Involuntary Commitment

Issues of Concern

Consumer Experience

Involuntary treatment can significantly affect a person's well-being, self-worth, and overall care experience.[8][9] Key concerns for consumers include:

• Psychological distress: The experience of involuntary detention and treatment can cause significant emotional distress, including fear, anxiety, anger, and frustration.
• Loss of autonomy: Involuntary treatment can erode a person's sense of autonomy and control, leading to feelings of powerlessness and resentment.
• Stigmatization: Individuals who have undergone involuntary treatment may experience stigma and discrimination, which can negatively affect social relationships and limit employment opportunities.
• Therapeutic alliance: The coercive nature of involuntary treatment can weaken trust between the individual and healthcare providers, hindering the development of a strong therapeutic alliance and potentially compromising treatment outcomes.

Healthcare Provider Challenges

Healthcare providers caring for individuals undergoing involuntary treatment face several challenges:

• Ethical dilemmas: Ethical dilemmas arise when balancing the principles of autonomy, beneficence, and non-maleficence, particularly when implementing coercive interventions.
• Legal and regulatory burden: Complex legal and regulatory frameworks are often time-consuming and stressful for healthcare providers to navigate.
• Resource constraints: Limited resources can affect the quality of care and the ability to provide appropriate treatment options.
• Burnout and compassion fatigue: The emotional toll of working with individuals who are often distressed and unwilling to receive treatment can contribute to burnout and compassion fatigue.

Other Stakeholders

Family and friends of individuals undergoing involuntary treatment often experience significant emotional distress and face challenges in providing support to their loved ones. Key issues are listed below.

• Emotional burden: The experience of witnessing a loved one struggle with emotional and behavioral issues, followed by the involuntary treatment process, can be emotionally draining. Family members may experience helplessness, frustration, and guilt, especially if they believe they could have prevented the situation.
• Strained relationships: The stress of involuntary treatment can strain relationships with the individual receiving care. Family members may feel resentful or angry, especially if they perceive the treatment as coercive or harmful.
• Ambivalence about treatment: Although family members may acknowledge the need for treatment, they may also be concerned about the distress and harm caused by involuntary care. They may struggle to balance their loved one's long-term health and well-being with the desire to ensure their immediate comfort.
• Lack of information and support: Family members may feel uninformed and unsupported during the involuntary treatment process. They may struggle to obtain details about their loved one's condition, treatment plan, and prognosis. Additionally, they may lack access to support services and resources to help them cope with their challenges.

Clinical Significance

Healthcare providers across various disciplines and settings, including general practice, psychiatry, psychology, nursing, social work, and emergency medicine, encounter unique challenges when working with individuals undergoing involuntary treatment. While evidence-based processes and treatments are limited, key clinical guidelines derived from existing evidence [4][9][2] and broader principles of quality, consumer-centered care can help maximize benefits for consumers while minimizing adverse consequences.

Key clinical implications include:

• Ethical considerations: Balancing the principles of autonomy, beneficence, and non-maleficence when treatment is administered against the individual's will.

• Therapeutic relationship building: Developing strong therapeutic relationships with patients who are resistant to treatment.

• Risk assessment and management: Assessing risk while avoiding both over- and undertreatment.

• Crisis intervention: Providing effective support to consumers during acute crises.

• Legal and ethical considerations: Adhering to complex legal and ethical guidelines, including informed consent, the least restrictive treatment, and human rights principles.

• Interdisciplinary collaboration: Fostering effective communication and collaboration among diverse healthcare professionals to ensure coordinated and patient-centered care.

• Long-term care planning: Developing comprehensive, collaborative discharge plans to support consumers' recovery and prevent relapse.

Due to the inherent undermining of autonomy in involuntary treatment, clinicians face additional interpersonal demands to prevent adverse consequences for healthcare consumers, which are listed below.[4][9]

• Prioritizing consumer-centered care: Using language consistently that emphasizes the goal of providing care to help the consumer at that specific time rather than serving the needs of the clinician or service. This approach fosters trust and collaboration, enhancing the consumer's experience and engagement in treatment.

• Enhancing the care experience: Providing a higher level of care to ensure the consumer feels supported and valued despite not having chosen the treatment. This includes validating their experiences of being subjected to involuntary treatment. Creating a safe, supportive, and comfortable environment is crucial to minimizing distress and promoting well-being. Offering opportunities for choice, control, and privacy, while addressing physical and emotional needs, can significantly improve the overall experience. By focusing on these elements, clinicians can reduce distress and foster recovery. 

• Protecting consumers from harm: Ensuring consumers' safety by including safeguarding them from potential risks posed by other involuntary healthcare consumers with emotional and behavioral regulation issues. This approach helps create a safe and secure environment for all individuals receiving care.

• Providing support and understanding: Providing support and understanding during involuntary treatment includes offering clear, concise information about the treatment plan, addressing concerns or fears, and involving the consumer in decision-making as much as possible.

• Addressing long-term adverse impacts: Mitigating increased stigma and rebuilding trust in healthcare providers, which can support recovery and reduce the likelihood of future crises.

• Evidence-based practices: Utilizing evidence-based practices ensures the effectiveness and appropriateness of treatment interventions. By incorporating these approaches, clinicians can optimize outcomes and minimize the risk of adverse effects.

In addition, clinicians can enhance consumer care by following these steps:

• Consistent language: Clinicians should use language that reinforces the goal of providing care to help the consumer at that particular time rather than to meet the needs of the clinician or service. This approach fosters trust and collaboration, improving the consumer's experience and engagement in treatment.

• Cultural sensitivity: Clinicians should incorporate cultural sensitivity into the delivery of care to respect individual beliefs and preferences. This can improve communication, build trust, and enhance the overall care experience.

Addressing these factors allows clinicians to improve the experience of involuntary treatment and promote positive outcomes for consumers, which aligns with the goals of the legislation.

Nursing, Allied Health, and Interprofessional Team Interventions

Effective interprofessional collaboration among healthcare providers is crucial for delivering optimal care to individuals undergoing involuntary treatment. By working together, healthcare professionals can ensure consumers receive high-quality care, minimize restrictive interventions, and promote recovery. Various levels of evidence highlight the benefits of staff training, shared decision-making interventions, and integrated care approaches in reducing coercive treatment in mental health services.[10] The strongest evidence supports staff training to reduce the use of restraints and shared decision-making with consumers.

Shared Understanding and Communication

• Common goal: Healthcare providers should establish a shared, consumer-centered understanding of the purpose of involuntary treatment, which is to support the individual during acute distress and facilitate their recovery.
• Consumer-centered language: Healthcare providers should use a language that prioritizes the individual's needs and well-being rather than focusing on legal or bureaucratic requirements.
• Effective communication: Healthcare professionals must ensure clear and open communication to facilitate coordinated and effective care.

Safe and Therapeutic Environment

• Respect and dignity: Healthcare providers should treat every person with respect and dignity.
• Protecting the consumer: Healthcare professionals must protect the consumer from exposure to other individuals with emotional and behavioral disturbances. Exposure to unpleasant, distressing, or fearful situations without the option to flee can be traumatic.
• Minimizing isolation: Healthcare providers should minimize the time consumers spend alone, preventing them from ruminating on unhealthy coping strategies or feeling worthless and imprisoned.
• Shared decision-making: Healthcare providers should allow individuals to make decisions whenever possible, respecting their autonomy and preferences.
• Autonomy: Healthcare providers should offer opportunities for choice and control within the limits of involuntary treatment, such as allowing the individual to select meals, choose activities, and determine visitation preferences, as well as, where possible, choose treatment providers.
• Positive reinforcement: Individuals undergoing involuntary treatment often have a history of interpersonal trauma, which can affect their self-perception, emotional and behavioral regulation, and social skills. Treatment should prioritize preventing further harm while fostering a supportive and caring environment. Reinforcing positive behaviors can help individuals develop better behavioral regulation in a safe and nurturing setting.

Strategies for Providing Support During Distress

• Empathy and validation: Healthcare providers should demonstrate empathy and understanding for the individual's feelings and experiences.
• Therapeutic relationship building: Healthcare providers should develop therapeutic relationships based on trust, respect, and care.
• Crisis support: Healthcare providers should respond to emotional and behavioral problems with empathy and care while minimizing restrictive interventions.
• Coping planning: Healthcare providers should assist consumers in identifying and using healthy coping strategies that have worked for them in the past.
• Pain management: Healthcare providers should address physical and psychological pain by providing appropriate treatment and support for recovery.

Interdisciplinary Collaboration

• Regular communication: Healthcare professionals should maintain open and regular communication with other team members, including general practitioners, psychiatrists, psychologists, social workers, and occupational therapists, to ensure the consumer receives a seamless continuum of care.
• Shared goals: Healthcare providers should develop shared goals for consumer care and create coordinated treatment plans, involving the consumer to the extent possible at each stage of their care.

Social Support

Social support is crucial in helping individuals manage unpleasant emotions and prevent them from becoming overwhelmed. Access to quality social support can vary among individuals. When possible and desired by the consumer, incorporating social support into the treatment plan can enhance treatment outcomes.

A few interventions to incorporate social support into the care plan are listed below.

• Identifying supportive individuals: Consumers should be encouraged to identify their social supports, such as family, friends, or community members.
• Clarifying roles: Consumers should be asked whether (and with whom) they would like to discuss their information regarding socially supportive individuals.
• Facilitating communication: Healthcare providers should facilitate communication between consumers and their social supports, whenever possible and in accordance with the consumers' preferences.
• Minimizing intermediary roles: Healthcare providers should act as intermediaries only when necessary and gradually phase out this role to enable the consumer to manage their communication.
• Respecting patient privacy: Healthcare providers should respect consumer privacy and confidentiality when communicating with other stakeholders.
• Supporting social connections: Healthcare providers should encourage social activities and connections within the treatment setting and community.

Discharge Planning

A well-structured discharge plan is essential for ensuring a smooth transition from involuntary treatment to community-based care. The plan should provide a continuum of care that supports the consumer's recovery and helps prevent relapse.

Collaborative planning: Healthcare providers should collaborate with the consumer to develop a personalized discharge plan. The consumer may choose to involve social and professional support in the planning process.

• Identifying strengths and building on them: Healthcare providers should identify the consumer's strengths and skills, such as problem-solving abilities, healthy coping strategies, and social connections. These strengths can be leveraged to develop new skills. For example, if the consumer has strong social connections, providers can help them utilize these relationships for additional support.
• Facilitating community connections: Healthcare providers should connect consumers with appropriate community resources, such as community treatment providers and housing services, to support their recovery and reintegration.
• Continuing treatment: Healthcare providers should ensure that the consumer understands and agrees with their treatment plan and has access to the necessary resources to continue treatment after discharge.
• Scheduling follow-up care: Healthcare providers should schedule regular follow-up appointments to provide support, monitor recovery, and address any consumer concerns.
• Coping planning: Healthcare providers should provide the consumer with a copy of their coping plan for reference strategies that have proven helpful in managing unpleasant emotions in the past. 
• Empowering the consumer: Healthcare providers should restore the consumer's ability to manage their recovery by providing the necessary tools and resources for success.

Consumer-centered healthcare enhances the treatment experience and improves outcomes, even in the context of involuntary treatment.