Getting mental health right for all

Our need to put forward policies that benefit the full continuum of mental health

We all have stories as a kid being made to do something we didn’t want to do. Most of the time, it was our parents teaching us, protecting us. There are countless examples where what we want may not be what’s best for us. Of course, this is assuming we know what’s actually best for us. Having cookies for dinner seems like a pretty good idea on the surface, but is it what’s actually best for us? And yes, I have had these conversations in my house.

Today’s post is a hard one to write. It’s hard, and I can say up front that I am not sure what the best answer is here. This is a longer post because it is a complex topic and often brings out a lot of emotion in our field. All I know, which you will see laid out in the write up below, is that this is a growing issue, and one where there are a lot of opinions and much less data to support those opinions.

Yes, my friends, on the surface I am talking about the issue of involuntary commitment. Involuntary commitment, often referred to as civil commitment, involuntary hospitalization, or forcible hospitalization, encompasses the legal procedures by which individuals are involuntarily admitted to mental health facilities due to concerns about their mental health. Civil commitment generally applies when an individual is considered a danger to themselves or others and cannot make informed decisions about their treatment, without the involvement of a criminal offense. These terms, while often used interchangeably, may imply variations in the level of coercion or urgency involved in the process. The specific legal definitions and procedures for involuntary commitment can differ by jurisdiction, but they all posit to ensure that individuals with mental health issues receive necessary care while upholding their rights and following ethical and legal standards.

The history of involuntary commitment predates the establishment of all mental health professions. You can go as far back as the 4th century B.C., with Hippocrates, considered by most to be the father of medicine, suggesting the confinement of those with mental illness. In fact, he said that they should “be confined in the wholesome atmosphere of a comfortable, sanitary, well-lighted place.” Hippocrates was not alone in his thinking on this; throughout history, various societies have made reference to clinicians getting involved in the civil affairs of individuals who were deemed mentally unfit.

Our history has not been kind to those who have experienced mental illness. If you haven’t read Anne Harrington’s excellent book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, do so. In her book, Harrington explores the complex history of the mental health field, focusing on the rise and fall of various treatments for mental illness. It’s as bad as you think it is! She delves into the evolution of psychiatry and psychotherapy, from early somatic treatments like lobotomies (!!) and electroshock therapy to the advent of psychopharmacology and the influence of pharmaceutical companies. The book investigates how these treatments were developed, marketed, and sometimes debunked, shedding light on the ever-changing landscape of mental health care. Harrington's narrative underscores the broader societal and cultural influences that shaped these treatments and offers a brutally critical examination of our field's quest to define and treat mental illness over the years.

And it’s in the space of defining the problem and doing something about it that we come full circle to the issue of involuntary commitment. You see, we are not that far removed of housing people, often against their will, in psychiatric hospitals. I mean for decades, this was the standard of care because other options were not available and people just didn’t understand or know what to do with those with a mental illness. We pushed them aside, with little to no asking of their wants and desires, and moved on as if that place, that facility, was going to be where progress was made and positive outcomes were achieved.

If you look at the history of mental health, we have been on an elusive quest to find more humane and effective treatments. When President Kennedy signed the Community Mental Health Act of 1963, it was to help bring people who were housed in psychiatric facilities into the community where more effective and less restrictive treatment was available. And here’s the crux of our problem today - we have never, and I mean never, properly invested in a mental health system that adequately addresses the full continuum of mental health needs while also looking at the full continuum of care, from prevention to treatment to maintenance and recovery. We also entirely failed to recognize the role of community factors and social issues in contributing to so many of our broader problems. Sure, we’ve gotten pieces of it right, but we have not fully created a functioning system that helps along all aspects of this continuum, including social issues.

The implications for this are obvious.

We may have less people in hospitals, but we have more people in jails.

We may have less people in hospitals, but we have more people languishing on the streets.

We’ve created amazingly effective evidence-based treatments, yet people can’t afford a home.

These major social issues, like housing and poverty, we are now trying to solve using things like involuntary commitment. But when you look deeper at these social issues, it feels like mental health is yet another scapegoat for our inability to make meaningful progress.

As I have said before, more beds is not the solution; no, we need to truly begin to approach the problem from a systems lens, which requires us to see things that are often disconnected, connected, and for us to move from reacting to being more proactive. At our core, we are failing at housing, failing at poverty, and this means that we are not addressing mental health where it matters most, early in the continuum where prevention is most important. Now, we are creating policies and programs that penalize people for their mental health because we were unable to solve the broader social and community problems.

Currently, every state, and Washington, D.C. have involuntary commitment laws on the books. If you want to know what your state’s laws are, you can see some overviews here. From a legal perspective, involuntary civil commitment is a process governed by state law that also raises constitutional considerations, notably under the Fourteenth Amendment's Due Process Clause. This clause safeguards the liberty interests of patients subjected to involuntary civil commitment, emphasizing both procedural and substantive due process rights. Basically, it’s there to make sure that people are still treated fairly and humanely. Procedurally, this includes the right to notice and a hearing, with a minimum burden of proof established by the Supreme Court. While certain federal statutes address civil commitment, state laws ultimately shape the procedures and protections for individuals facing involuntary hospitalization.

Ok, so I think most of us agree that when someone is a threat to themselves or others, we should do something about it, right? There are always extreme cases where we need to protect the person and those around them. But does this even work? Taking someone off the street and putting them into a hospital does not create a new pathway for affordable housing; it does not help bring them out of poverty. No, it’s like we don’t know what else to do so we default to thinking that this must be the answer - it must help in some way - only it often doesn’t.

One study found that even if a person perceives coercion during psychiatric hospitalization, there is an increased risk of post-discharge suicide attempts. Even after adjusting for various factors, those who perceived coercion were more likely to attempt suicide post-discharge. Notably, there was no interaction effect between recent self-harm or suicidal ideation at the time of admission and perceived coercion on the likelihood of post-discharge suicide attempts. Another study found that people are often at highest risk for suicide after being discharged from a hospital.

All this means that without a system of care that can catch people once they are out of a hospital, whether involuntary or not, we run the risk of making things worse. But because we are so desperate for something to happen with all the people who are in need of help, we are beginning to see more and more states pass laws pushing us to put more people into care. It’s almost like people don’t have answers to these larger social issues and can’t grasp how big the problems are getting so they assume that putting people into a hospital or into care fixes it somehow.

For example, California has now adopted a law that allows for a judge to “compel” a person to treatment even if the person doesn’t want to go. New York made it easier for people to be involuntarily committed due to the high rise of people on the street with a mental illness. All these efforts are well intended, to help get people off the streets, but one can’t help but wonder if they are misplaced. And again, data on these programs working for mental health is weak at best.

Those that have been around these issues before see them as a consistent pattern. Dr. Mike Hogan, a friend and colleague over the years, wrote in JAMA “Here we go again,” referring specific to the changes in New York. He’s right as it seems we keep trying the same thing over and over again without seeing any change.

It's become apparent that certain states, including California and New York, are grappling with a surge of complex social issues that have long simmered beneath the surface. These are not new, and we should not be surprised at their increase. While these problems span housing disparities, law enforcement practices, and racial inequalities, they're now thrust into the limelight, demanding immediate attention. In the rush to quell these social ills, mental health issues are all too often conveniently placed in the spotlight, serving as a scapegoat to mask the deeper-seated problems. Instead of addressing the root causes, some policymakers seem to be focusing on mental health as a quick fix. However, the reality is that these issues can't be solved through hasty or one-dimensional approaches. This practice not only oversimplifies the complex challenges we face but also sidelines the genuine needs of those affected by mental health issues across the continuum of care.

In this context, it's crucial to recognize the interconnectedness of these problems and advocate for more comprehensive and lasting solutions. As I reflect on these issues, it's true that many of these challenges in the mental health system have been discussed repeatedly. However, we can't afford to let these discussions fade into the background. The urgency lies in recognizing that the mental health system is intricately linked with broader social issues, from housing to police reform to racial equity. These complex problems have been brewing for years and have become particularly acute in the wake of the pandemic. It's clear that elected officials are under immense pressure to address these issues quickly, often for political reasons. However, it's crucial to remember that the individuals we're ultimately trying to help aren't just those with mental illness and their families. We are all part of a larger narrative, and we can be proactive in pushing for more effective solutions. By involving the community, promoting transparency, and addressing issues like racism head-on, we can encourage positive change and inspire elected officials to tackle these complex social ills comprehensively. This message isn't meant to point fingers but to drive a collective call for change and accountability.

It's time to put the control back in the hands of the people and rewrite this narrative, not just for the ones we love but for all who are affected.