The Need for Appropriate Use of Involuntary Commitment

To the Editor: In an article in the February issue, McGarvey and colleagues (1) reported the results of a study of factors that play a role in decisions to initiate involuntary commitment among emergency evaluators employed by community service boards in Virginia. The authors conclude, “The findings provide a sound empirical basis for the claim that investing in a continuum of crisis stabilization and other intensive outpatient services would reduce the need for involuntary interventions.” But the article does not provide data to support this conclusion.

And what was this study? It was a questionnaire completed by emergency clinicians throughout Virginia after they had conducted an evaluation. The questionnaire asked whether certain currently unavailable services would have better addressed the individual’s needs. Well, sure. We didn’t need a study to find that out. This study basically says: “Here’s what you currently have for resources. Now fantasize about all these other possible resources. If one of them were available, would this have better met the needs of the person you evaluated?” Is nirvana better than reality?

I have fantasized about, designed, and implemented services, and I have also evaluated the relationship between the conceptualized service and reality and examined outcomes (including outcomes in Virginia). And, like others, I know that it is a big stretch from conception (fantasy) to the delivered service.

In the study by McGarvey and colleagues, respondents were not asked: “Would you actually have been able to access the service for the individual? What would have been the impediments to obtaining the service? If it took three to four times longer to obtain the service than to involuntarily commit the individual, would you have been able to wait? Would the patient have been willing to use a proffered service voluntarily? Would there be financial impediments to using some of the alternatives?”

I am not saying that expanded, well-provided community services would not divert individuals from involuntary hospital admission to voluntary community services. But these community services might do such a good job at case finding that more individuals would end up being involuntarily admitted after the development of the community services than before. This was our conclusion when Massachusetts doubled its mobile crisis capacity with no subsequent decrease in inpatient hospitalization rates (2).

Finally, if psychiatrists don’t figure out how to appropriately use involuntary services, others will tell us what we must do. In the wake of Seung-Hui Cho’s massacre at Virginia Tech in 2007, many thought that too few involuntary treatments were available (3). The same has occurred in the wake of Adam Lanza’s shooting spree at Sandy Hook Elementary School (4).

We need to be at the table both to design effective involuntary interventions—those that we can actually use—in the hospital and in the community and to expand intensive community services. These can be complementary. They must be.