Before her suicide in 2020, streamer Ohlana put out a statement regarding suicide intervention stating that “depressed [people] struggle to reach out in fear the ones closest to them will have cops show up and confine them against their will,” leaving them “alone with their dark thoughts.” They are, as she said, “stuck because they don’t want to be trapped where they just feel worse.”
“It’s not anybody’s fault,” she added shortly before her death. But is it not?
Currently, in many parts of the world, the penalty for suicidal behaviors is involuntary commitment; that is to say, whether you want to or not, you will be hospitalized. Here in the United States, this often takes the form of a civil commitment order. Subjects can also expect other potential penalties, such as removal of gun rights, denial of the opportunity to serve in the military, and, indirectly, maybe even loss of employment, academic standing, financial stability, and child custody, to name a few.
Carceral suicide intervention is a question of culture and government policy. Advocates say it is a necessary, life-saving measure, even if it is not appreciated in the moment by the person subjected to it. Critics say it exacerbates the issue, making things worse for those in crisis, teaching them and others not to reach out before it is too late.
With the general rise in civil commitment over the past few decades, suicide rates have been increasing. Defenders of civil commitment propose that the situation would be even worse without the penalty in place, but there are many good reasons to indicate this is not the case.
While allegedly intended to help, institutionalizing people against their will does more harm than good. The process of psychiatric coercion is recounted as dehumanizing by more survivors than not. Mental health and social outcomes for those who reported coercion were overwhelmingly negative. Fear can dominate their experience in a coercive environment, prompting people to repress emotions into what’s deemed as sufficiently stable for release. (This can also happen by proxy, where if people know this is what they will face if they open up, they may avoid doing so.) The already-hasty diagnostic process may also be affected by the extreme distress of the committed subject whose crisis, if it existed upon commitment, has been exacerbated; and whose necessary trust in the psychiatrist is transformed into a need to perform normalcy to escape.
All this does, for many, is teach them their feelings are shameful, to be punished, hidden, repressed… which is why, following hospitalization, suicide rates skyrocket. A 2014 study showed that increased contact with psychiatric staff was a massive risk factor for death by suicide when analysing thousands of completed suicides. While those who are more disturbed to begin with are likely to have more contact with psychiatric staff, the authors believed the hospitalizations, particularly if involuntary, constituted a substantial independent risk factor. The study and accompanying editorial note indicated that the trauma and stigma inherent in psychiatric hospitalization were so significant that they likely caused some of the suicides. As Robert Whitaker commented in an article on the Absolute Prohibition site, “[The Danish study concluded] that ‘it would seem sensible, for example, all things being equal, to regard a non-depressed person undergoing psychiatric review in the emergency department as at far greater risk [of suicide] than a person with depression, who has only ever been treated in the community.’”
The only study in my search which produced mixed results for involuntary commitment was a study from 2006 in which they did not distinguish between people who were forced or coerced and those who were not, which muddied the waters. (“Involuntary” means treating a subject as though they are unconscious; that is to say, whether the person wants it or not, they will be treated.) “Retrospectively, between 33% and 81% of patients regard the admission as justified and/or the treatment as beneficial.” However, the biggest thing to note is most people (52-72%) in the study agreed with their hospitalization while it was happening, meaning that they likely would have voluntarily gone regardless of the hold. There is still no evidence of any benefit for people who did not agree with their “treatment,” nor any randomized or controlled trial showing benefit of forced commitment.
If one is still not convinced coercive hospitalization is an independent risk factor, there is further evidence with more controls indicating coercive methods independently increase suicidality. For example, even if suicidality was not present upon admission, suicidal behavior increases after hospitalization, especially if admission was coercive. The smoking gun is a 2019 study from the Harvard Review of Psychiatry which showed that patients who were hospitalized had massively increased suicide attempts and deaths versus clinically comparable patients who were not.
Another issue is that suicide is notoriously hard to predict, even by professionals in the psychiatric industry. This has been shown over decades, as summarized in the 2023 “Report on Improving Mental Health Outcomes” by The Law Project for Psychiatric Rights citing a 2017 meta-analysis of 50 years of research. Evidence from extensive newer research has also shown the struggle to predict self-harm and suicide. A 2020 review in The Lancet showed that “risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment,” in part because “the effectiveness of risk tools in predicting suicide or self-harm is limited.” Caregivers and patients both reported “a lack of clarity on what to do in a crisis.”
People also struggle to predict it in themselves, as suicidal ideation rarely results in suicide (<1 in 14 people with suicidal ideation attempt within the next 2 years). Often, the person is simply in great emotional pain, and subconsciously seeking support; furthermore, even if deep down they want to die, when they will actually follow through is hard to predict. There has never been a controlled study, let alone randomized controlled trial, indicating that coerced patients are helped by this practice, much less the population at large. (One must factor in the suicidal people who purposely evade getting caught so as not to be targeted.) Patients claiming to be helped by coercive practices may be experiencing the placebo effect, as suicide attempts and deaths are so difficult to anticipate.
The lack of evidence for the effectiveness is true in all countries, even ones with better conditions than the United States. In places where use of restraints, forced stripping/other sexual assault, and confiscation of phones are less common, there has still never been quality evidence for the use of coercion in admission. At least with coercion and force in other medical fields, the goal tends to be accomplished; while the patient may be traumatized, the procedure itself likely functions as anticipated. Forced commitment does not even accomplish the goal it sets out to do, which is reduce the chance of patient suicide.
Additionally, in the U.S., proper procedures are rarely followed, and false testimony is accepted easily; it is likely less than 1 in 10 patients detained in institutions meet the criteria for a hold. Recourse is made difficult by common practices, such as banning the exchange of contact information with other subjects and the use of personal phones, internet, and recording devices in psychiatric wards.
Coercive inpatient commitment was never evidence-based medicine, but rather a legal and cultural standard motivated by a misunderstanding of mental illness and human despair. Cultures do not need to penalize suicidality to have effective prevention, and having this policy in place harms far more people than it helps. Italy, for example, which does not use the standard of “threat to self” as a basis for commitment, has a suicide rate of only 4.3 per 100,000—less than one third of the U.S. rate, less than half the global average, and among the lowest in Europe.
Arguably, ableism is at the root of forced intervention, where others determine that those labeled as severely psychiatrically disabled are unable to make their own decisions; or worse, that the comfort of others is more important than the impacts to the person themselves. Infantilization, or even downright objectification, of patients to this degree is not seen in any other area of medicine.
As the “Report on Improving Mental Health Outcomes” points out, disability discrimination towards perceived psychiatrically disabled patients in this manner is discouraged by the United Nations. The World Health Organization concurs. Both organizations have called for the banning of forced commitment on the basis of it being a human rights abuse. Whether suicide is always the result of a psychiatric disorder or not, this is no basis to force or coerce psychiatric hospitalization. Incarceration, even if it is in a mental institution, is not a humane method of intervention.
Survivors of coercive commitment commonly compare it to rape. It is easy to see the comparisons. Something that is supposed to be consensual and trusting is made into a reign of terror. If the subject is coerced into exhibiting signs of responding favorably, this is taken as evidence that it was not a real violation. Data may show the consensual version of each (i.e. hospitalization and sexual intercourse) to be helpful for mental health in ideal circumstances, but it would be a gross misapplication of said data to assume it generalizes when coercion is involved. Quite the opposite is true. Furthermore, the inherent lack of respect may contribute to the experience of coercion itself. For example, imagine you adore your partner and wish to be intimate with them. This may well change if they say your opinion is irrelevant and they will have sex with you regardless of what you think; the sex is involuntary. The lack of respect inherent in such an insinuation is inherently insulting and damages the relationship at its core. The same is true for involuntary commitment.
The same may be said of coercive drug intervention. For a comparison, there is some evidence suggesting moderate use of alcohol may benefit wellbeing; however, may the same be said for peer-pressured drinking or downright spiking? This is unlikely, like with sexual activity versus rape. Hence, study results must always be used in their proper context when discussing interventions; coercive drugging is not the same as consensual drugging. In fact, even outpatient CTOs have substantial, international evidence against their use in systematic reviews and meta-analyses. This is unsurprising to anyone who understands proper mental health treatment and its vital relationship to humanization and trust.
The elephant in the room is: Why do people not want the “help?” Why would one have to force the “help?” The answer often lies in the services provided and the methods used. Rather than an isolating, diagnosis-, drug-, and electroshock-pushing, carceral experience, people often need tangible solutions to life problems, like employment, human connection, and consensual ways to escape difficult abusive situations. This is especially true when patients know the treatments they are likely to be prescribed are proven to increase suicidality. Humanization is most needed at times when people’s distress is at its highest. People do not prefer to be gaslit that their distress must be a psychiatric drug deficiency, especially if they have had experience with psychiatry which created or exacerbated their issues.
In investigating the mental health field and its abuses via civil commitment, journalist Rob Wipond found that organizations which openly opposed the WHO’s and UN’s stance, such as the American Psychiatric Association, NIMH, and others, were all unable to provide quality outcome data showing benefits of forced commitment or treatment. The studies on the topics overwhelmingly show no benefit—that the practices are traumatizing and suicidogenic, not healing. There are other involuntary treatments in medicine, such as vaccinating children and treating heart attack patients; however, these are used because they are effective and appreciated by most patients later on. Neither is true for those coercively subjected to psychiatric detention, and the more coercive the experience, the worse the outcomes tend to be.
Via suicidogenic trauma, terror, and medicine, civil commitment has blood on its hands. Humanization and feelings of control are needed most when a person feels they have lost all meaning. When the alleged answers have proven not only to be human rights violations, but to be medically unsound, they must be done away with. Prohibition and the War on Drugs have long been linked to increased overdose deaths due to stigma, fear, and lack of legal, consensual resources. Likewise, the suicide epidemic can be reasonably attributed, at least in part, to the War on Suicide. The added factors like traumatic hospitalization and many of the drugs themselves being suicidogenic only worsen things further. As Dr. Peter Gotszche states, “Forced treatment kills patients.”
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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