Psychiatric hospitalisation; transitioning from consenting to involuntarily admitting–re-conceptualisation and a procedural framework

Abstract

Involuntary psychiatric hospitalisation (IPH) is a form of acute psychiatric service delivery that is practiced in some forms worldwide. When feasible, clinicians attempt to obtain consent from a patient for psychiatric hospitalisation before transitioning to consider IPH. Influenced by their clinical experience and local laws, clinicians develop variable practices to make this transition. Subtle forms of coercion are found to take place during the consenting process, many of which remain under-recognised. In this article, we propose a reconceptualisation for IPH that distances it from being a consequence of declining to consent for hospitalisation. Building on this, we then outline a step-by-step procedural framework to exemplify how to transition from conducting informed consent for psychiatric hospitalisation to pursuing it on an involuntary basis while maintaining clear ethical boundaries. Finally, we suggest how to respond to patients’ inquiries about their admission status and negotiation requests and explain the usefulness of this framework for the patient and the mental health professional.

Introduction

The ethical considerations concerning involuntary psychiatric hospitalisation (IPH) focus on the competing interests of beneficence and autonomy. In this context, IPH is justified when violating a patient’s short-term will is the only means to fulfil other more valuable goals, such as patient safety and long-term autonomy (1). The authority to involuntarily hospitalise a person with a mental disorder is rooted in two legal principles: (1) Parens patriae, where the state intervenes on behalf of a citizen who is not acting in their best interests–here to mitigate the risk of dangerousness to oneself; and (2) Police power, which obligates the state to preserve the security and interests of its citizens–here to mitigate the risk of dangerousness to others (2,3). While it remains one of the most controversial topics in contemporary psychiatry (4), IPH is practiced in some forms worldwide (5), indicating the acceptance of its role by the general public and governing legislation bodies across countries and cultures. To carry out the procedure, many laws have been enacted worldwide (1,6,7). Even lawyers representing patients in civil commitment trials increasingly endorsed IPH as the needed intervention when the level of the apparent danger was notably increased (8).

In pre-modern psychiatry practice, IPH was the mainstay of delivering acute psychiatric care (3,9). For example, the first statute allowing psychiatric hospitalisation on a voluntary basis in the United States was not enacted until 1881 (10). In 1949, voluntary admissions composed only about 10% of all admissions to psychiatric hospitals (10). Standards such as ‘need for treatment’ and later ‘dangerousness’ evolved as the basis of IPH, with the civil rights movement influencing this evolution in the 1950s and 1960s (3). To meet the dangerousness standard–and subsequently be committable–a person with a treatable mental disorder must pose an imminent risk to themselves or the community if they were not held in a psychiatric unit for treatment (3).

IPH is one of several so-called formal coercion measures practiced in modern psychiatric care. Examples of other formal coercive measures include court-ordered outpatient treatment, involuntary administration of medications, and using restraints and seclusion (11). In these measures, the patient is not consented to treatment. The treatment often takes place against the patient’s will and is documented as such. Like the other coercive measures, IPH is associated with distress to the patient and disruption of their everyday routines. Unsurprisingly, many individuals experience a sense of coercion when they are hospitalised against their will (12). In the landmark case of Addington vs Texas, the United States Supreme Court recognised that ‘Civil commitment for any purpose constitutes a significant deprivation of liberty that requires due process protection’, and the court established the standard of proof for civil commitment as ‘clear and convincing evidence’ (13). Therefore, it is agreed that IPH should be limited to patients who decline psychiatric hospitalisation but pose imminent safety risks, those who have a grave disability, such as individuals who are unable to secure basic survival needs, or those who otherwise are unable to provide consent for psychiatric hospitalisation (3,5,14). Procedural safeguards, including judicial and institutional periodic reviews, are implemented to ensure legal and clinical oversight of the procedure.

When feasible, patients are frequently offered inpatient psychiatric treatment on a voluntary basis (5). If the offer is declined, the clinician must consider whether IPH is needed (15). Clinicians often learn from their own experiences and develop certain practices to transition from consenting for admission to pursuing IPH. Trainees can be challenged with patients’ demands and inquiries and–at times–can be uncertain how to respond to patients’ negotiation requests about the legal status of hospitalisation. Occasionally, IPH may be presented as a consequence of declining the recommended hospitalisation. Patients may sometimes be informed that IPH will be pursued should they decline ‘voluntary’ admission. Other patients may be allowed to ‘choose’ between voluntary or involuntary status (16,17). These practices, which are considered forms of informal coercion (17,18)–to be distinguished from formal coercive practices mentioned earlier–are often exercised based on claims of paternalism (a physician decides treatment on behalf of a patient) (19), and adequate disclosure of information (informing a patient that IPH will be pursued should they decline to consent) (20). There appears to be a deficit in recognising these forms of coercion among clinicians, even for those who frequently work with patients in acute settings (21). It is unknown to what extent these types of coercion influence a patient’s decision to accept or decline psychiatric hospitalisation, but some authors believe that at least some patients are admitted under ‘voluntary status’ because of the use of these informal coercive measures (5).

Adding to the complexity, a patient may decide to accept the recommended psychiatric hospitalisation after they declined it earlier to avoid unwanted involuntary status. Such a change in the patient’s attitude may occur due to concerns associated with IPH, such as stigma, level of autonomy, length of hospitalisation, and fear of legal consequences (22–26). To the clinician, the patient’s proposal may recall some competing interests. On the one hand, accommodating the patient and allowing for voluntary status can lessen the distress associated with involuntary treatment, preserve the therapeutic alliance (27), and save resources needed for a civil commitment court hearing. On the other hand, this accommodation falsely designates a voluntary status since the patient no longer exercises genuine autonomy when they accept–or are pressured to accept–treatment to avoid involuntary status.

In this article, we refute the practice that considers IPH a consequence of declining to consent for psychiatric admission, and explain how it introduces logical errors in the consent process. To avoid this, we re-conceptualise IPH and suggest a procedural framework to transition from consenting to psychiatric admission to pursuing it on an involuntary basis. Finally, we present clinical vignettes familiar to everyday psychiatry practice to exemplify how to operationalise this framework and use it to respond to challenging patients’ questions. Our goal is to maximise the chance for voluntary psychiatric hospitalisation while avoiding informal coercive measures and maintaining ethical boundaries.

Is IPH a consequence of declining psychiatric hospitalisation?

While conducting informed consent for inpatient psychiatric treatment, the patient is educated about the rationale for this recommendation and alternative treatment options if appropriate. The patient is also educated about potential consequences for declining this treatment, such as receiving inadequate care in other settings, legal consequences from endangering the community, the risk of suicide, or failure to attend to essential needs.

When hospitalisation is deemed inevitable, some clinicians inform the patient that IPH will be pursued if no consent for inpatient treatment is secured. Some may consider this information part of the informed consent for voluntary hospitalisation, formulating the involuntary route as a ‘risk’ or ‘consequence’ for declining to consent. On a separate but related note, there are different–and often compelling–opinions about the ethics of disclosing or concealing the authority to pursue IPH early in the mental health evaluation using a Miranda-like warning. Literature in this area contrasts the right of a patient to know how their decisions of accepting or declining recommendations may affect their treatment plan against the concern of deviating from an objective assessment and precise safety risk stratification (28). While there are no specific statutes in most states requiring such warnings, some legal practices go as far as mandating such disclosures before conducting a mental health evaluation, with judicial review occasionally dismissing the civil commitment hearing if such warnings were not issued before the assessment (29).

Declaring the authority to pursue IPH early in the evaluation can be appropriate or even legally mandated in some states. However, declaring whether this authority will be exercised in the current clinical case while conducting informed consent for psychiatric hospitalisation seems logically and ethically inappropriate. It would imply informing the patient that hospitalisation would take place regardless of their consent while obtaining that same consent. This is inconsistent with the core principle of ‘voluntariness’ of the informed consent procedure (20), rendering consenting to voluntary treatment impossible in the first place. Indeed, some law experts believe that if admission occurs under the threat of IPH, it–by definition–cannot be voluntary (22).

In the following case vignettes, we attempt to clarify this point further. The first case demonstrates conducting informed consent for a non-psychiatric procedure. The goal is to highlight the process and then use a similar one while approaching the second case, demonstrating conducting informed consent for a psychiatric hospitalisation.

Clincal vignette (1)

Mrs. A is in the operation room for trans-metatarsal amputation of the left lower limb. The surgical fellow conducts an informed consent, explaining the condition of the limb, the recommended procedure, the benefits and the risks of the surgery, and the risks of not performing the surgery. The fellow also explains that the surgery is highly recommended but that if Mrs. A declines the recommendation, her other options would be no treatment or antibiotic therapy, which would only slow the spread of the infection; however, a more extensive surgery would likely be needed in the future. Mrs. A provides her consent for the procedure.

In this example, the consequences of not consenting to the procedure do not include forcing it. Had Mrs. A been told that the surgery would take place regardless of her will, her consent could no longer be voluntary.

Clinical vignette (2)

Mr. B is recommended inpatient psychiatric treatment. He is educated about his condition and how inpatient treatment is needed. The benefits of inpatient treatment, including close observation of symptoms and expedited therapeutic interventions, are explained. Risks of interrupting regular routines such as work and social activities are discussed. Mr. B is also educated that given the severity of his symptoms, his condition will likely continue to deteriorate should no treatment happen or if it takes place in other settings. Mr. B consents to inpatient treatment.

Like the consent conducted for a non-psychiatric condition, informed consent for inpatient psychiatric treatment may not include forcing hospitalisation as a consequence of not consenting. While there is a reason to believe that informing the patient about the possibility of pursuing IPH if needed may inform the patient’s decision, a general disclosure about this possibility early in the evaluation is sufficient. The provider should be careful not to impede the informed consent for psychiatric hospitalisation by discussing whether this authority will be exercised in this particular case, should the patient decline the recommended hospitalisation while conducting informed consent for it.

IPH–re-conceptualisation

IPH may not be considered or practiced as a consequence of declining inpatient treatment, as noted above. However, there is a broad acceptance of the role of IPH in maintaining safety for the individual patient and the community (30–32). These two seemingly conflicting considerations can be reconciled by re-conceptualising IPH as a decision made by the clinician that follows–but is separate from–the patient’s decision to decline inpatient treatment. In this context, the clinician faces two clinical facts: (1) Psychiatric hospitalisation is inevitable, and (2) There is no access to voluntary psychiatric hospitalisation. This conceptualisation does not consider IPH as a decision independent from the patient’s declining inpatient treatment but that the former is made in light of – rather than as a consequence of – the latter. Here, the patient’s decision to decline inpatient treatment is viewed as additional ‘clinical information’ the clinician combines with the fact that hospitalisation is inevitable to decide to pursue IPH. Mitrossili et al. point out that the informed consent in psychiatric treatments and involuntary treatment are distinct processes, although not always mutually exclusive ones (33).

Procedural framework for the motion towards IPH

Depending on laws, local practices, and personal preferences, the clinician may inform a patient earlier in the evaluation about the clinician’s authority to pursue IPH if needed (see Figure 1). Following the assessment, the patient is educated about this option if inpatient treatment is recommended. For those not interested, more education about inpatient hospitalisation can be offered, and their barriers to admission can be explored and addressed. Spending this time educating patients about hospitalisation is essential. For example, some patients report that involuntary measures would not have been needed if enough time had been spent explaining the necessity of the interventions (34). Furthermore, a new study found that about a third of involuntarily hospitalised patients wanted to be hospitalised (35). Although it is unclear how many individuals were assigned involuntary status because of the inability to consent, those who wanted to be admitted seemed to be less sick–and therefore more likely to be able to consent–than those who did not wish to be admitted. For this framework, after exhausting the needed discussion to inform the patient’s decision and address their concerns, we recommend that the clinician elicit a clear and final decision about accepting or declining hospitalisation before considering or disclosing whether IPH will be pursued. The goal is to strengthen the clinician’s position if the patient later attempts to negotiate the legal status of the admission. This will be further clarified in the clinical vignette (3) below.

Figure 1.

Step-by-step framework to transition from consenting to involuntarily admitting.

*Optional step depending on clinician’s preferences and local laws. **Optional step depending on clinician’s preferences. IPH: involuntary psychiatric hospitalisation.

If the patient accepts inpatient treatment at this point, it can proceed as voluntary treatment. If the patient declines this option as a final decision, clinicians may consider taking a break before deciding or disclosing whether IPH will be pursued. This break can be used to do more medical records review, consult with the patient’s social network about safety concerns and the ability to maintain the patient’s safety in the community if not hospitalised, and further consider the risks and benefits of IPH. This break may provide the clinician with the space and time to examine whether considering IPH is driven by clinical factors or primarily by medicolegal anxiety, leading to unnecessary involuntary admission. This break can also be used to prepare for security presence in case of anticipated patient elopement, agitation, or violence. Although many clinicians would have already decided about the need for involuntary commitment at this point, taking this break may still be helpful to reduce the tension that occasionally arises in these conversations. It can also serve as a ‘time out’ to provide the clinician with mental clarity and a time away from the pressure of the patient, the family, and any countertransference that may impact clinical judgement (36). If involuntary commitment is deemed necessary, this break can also emphasise the clinical nature of the commitment decision and distance it from being a consequence of or retaliation for the patient’s decision to decline the recommended inpatient treatment.

Once a decision about the need for IPH is made, the discussion with the patient may resume, and they can be informed about the decision in a compassionate but firm way. This can be followed by explaining the reasoning behind the decision and the rules for IPH, depending on the local laws and practices. The patient may be encouraged to ask questions and to express feelings. Difficulties that may result from this unplanned admission, such as childcare disruptions, inability to care for a pet, and missing school or work, can be explored, and a consultation with a social worker to help address these concerns can be arranged. In a recent study, Sibitz et al. showed that patients highlighted respectfulness and knowledgeability as features of value for clinicians during patients’ involuntary experiences (Figure 1) (34).

Responding to patients’ inquiries

Once a decision for IPH is made, a patient may express their desire to cooperate with the voluntary admission after declining it earlier. Converting the legal status to voluntary after the patient gets admitted into a psychiatric unit is a common and often reasonable practice after adequate observation to ensure genuine interest in treatment (37,38). Some authors even studied those whose legal status gets converted during the admission as a cohort with unique characteristics and treatment outcomes (39). Sometimes, a patient may have declined hospitalisation even after education about its necessity had been exhausted. In these cases, honouring a patient’s desire to avoid involuntary status early by the same clinician who determined the need for IPH can be problematic. Ethically, the patient should be assigned the status by which the treatment will be delivered and not what the patient wishes. From a patient-centred perspective, the perception of coercion is only partially related to the assigned legal status (40), indicating that designating a voluntary status does not necessarily eliminate the perception of coercion experienced by a patient. Furthermore, a recent study found that the legal status of psychiatric hospitalisation did not align with perceived coercion–or lack thereof–by the admitted patients in both the voluntary and the involuntary groups (41). Clarifying the patient’s final decision before disclosing whether the authority to pursue IPH will be exercised in this specific clinical situation is essential. This clarification can minimise claims of miscommunication with a patient and strengthen the clinician’s position if a patient later attempts to negotiate their hospitalisation legal status. The following case vignette demonstrates the procedural framework and a response to a common negotiation request.

Clinical vignette (3)

Ms. C is recommended inpatient psychiatric treatment. She declines the recommendation and demands discharge even after adequate education, exploring barriers to inpatient treatment, and attempts to address concerns. The psychiatrist asks if he could consider this decision as final, and she affirms that it is. The physician tells Ms. C that he will take a break to decide whether involuntary hospitalisation is warranted. After a brief break, the clinician informs Ms. C that involuntary hospitalisation will be pursued based on the assessment and the available information. Ms. C realises that she will be admitted anyway, and she now demands to be assigned voluntary status, saying that she is willing to sign the needed documents. The psychiatrist gently declines and explains that she cannot be assigned voluntary status at this point, given that the treatment cannot be genuinely voluntary. Ms. C argues that she has changed her mind, but the psychiatrist continues to decline her request while sharing sincere empathy. He then explains that if Ms. C does show genuine interest in treatment while hospitalised, her status can be changed to voluntary in the inpatient unit.

At times, a patient may avoid explicitly declining inpatient treatment until they find out whether IPH will be pursued if they disclose their desire to decline. Patients may ask questions like ‘Do I have a choice?’, ‘What will happen if I decline?’ or ‘Am I going to be detained if I say no?’ The following case vignette demonstrates an example of how to respond to these challenging inquiries, and it highlights how the clinician’s response is crucial in keeping the door open for voluntary status without engaging in informal coercive practices.

Clinical vignette (4)

Mr. D is recommended inpatient psychiatric treatment. After adequate discussion with the psychiatrist, the patient asks if he has a choice. The physician responds by explaining the process by which Mr. D must first share his final decision about accepting or declining this recommendation before she (the psychiatrist) decides or discloses whether involuntary hospitalisation will be pursued. Mr. D pressures the physician more to disclose her decision. In response, the physician explains that if she must reveal the decision before Mr. D makes a final decision, then Mr. D will not have access to actual voluntary treatment and will not be assigned one if hospitalisation is deemed inevitable. Mr. D verbalises appreciation of the situation and accepts the recommended inpatient treatment. He is given a voluntary status.

Impacts on patients and providers

This framework allows a greater opportunity for voluntary hospitalisation without using informal coercive practices. When faced with threats of IPH during the consenting process in some current practices, patients may decline inpatient treatment to challenge the provider’s authority and compensate for the experienced difference in power. Subsequently, these threats may unintentionally decrease the chance of otherwise possible voluntary hospitalisation by triggering a sense of powerlessness and placing the patient in a defensive state. Therefore, exhausting the discussion with a patient as to why inpatient treatment is needed before deciding or disclosing the plan of pursuing IPH allows the patient’s decision to be informed, providing the opportunity to receive inpatient treatment on a voluntary basis. Some patients report that involuntary measures could have been avoided had they received adequate information before implementing them (34). It is of concern that some clinicians would not put effort into educating a patient about the need for treatment before proceeding to involuntarily applying such therapies (42). Taking the time to inform the patient’s decision would be particularly helpful for patients at risk of developing intense responses when faced with threats. Commonly, transference processes drive such responses in patients with a history of trauma or those with previous negative encounters with mental health services.

Clinicians may experience a surge of anxiety when a patient declines the recommended inpatient treatment. Medicolegal concerns may surface and even supersede clinical factors in driving the decision-making. Additionally, clinicians may experience a sense of rejection–and a deeper unconscious narcissistic injury–when a patient declines their recommended psychiatric hospitalisation. These perceptions experienced by the clinician can partially influence the decision to pursue IPH. Therefore, the clinical nature of the decision to pursue IPH–as emphasised by the stated re-conceptualisation–may distance clinicians from exercising their authority in a retaliatory manner or to treat their own anxiety. This can be particularly of value for busy clinical services where robust counter-transference processes are at play and not appropriately handled due to time constraints, service acuity, and burnout (43). Such unconscious processes and the associated intense emotions can cloud clinical judgement. Implementing a ‘time out’ represented by the break in the procedural framework may provide a platform to process these perceptions and recognise possible overflowing emotions so the clinician can move on with sound clinical decisions.

Limitations

This framework defines the proper legal status for the psychiatric hospitalisation as the one that best describes the way by which treatment is delivered, rather than what the patient wishes for the legal status to be. Given some of the consequences of IPH, particularly stigma and legal consequences, some providers tend to allow patients to sign in voluntarily whenever possible, even in the absence of genuine interest in treatment. Such practices favour avoiding consequences associated with IPH over adhering to the ethical principles of the informed consent. Still, it is helpful to structure the transition to pursuing IPH so clinicians can use it once needed. For clinicians to avoid this pitfall and be able to assign the proper legal status without imposing negative consequences on those involuntarily hospitalised, a call for high-level discussion at the state and federal levels to reconsider the negative repercussions of IPH is needed.

Some statutes preclude providers from pursuing IPH if a patient explicitly asks to be admitted voluntarily as long as they have decision-making capacity. For example, under New York Mental Hygiene Law § 9.21, a patient can veto the motion towards IPH and choose to sign in voluntarily to avoid IPH even if not interested in treatment (44). In this case, the admitting provider must accommodate this request, which limits the ability to apply this framework practically in the presence of such statutes.

Conclusion

Transitioning from conducting informed consent for psychiatric hospitalisation to pursuing it on an involuntary basis is a sensitive transition and needs to be undertaken carefully. Even soft forms of coercion that are occasionally practiced in the consenting process can falsely designate voluntary status to involuntary hospitalisation. While the authority to pursue involuntary hospitalisation can be disclosed to a patient early in the evaluation, prematurely revealing the clinician’s plan to execute this authority contingent upon the patient’s decision is equivalent to threatening involuntary hospitalisation. This practice can be problematic as it impacts the informed consent process and may deprive a patient of receiving inpatient treatment on a truly voluntary basis. Involuntary hospitalisation can be conceptualised as a necessary intervention to maintain safety in the light of having no access to voluntary inpatient treatment rather than a consequence of declining to consent.

Ethical standards

Declaration of conflicts of interest

Ahmad Shobassy has declared no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.