The Necessity of Involuntary Hospitalization and its Existing Faults

Public safety in the U.S. has always been a difficult balance between maintaining the wellbeing of our communities and protecting civil liberties. This issue becomes even more controversial when discussing involuntary hospitalization. Each state has their own laws dictating who has the authority to commit these individuals, what situations would deem it necessary for these individuals to be forcibly admitted, and what mechanisms will they use to combat potential abuse (Johnson & Stern, Clinical Points Section). In the state of Massachusetts, our law dictating the process by which people are involuntarily committed due to mental illness is Massachusetts General Law Title XVII Chapter 123 Section 12 (The General Court of the Commonwealth of Massachusetts, Section 12). Although there are many criticisms of MGL Chapter 123 Section 12 and involuntary hospitalizations nationwide, I believe that it is society’s obligation to protect the safety of all our residents. Social workers play an important role in protecting people with mental illness from harming themselves or others and it is Section 12 that allows them to fulfill this role.

Since the 1950s all across the U.S., the government has been deinstitutionalizing patients who were living in psychiatric hospitals due to the high number of patients who were being abused in these facilities (Treatment Advocacy Center, 2016, p. 2). In the face of this abuse, states like Massachusetts set goals to decrease the number of individuals who were forced to be hospitalized. This led to laws in the 1970s dictating the narrow scope that allowed doctors to involuntarily commit people to hospitals temporarily. These were initial attempts to meet the needs of the mental health community without unnecessarily admitting them into a long-term facility (Joost & McGarry, p.95-96). 

In January 2009, Massachusetts’s legislators again attempted to update the regulations around involuntary hospitalization by introducing Bill H.3465 to the Mental Health and Substance Committee. The committee reported the bill as a favorable and they sent the bill to Health Care Financing Committee for review that made amendments changing the bill to H4681 (The General Court of the Commonwealth of Massachusetts, Bill H.3465). The new bill was unanimously passed in the House and was signed into law by the Governor on August 9th, 2010 (The General Court of the Commonwealth of Massachusetts, Bill H.4681). This new bill also known as Section 12 now gives doctors, psychologists, psychiatric nurses, police officers and social workers the ability to involuntarily admit people to the hospital with a possible stay up to 72 hours. However, there are limits to how these professionals can involuntarily hospitalize someone. In order to commit someone to the hospital for a 3-day stay, a social worker has to “believe that failure to hospitalize such person would create a likelihood of serious harm by reason of mental illness” (The General Court of the Commonwealth of Massachusetts, Section 12, subsection a).  The social worker has to file a Section 12 form demonstrating symptoms of mental illness impairing the individual’s judgment and other cognitive functions. In their application for Section 12, the social work must also demonstrate how the person’s mental health symptoms place them at an extremely high risk of bodily harm to themselves or others (Department of Mental Health, 2013). If during an evaluation a social worker can prove that the individual has both symptoms of a mental illness and that he or she is likely to become a danger to him or herself or others due to this mental illness then the social worker can involuntarily hospitalize said individual. If the licensed social worker can not exam the individual in person they may use the information gather from other sources such as family members, friends, concerned citizens, non-licensed staff, etc. to admit them to the hospital (Mental Health Legal Advisors Committee, 2018). 

Even though social workers have the ability to involuntarily commit individuals to the hospital there are provisions that are set up to protect patient rights and ensure that qualified professionals can not improperly commit people through a misuse of power.  Despite the fact that individuals can be sent to the hospital by social workers once admitted to a hospital a doctor must evaluate them. This doctor can agree or disagree with the Section 12 petition filed by a social worker (the General Court of the Commonwealth of Massachusetts, Section 12, subsection b). Another provision included in the law is that before an individual can be involuntarily admitted into a hospital this person, their family, or their guardian must first be given the option to voluntarily admit himself or herself to hospital for a period that cannot exceed 72 hours (the General Court of the Commonwealth of Massachusetts, Section 12, subsection c). Even if the doctor agrees with the decision to involuntarily commit a patient for 3 days, the doctor can determine that the person is no longer a risk to themselves or others and can discharge them early from the hospital (The General Court of the Commonwealth of Massachusetts, Section 12, subsection e). If a doctor is the one who files the Section 12 application or agrees with Section 12 application filed by a social worker, the hospital must inform the patient of their rights such as a right to speak with an attorney about their options regarding their case. Most importantly if the individual who was involuntarily hospitalized “believes that ‘an abuse or misuse’ of the admission process has occurred, the person … may seek emergency judicial review in district court” and “the hearing must be held no later than the next business day after the request for the hearing” (Mental Health Legal Advisors Committee, 2018). This last piece is vital to ensuring that qualified professionals use integrity when filing a Section 12. Despite all of the elements included in the bill to protect the safety of the individuals and maintain their rights, the bill still impacts people’s lives sometimes in negative ways.

In my previous work place, I served as a direct staff counselor working with clients who had severe mental illness, many of whom had thoughts of or attempted suicide.  As a mental health counselor at this program, I was not licensed and therefore unable to file a Section 12, however I was still able to utilize the law by contacting either my licensed supervisor or calling the police who could Section a client. I would provide the police officers, my supervisors and eventually the admitting doctors with details about the mental health symptoms exhibited by the client that would merit involuntary hospitalization on the basis of mental illness and likelihood of serious harm. The clients I served were a varied population who had diagnoses ranging from mood disorder to schizophrenia.

One client in particular that I worked with for over a year illustrates the necessities of involuntary hospitalization but also many of its shortcomings. This client, with the initials A.F., was a young woman who had borderline personality disorder, reactive attachment disorder along with several other comorbid disorders. When the symptoms of her mental illness presented themselves it was often in the form of self-harming behavior, suicidal thoughts/attempts, disassociation, and homicidal threats. The times when she was disassociating were the most dangerous because she could unknowingly harm herself or others. One example of this was when she ran into on coming traffic. Other instances when the client was distressed and began injuring herself was when she began pulling nails out of wood or used lids of opened cans to cut her arms. In many of these moments her speech was incoherent and she was unable to regulate her mood.  For several months, my colleagues and I were sectioning her to the hospital on a weekly basis.

Despite the need to involuntarily hospitalize client A.F., it definitely put a strain on our client-counselor relationship. She felt that I betrayed her trust or acted against her by calling the police and forcing her to be hospitalized. Some other clients felt disempowered because they lost control over decision-making in their lives. Many of the clients had been to the hospital before entering our treatment facility and saw being hospitalized again as a failure. These sentiments were echoed by European patients who reported having “low self-esteem, … feeling stigmatized and discriminated against after discharge. … hospitalization has also led patients to feel vulnerable and to feel that their integrity has been violated. These feelings can contribute to the view that hospitalization is unjust and can have a negative impact on their therapeutic relationship with treaters”(Johnson & Stern, What is the Emotional Impact). These feelings of distrust make it difficult to build rapport with clients and maintain a relationship after involuntarily admission. After one incident where I had to contact the police to file a Section 12 on A.F., we discussed what events had transpired that caused me to contact the police. In this discussion she revealed that she often struggled to open up to me and be honest about her mental health symptoms because I always seemed so scared of her. Luckily, I was able to improve our relationship by explaining to A.F. that I was not afraid of her but instead concerned for her wellbeing and that I sent her to the hospital because I cared about her safety. These post hospital discussions often allowed me to rebuild relationships with my clients. Sending a client to the hospital paused the progress we were making but having post hospital conversations allowed me to provide reasons for why I called the police. This helped them understand my perspective and rebuilt trust by demonstrating my genuine concern for them. However, these post hospital discussions are not always possible for clients who live independently in the community. I believe this is one area in which changes to the Section 12 can greatly improve the recovery process for clients. Individuals who live in the community are often discharged back to their home. This leaves them vulnerable and puts them at risk of becoming dis-regulated and having to go to the hospital again. A study done by Giacco and Priebe (2016) surveyed individuals from Europe who had been involuntarily hospitalized and followed them after they were discharged. The authors discovered that directly after discharge, 46.1% of participants exhibited some level of hostility and 13.9% exhibited symptoms of suicidality. I believe that including a provision in Section 12 to mandate that discharged patients must participate in wellness check-ins with either police officer or social workers would reduce feelings of hostility and suicidality. Mandated post hospital discussions with mental health worker would hopefully mirror the conversations I had with my client A.F. and help them utilize community supports. This type of provision might allow individuals to reflect differently on their time in the hospital; where a social worker could reframe a hospital stay as necessary to the cycle of change rather than a failure.

Another change that could empower clients would be better education and training about the law for all members of the community. There should be funding attached to this new mandate that would provide hospitals, community centers, and mental health treatment facilities with educational materials to help individuals understand their rights and the limits of the law.  If clients are exhibiting mental health symptoms so severe, then they may not be able to comprehend the legality of the law that is keeping them in this facility. The public often over estimates how dangerous mentally ill individuals are and often fails to understand warning signs that someone might attempt to kill themselves. This misinformation could potentially be remedy by broader education in the community, especially for families who are attempting to support loved ones. This proposal would have benefitted my clients because I only had a loose understanding of the parameters around the use of Section 12. I often did not know if the symptoms my clients were exhibiting meant they needed program intervention or if they were in serious danger and in need of hospitalization. Further training about what behaviors and statements warrant a Section 12 application would greatly improve the work of other unlicensed mental health service providers. This proposal could prevent individuals from being unnecessarily traumatized though involuntary hospitalization when other interventions are available.

One last provision that would greatly improve Section 12 in Massachusetts would be to include involuntary community treatment known as “assisted outpatient treatment (AOT)” (Treatment Advocacy Center, Massachusetts). Massachusetts is one of only 3 states in U.S. that does not have involuntary community programs. This is a great alternative to hospitalization because while clients are still getting the treatment they need to keep them safe, AOTs have a smaller caseload allowing for more individualized and comprehensive care. (Treatment Advocacy Center, AOT Implementation FAQ). This would also help clients remain in the community, which gives them greater autonomy than they would receive in a hospital and allows for an easier transition back home. The program I used to work for was initially conceived to help clients who had been hospitalized transition back to the community. The program was not mandatory but many clients were more stable and had more coping skills that they could utilize while living independently in the community again. Program participants were less likely to be frequently hospitalized and had better connections to local resources. I believe AOT’s would act in a similar fashion by connecting those who are having acute symptoms to local supports so they can develop coping mechanisms to manage their symptoms in their own homes and avoid hospitalization in the future. Section 12 is a necessary and often helpful tool for social workers and other qualified professionals to use to keep their clients and members of the community safe, however the law needs several modifications to help connect clients to local community resources and longer term service providers.

References:

• Department of Mental Health. (2013). Application for an Authorization of TemporaryInvoluntary Hospitalization. Commonwealth of Massachusetts.
• Giacco, D. & Priebe, S. (2016). Suicidality and Hostility following Involuntary HospitalTreatment. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4865189/
• Johnson, J.M., & Stern, T. A. (2014) Involuntary Hospitalization of Primary Care Patients.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195632/
• Joost, R. H., & McGarry, A.L. (1974). Massachusetts Mental Health Code: Promise andPerformance. American Bar Association Journal, 60, 95-98.
• Mental Health Legal Advisors Committee. (2018). Your Rights RegardingAdmission to andDischarge from a Hospital Under Massachusetts Mental Health Law. Retrieved from:https://mhlac.org/wp-content/uploads/2018/10/admission_and_discharge.pdf
• Treatment Advocacy Center. (n.d.). AOT Implementation FAQ. Retrieved from:https://www.treatmentadvocacycenter.org/component/content/article/180-fixing-thesystem/3616-aot-implementation-faq
• Treatment Advocacy Center. (n.d.). Massachusetts. Retrieved from:https://www.treatmentadvocacycenter.org/browse-by-state/massachusetts
• Treatment Advocacy Center. (2016). The Medicaid IMD Exclusion and Mental IllnessDiscrimination. Retrieved from:https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/imdexclusion-and-discrimination.pdf
• The 191st General Court of the Commonwealth of Massachusetts. (n.d.). Bill H.3465. Retrievedfrom: https://malegislature.gov/Bills/186/H3465
• The 191st General Court of the Commonwealth of Massachusetts. (n.d.). Bill H.4681. Retrievedfrom: https://malegislature.gov/Bills/186/H4681
• The 191st General Court of the Commonwealth of Massachusetts. (n.d.). Section 12. Retrievedfrom:https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVII/Chapter123/Section12