Imagine the worst day of your life. You’re on the verge of a breakdown – or something worse. A well-meaning friend or family member calls for help and the response includes armed men taking you away, where you’ll be held, whether you think it’s in your best interest or not, for several days in a psychiatric detention facility – a jail without the bars and where guards have been replaced by nurses. For days you’ll be accompanied by only your thoughts – those torturous, agonizing thoughts – and the occasional scream from a patient down the hall.

The general public, those who haven’t had the pleasure of firsthand experience, wouldn’t be faulted for believing that involuntary psychiatric hospitalization is necessary to protect individuals in crisis and is a moral and legal responsibility of the state. ‘We need to get that person help.’ However, patients often experience trauma, a profound loss of autonomy, and a sense of betrayal during these holds, which can worsen their mental health and deter them from seeking help in the future. Therefore, involuntary hospitalization should be reserved only for the most extreme and immediate crises, which should be clearly defined, and patients must be given greater authority and collaborative control over their treatment plans to ensure recovery is both practical and grounded in trust.

All fifty U.S. states have legislation that allows law enforcement, medical personnel, and/or social workers to have a patient held for three or more days, without due process, based primarily on a perceived and subjective “threat to themselves or others”. Since the individual is not charged as a criminal based on mental illness alone, the same laws and civil rights for indefinite detention of criminal suspects do not apply. Even when the person is entitled to an eventual hearing, they’re more informal than criminal court and based on the decision of a judge and recommendations of the patient’s assigned medical staff. Oregon law allows any person up to five days of mandated ‘evaluation’ if one qualifies herein: “’Person with mental illness’ means a person who, because of a mental disorder, is one or more of the following: (A) Dangerous to self or others. (B) Unable to provide for basic personal needs that are necessary to avoid serious physical harm in the near future and is not receiving such care as is necessary to avoid such harm” (Title 35). Note the lack of clear, objective definitions. What qualifies as a danger? Is it just the opinion of the officer/medical worker? Are there specific words or actions that have to be observed? Without any additional information, this is left to be interpreted subjectively by whoever is applying the law, which can lead to disastrous outcomes due to human error. The second subsection of the law is equally vague. Where does the line exist between caring for basic needs and being a slob? Is failing to eat or wipe one’s ass worthy of imprisonment? Again, without clear language, it’s up to the person in the position of authority to interpret at will, leaving a patient in a helpless situation. The law, which is similar to other states’, continues with a third section that allows the internment of patients if they are exhibiting symptoms similar to what those that have led to hospitalization in the past, so they are essentially gearing the law at re-institutionalizing people who have previously been detained for mental health episodes. It’s worth noting that these laws, commonly known as ‘5150’ laws, are primarily applied to suicidal individuals, schizophrenics, and those under the influence of hard drugs. Effectively, these laws allow them to imprison inconvenient members of society without the need for a crime to have been committed.

But it doesn’t seem like a practical use of resources to have juries or independent panels decide the competency of a patient who isn’t being charged with a crime. The judge and psychiatric staff could easily be considered experts, with daily experience in these kinds of cases; who better to judge a patient’s suitability for release into the ‘real world’. Or if that three-day hold should turn into a life-altering one-hundred-eighty days, the maximum amount of time a patient may be held at the discretion of the courts until further evaluation is mandated. But is this one-size-fits-all approach to mental health in the best interest of the patients? Are their policies tedious and antiquated or do they produce positive results?

Some studies would argue that they are the ‘best’ practices that have been found. Dr. Nathaniel Morris of Stanford School of Medicine weighs the outcomes of psychiatric holds of different lengths, finding some data that supports three days as the ideal amount of time: “In 2012, researchers published a study of 500 patients in Virginia that lent some support to 72-hour limits. Virginia limited temporary detention orders (TDOs) to 48 hours before court hearings, but hearings could occur within 24 hours, and weekends and holidays sometimes delayed hearings; these variations enabled a naturalistic study that compared TDO lengths and hearing outcomes. The predicted probability of subsequent hospitalization was lower for patients after a 3-day TDO (0.76) than for patients who had been on 2-day (0.84), 1-day (0.89), or <1-day (0.93) TDOs” (Morris). This would suggest that between bureaucratic delays and patient outcomes, seventy-two hours is the best median time for all involved. If there were an ideal amount of time to hold a patient in custody for mental health reasons, this length would be in their best interest – at least, in this case, when recidivism is the metric used for ‘success’.

Surely, if emergency psychiatric care is necessary and a responsibility of the community or government, then advocates in favor of those policies would see preemptive mental health care as an easy solution to the problem. Unfortunately, many of the patients who are eventually held in a psychiatric facility do not have ready access to therapists and psychiatry providers, which seems like an obvious factor in the patients reaching extreme states of despair. In a study on global mental health availability, researchers with the Faculty of Medicine at the University of Toronto point out the difficulties in not only the capacity of the underfunded system to handle the needs of an ever-growing base of patients, but in the insufficient quality of care, especially in the United States, where 75% of counties report a shortage in mental health providers. They write, “Difficulties in accessing mental health services can exacerbate illness severity, complexity, and duration, which is not only challenging for the individuals themselves but also undermines any opportunity for early intervention and can increase the strain on the health care system and social services. Treatment for mental illnesses is underfunded compared with treatment for other illnesses of similar prevalence and severity; however, increased investment alone will not address the service gap” (Grant et al). The entire process of obtaining suitable mental health care, even when not in crisis, is confusing and difficult to navigate for patients and can contribute to symptoms. It’s no wonder a patient feels disoriented and uncertain when being held involuntarily without being given clear and objective expectations on the process.

The vague and subjective criteria for involuntary hospitalization creates an extreme power imbalance where the patient is more-or-less (more) treated like a prisoner than they are a patient who could, in fact, benefit from psychiatric care. Because medical staff can ‘recommend’ an extension of the prisoner’s patient’s stay, it can be used as a threat by any staff member to any patient. Despite some guarantees to an informal hearing, to a patient, it can feel like they are being detained indefinitely. Dr. Adam Borecky and colleagues from Loma Linda University report in an aggregate study, “The use of and experience of coercion through involuntary hospitalization has been connected with feelings of humiliation, which are a risk factor for the development of mental disorders, specifically depression. The person who commits suicide in an inpatient setting is typically frightened, sad, lonely, disaffected, tired from sleepless nights, and feels that life is hopeless and futile. Other studies show that involuntary hospitalization can lead to feelings of confinement and impaired autonomy, lower satisfaction with care, and deterioration of care” (Borecky et al. 73). There’s a lot to unpack in that statement, but a retelling might say that involuntary patients feel coerced, humiliated, frightened, and a full spectrum of negative emotions. Not only are they not receiving proper care (the only standard of care in Oregon state law is that a nurse must always be on-site), but their symptoms are exacerbated by the experience. Some are even killing themselves while confined.

Borecky’s study also found that, “Fear of involuntary hospitalization is already a major barrier for individuals with a mental disorders and substance use disorders engaging in treatment. For those with past-year suicide ideation, plans, and/or attempts, the rate of mental health service use across studies was approximately 29.5% based on weighted averages. The use of coercion in mental health care may be one explanation of patients’ reluctance to seek treatment” (74). Not only is a patient subjected to a humiliating experience, but fear of a similar experience leads them to be less likely to pursue any kind of mental health care in the future. This could carry over into other levels of health management. If a patient is gaslit into thinking their physiological symptoms are all in their head – a side effect of their mental illness – and if they are denied medical care when under an involuntary hold, they might reconsider their ability to get comprehensive care in the future.

Additionally, the previous involuntary hold on their record could influence a doctor’s decision to diagnose or treat a patient in a certain way when compared to a patient without a history of mental illness. A study by Dr. Kathleen Crapanzano and cohorts and LSU School of Medicine on patient and provider-reported biases found conflicting opinions where only 9% of providers believed they treated a patient with previous mental health conditions negatively, while up to 79% of patients with a history of mental illness had negative experiences or results after disclosing this information. The study found, “It is notable that some provider beliefs were in direct conflict with patient perspectives. Some providers believed people with SMI (serious mental illness) were not interested in preventative care, whereas patients reported great interest. Providers also tended to believe people with SMI miss appointments for personal reasons, whereas patients perceived structural barriers to access, including a lack of outreach from providers. These results suggest that providers may not recognize their own biases to report them accurately” (Crapanzano). Considering all of the negative impacts of involuntary hospitalization, are the present methods ‘working’?

Given the outcomes experienced by patients, it’s clear that the current system is not working. The solution is twofold: greater patient authority over their treatment and improvement of current practices. Expedited triage and evaluation would be a fair start. Three-to-five days of confinement can be detrimental to a patient’s life. They could lose jobs, pets, and homes. Since the law requires nursing staff to be on-site at all times, there could be an evaluator certification available that allows this staff to speed up the process instead of waiting several days for a doctor – who has not observed the patient – to do an evaluation.

All of this should be done with concrete evaluation standards. Simply asking a patient if they have thoughts of suicide or are hearing voices is not sufficient. Patient reporting of symptoms is the standard for psychiatric diagnosis in the DSM-V, and that should be carried over into emergency psychiatry, as well, instead of the default attitude of skepticism about a patient’s self-reported symptoms. The ultimate judge of a patient’s danger to themselves or others, or a patient’s ability to care for their basic needs is the patient themselves. Patients who are unable to communicate, who are combative, or who are hallucinating would be the exception, rather than the rule.

Dr. Jason Barrett of University of Cincinnati College of Medicine proposes a standard of diagnosis for commitment that includes, “a) Evidence beyond a reasonable doubt; b) Clear and convincing evidence; c) Preponderance of the evidence; d) Medical certainty; e) Substantial probability.” He also suggests the ethical standards: “Doing good in the patient’s best interest; Physicians should not engage in actions that harm patients; Respecting the patient’s capacity to make decisions; Patients should be treated equally and medical resources should be distributed fairly” (Barrett). While these criteria are still open to subjective interpretation, they provide the framework for a greater level of certainty before subjecting a patient to a potentially traumatizing experience. Hopefully, language like that which Dr. Barrett has chosen to use would lead medical and government staff to a more individualized, compassionate approach to involuntary hospitalization.

In addition to increased concern for the patient’s opinion on their need for treatment, their treatment needs should be addressed. Since most regulations only require the bare minimum of medical care, patients are often left to sit in their room or a common ‘TV’ room for most of the day. If there aren’t therapies and activities going on, what is the value of having these facilities at all? Those both for and against the current system of involuntary holds could argue that having a nurse on staff at a jail – which is already commonplace – would be a comparable standard of care. There’s no point in giving a patient authority over their treatment when there isn’t any treatment happening. In order for this to happen, there would need to be a reevaluation of the purpose of these facilities and their standards of care.

Some jurisdictions do offer various enrichment and treatment services, from therapy to exercise rooms, but this isn’t standardized practice. While well-meaning, not all activities are created equal. By far, the most common service provided that isn’t mandated by law is group therapy. You know the type – a dozen or so patients sit around in a circle, talking over each other, while a facilitator asks, “And how did that make you feel?” In a study on teen inpatient mental health services, researchers from Western Sydney University found that a majority of patients found group therapy sessions to be least helpful of all surveyed activities, stating, “Young people consistently gave negative feedback regarding groups which were primarily verbal, expressing they were ‘boring’, ‘unhelpful’, or ‘confronting’; this was reflected in the in quantitative data wherein few participants endorsed these groups as either enjoyable or useful” (Versitano). Their study found that activities like art therapy provided the greatest patient satisfaction and the highest reduction in depression and anxiety symptoms. While individual therapy was more effective than group therapy.

While adding therapies and enrichment to the existing hospital-meets-jail model is a good start, others propose altering the system to move away from the clinical design and into an environment that is more supportive to the fragility of the patients’ mental health. In a book on his first-hand experience with involuntary hospitalization, Tweed Jefferson proposes a new system for emergency psychiatric care: “A ‘third step’ in the recovery process, focused on creating individual care, coping skills, and accountability” (Jefferson 246). His alternative is residentially based and operates more like a summer camp than a prison. Patients would have access to art and music activities, as well as gardening, cooking, and other skill-building exercises that they can take home. Jefferson’s design accentuates patient involvement in caring for each other, from leading activities to planning meals, with a focus on internally-built support systems, teaching patients how to give and receive support in their regular lives, the lack of a support system being something he cites as the cause of many crisis situations. This proposal for a residential, activity-rich mental health facility notes that the per-patient cost per day would actually be significantly lower than the current clinical model.

In fact, research backs the idea of residential inpatient treatment for all but the most disabled. In a comparison study, researchers from Stanford and the University of Arizona investigated the efficacy of an unlocked, casual residential facility. While the ‘severely disabled’ did not see a change in outcome between the two facilities, there was a slight improvement in patient satisfaction for others in the residential facility. They write, “Persons with psychiatric crises who are not deemed a danger to others, the less restrictive crisis residential alternative, together with available community outreach, is at least as effective as standard care—inpatient hospitalization in a locked facility” (Greenfield, et al). Greenfield’s study also found the residential facility to be more cost effective than the clinical model.

Those with mental health crises are an often overlooked and neglected part of our society. Some may think that the status quo is ‘good enough’ for such a minor portion of the population, but there’s room for improvement that can not only improve the patient experience, but could be more efficient, reducing the need for government spending – something someone could get behind even if they don’t have a personal stake in the quality of mental health treatment. A change in the language (and, thereby, stigma) and purpose surrounding involuntary holds would ensure those most in need are receiving treatment, while those who are stable are not subjected to an unnecessary traumatic experience. Likewise, standardized and expedited evaluation would decrease the length of the stay, creating both lower costs and lower instance of patient trauma. For those who do go through the experience – voluntarily or involuntarily – greater patient involvement in their treatment plan and access to various forms of enrichment and therapy can lead to a decrease in symptoms and improved overall mental health. In the short term, this could mean the mandated addition of services to the current medical model. Though, alternative inpatient systems may be the best long-term solution for both patient care and bureaucratic results. However the change is made, it should be made soon. It’s clear that the current model is not effective, and with mental illness increasing rapidly, the already-overburdened system is destined for disaster.

Works Cited

Barrett, Jason A. MD. “Hold of Not to Hold: Navigating Involuntary Commitment.” Current Psychiatry, Vol 21, No 9, September 2022. https://cdn.mdedge.com/files/s3fs-public/CP02109041.pdf, Accessed 5 June 2025.

Borecky, Adam, et al. “Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients.” American Journal of Bioethics, vol. 19, no. 10, Oct. 2019, pp. 71–83. EBSCOhost, research.ebsco.com/linkprocessor/plink?id=8fc5b4be-7d3b-3302-b291-eb410199720c, Accessed 26 May 2025.

Crapanzano, Kathleen A et al. “The Role of Bias in Clinical Decision-Making of People with Serious Mental Illness and Medical Co-morbidities: a Scoping Review.” The Journal of Behavioral Health Services & Research vol. 50,2 (2023): 236-262. https://pmc.ncbi.nlm.nih.gov/articles/PMC10016362/, Accessed 26 May 2025.

Grant, Kiran L., et al. “Three Nontraditional Approaches to Improving the Capacity, Accessibility, and Quality of Mental Health Services: An Overview.” Psychiatric Services, vol. 69, no. 5, American Psychiatric Publishing, May 2018, pp. 508–516, https://psychiatryonline.org/doi/full/10.1176/appi.ps.201700292, Accessed 26 May 2025.

Greenfield, Thomas K., et al. “A Randomized Trial of a Mental Health Consumer-Managed Alternative to Civil Commitment for Acute Psychiatric Crisis.” American Journal of Community Psychology, vol. 42, no. 1-2, 2008, pp. 135-44. https://www.proquest.com/docview/205353246, Accessed 6 June 2025.

Jefferson, Tweed. The Walls Instead. Squill Publishing, 2021.