death. The incidence of so-called PTSD after seclusion or restraint ranges from 25% to 47%, especially adversely impacting patients with past trauma, according to the findings of a 2019 study.
The power imbalance between staff and patients in inpatient psychiatric facilities can lead to physical, psychological, and sexual abuse by staff, leaving patients feeling threatened, humiliated, dehumanized, and powerless. In particular, sexual abuse and sexual assault are recognized risks in mental health care settings. The perpetrators may be mental health staff or other patients.
