Involuntary Hospitalization: From Ally to Adversary?

Helping Suicidal Client

You are listening to a client describe very specific plans to attempt suicide by overdosing. She has 94 pills of a potentially lethal medication at home. She knows the number because she has counted, again and again, in a sort of ritual to prepare herself for the act.

A familiar unease settles in you. You ask her if what she is describing are merely thoughts, or plans. That is, does she really intend to actually attempt suicide very soon?

“Yes, yes,” she says quietly, sobbing. “I just don’t want to live anymore.”

You invite her to tell you more about her situation, her pain, her plans. She tells you she will take the pills tonight and that nothing will deter her. You probe for ambivalence, hope, desire to live. There is none. She says she is beyond hope or help. She is insistent on killing herself that evening in a motel room out of town, so that she will not be interrupted.

Eventually you tell her that you believe she needs to be in a hospital to ensure her safety.

“I would die before going to a hospital,” she says. She then tells you that if you do anything to make her go to a hospital, then if she does survive, she will quit therapy and hate you forever, because you will have shattered her trust.

What next?

The Role of Psychotherapists

A very difficult tension exists in the role of psychotherapists. On the one hand, we want to provide a safe space for people to reveal their deepest thoughts without judgment. Our goal is for clients to be understood, safe, and, above all, helped.

On the other hand, if a person’s statements indicate that he or she will act soon on suicidal or violent thoughts, then we may need to move beyond supportive, nonjudgmental listening. We may need to take action – whether the client wants us to or not.

Some clients will recognize that they need to be in a safe environment. These clients will go willingly, perhaps even gratefully, for an evaluation to see if they need inpatient hospitalization to protect them.

But when severely suicidal clients resist our efforts to keep them safe, we risk moving from ally to adversary. We now are in the position of using the information that they shared with us to thwart their plans to do violence to themselves or others.

Danger of Overreacting

It is extremely difficult to have someone involuntarily hospitalized, and appropriately so. Commitment to a psychiatric hospital is a drastic move. It takes away a person’s freedom, potentially harming the person’s livelihood, social relationships, and emotional state. 

Commitment to a psychiatric hospital also can strain or even rupture the therapeutic relationship with a client. The client may become angry about needing to go to a hospital for an evaluation or admission. And the client may find it unsafe to ever confide again in you or, perhaps, any other mental health professional. 

For these reasons, psychotherapists must avoid overreacting. Clients need to have a safe space in which they can talk about their suicidal thoughts without the therapist “freaking out” or moving to hospitalize when it is not actually justified.

Suicide and therapyDesire to die is not enough to constitute imminent risk of suicide, the criterion in many states for involuntary hospitalization. Persistent suicidal thoughts are not enough to constitute imminent risk. Even having a plan to die by suicide is not enough.

To justify involuntary commitment, the therapist must believe that a client will act very soon on the suicidal thoughts. (Psychosis or other features that make a person unable to control whether he or she acts on suicidal thoughts may also call for involuntary hospitalization.)

I have had clients describe to me in very specific detail how they would attempt suicide. And they expressed strong desires to die. But they did not strongly intend to act on their suicidal thoughts any time soon. For them, it was necessary over many sessions to be able to talk through their suicidal wishes, to not feel so alone, and to develop skills to stay safe and feel better. Premature or outright unnecessary hospitalization would have been devastating.

Even so, there are times when a therapist finds it necessary to seek involuntary hospitalization for a client. In the example I began with, the suicidal client had a clear plan to die by suicide that night, intent to carry out the plan, and the lethal means to do so. For the therapist to not take action would be irresponsible, even malpractice.

(I should note that some states allow for terminally ill people to die by suicide without interference if they use medication prescribed for that purpose. But that is material for a future post.)

Whose Adversary?

Earlier I wrote that we move from ally to adversary in our efforts to keep a client safe against his or her wishes. The reality is that, in trying to keep an imminently dangerous client safe, we are the ally of the client’s healthy self, the part that wants to live.

When we believe that the client truly intends to act on suicidal thoughts very soon, the adversarial relationship exists only with the client’s unhealthy self, the part that wants to die. 

When suicide is imminent, the client’s healthy self has become muted, cut off even from the client. The client may feel especially betrayed by our efforts to step in and keep them safe.  That is okay. If someone truly has every intention to die by suicide within hours or days, our most important task is to help them stay safe.

If all goes well, sometime later, they may even agree.

UPDATED: May 29, 2014

© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide

Photos purchased from Fotolia.com

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© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide

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  1. Anonymous says:

    Suicide is legal!

    [This comment was edited to abide by the site’s Comments Policy. – SF]

    • Stacey Freedenthal, PhD, LCSW says:

      Indeed it is – there is no law against suicide.

      However, professional ethics and civil statutes allow for – and some people would say require – mental health professionals to intervene when someone is at imminent risk of dying by suicide. I don’t always support this expectation, but it’s the reality we deal with.

  2. maria says:

    I was involuntarily hospitalized a couple months ago. I’m still LIVID. It was the most dehumanizing, hopeless situation I’ve ever been in and I left feeling more alone than ever, because it was now quite apparent that I couldn’t be honest without the threat of being hospitalized again. My trust was betrayed, and it put a huge strain on my relationship with my parents. I don’t trust them, I barely even like them. I refused to talk to the psychiatrist who hospitalized me (he’d been seeing me for 5 years beforehand) and quit. I don’t trust anyone, I cannot ask for help, I’m trapped- because if I talk to anyone, I’ll end up back there.
    Involuntary hospitalization is disgusting and borderline criminal.

  3. Zara says:

    The fact that she told you in no uncertain or ambivalent terms would indicate she actually wanted you to have her committed. If she didn’t want an intervention she could have either kept her mouth shut or denied immidiate planning making involuntary admission legally impossible (absence of serious risk of harm). The fact that she didn’t and at the same time told you she would hate you etcetera to me is clear evidence of irrationality.(unthinking, childish behaviour). Committing suicide under those circumstances would be a bad decision in my book (lack of clear headedness and rational decision making) and given your legal obligation I fully understand the decision you made.

    As long as therapists can be held liable for their client’s personal decisions they have little control over like suicide (which I think is ridiculous) the ethical thing to do for a person seeking therapy is to avoid puttng their therapist or doctor in that position. Which of course makes therapy aimed at uncovering the motives that lead someone to consider self-destruction difficult unless your moral view is that suicide is always wrong under any circumstances.

    That seems to be the guiding principle (I’d call it dogma since it cannot be substantiated objectively) for the mental health industry and in a way that’s fine (you’d want your therapist to go to great lengths to help you explore other options since no matter how you look at it suicide is a very grave matter with potentially devastating consequences) but not if the state grants him or her not only the power but also the responsibility to keep you alive against your will. In that sense I really don’t agree with your metaphor of a ‘healthy’ and ‘unhealthy’ self since such terms serve to disguise a moral position (anti suicide): to regard wanting to die as a sign of mental illness (whatever that may mean: I’ve read about this a lot and nowhere did I find a proper definition clearly stating what it is and isn’t) is a non sequitur (feeling depressed and committing suicide may be correlated but does not mean there’s a causal relationship) and a subjective opinion based on socio-cultural bias. To me it signifies nothing more than that the person in question has serious problems and is looking for a way to solve them.

    In my mind suicide is a private matter and a decision, like most everything in life, that can be regarded as a good or a bad idea depending on the circumstances. If your life is utter excrement and you really are not able to enjoy it no matter what you try then to me it makes sense to end it. If on the other hand you are distraught, wracked with guilt, pain or despair and because of that (or complete detachment from reality as in psychosis) unable to think clearly and evaluate your options carefully (which would imply sufficient knowledge and consultation of specialists and others) then I don’t agree with it. Whether that is sufficient justification for the state to take away someone’s freedom is another matter.

    Unfortunately the law does not differentiate between rational and irrational suicide: the first should be legal owing to the unalienable right a person has to his or her body and life, in the latter a case could be made the state would be acting in the person’s best interest when they intervene to preserve life. Such a provision in the law would safeguard the people’s right to self-determination, allow for the rescue of those in the middle of a mental crisis (when you feel you compelled to suicide a wise person would advise to get help and consider the matter again in a better frame of mind) and relieve professionals of the need to act as their clients’ keeper or surrogate-parent when it’s clear they’ve made a reasoned, personal decision about the issue (regardless of whether one agrees with it or not: how can anyone know what’s truly in another’s best interest?).

    If there is a procedure that guarantees one the right to suicide (after having spoken with a mental health professional, been told the options, waited a few months to see whether they’d change their mind etcetera) and people still try to commit suicide on their own (that usually doesn’t bode very well for the outcome) or threatens others with it for any reason they should be committed to a mental hospital because either they’re just weak-willed folks who can’t fend for themselves or they have a serious condition that justifies forced intervention.

  4. Amanda says:

    I was “voluntarily” hospitalized about a year and a half ago. I was gradually recovering from multiple years of chronic depression, self injury, and suicidal thoughts but I still had trouble sometimes. I hadn’t hurt myself in months but I still kept vague plans for suicide and razorblades as an option and I was talking about this with my therapist. She told me she wanted to take me to the hospital immediately, but I didn’t want to go and I didn’t think it was necessary. Then she explained the whole “voluntary” thing. Basically, they wanted me to come quietly but I didn’t really have a choice anymore.

    The local mental hospital didn’t have any beds open, so I spent the first night on a couch in an empty room with a two-way mirror. I most definitely did not sleep. The next morning, I was packed up in a car with a police officer and some other guy and driven four hours away over snowy mountain passes to the nearest hospital with available rooms. I was put on a seventy-two hour hold but was actually made to stay there for closer to a week. There was a lot of weird double speak; you can leave after three days but actually you can’t leave until I say you can, this is voluntary but we’ll keep you here if you don’t choose to stay. I spent a lot of the time confused about my situation.

    I hadn’t hurt myself in a long time, like I said, but I relapsed almost immediately when I got there. I threw all my food away instead of eating it. This went unnoticed because it was all packed in to-go boxes with lids. I lied and said I’d been taking my antidepressants when I hadn’t been so that the dose they gave me made me sick. I scratched my arms and hands with my fingernails until I drew blood and then hid it under the blankets and the sleeves of my hoodie when they’d check on me. Just because I felt I had to prove that I could, to take back some of the control that I’d lost.

    I was tachycardic the entire time I was there. Due to heightened stress and lack of sleep, I experienced a resurgence of my mayoclonic seizures — uncontrollable movement while remaining conscious for the most part — something which the doctors there apparently chose not to record? I had to explain to each new nurse that came upon me when I had one. They would approach me with suspicion if they found me jerking uncontrollably in my bed at night. One particularly bad night, I was drugged against my will with something that I knew hadn’t helped with the seizures in the past. I told the nurse “No, it doesn’t work, it doesn’t work” and they held me down and stuck me with it anyway. I knew it wouldn’t do anything to help and that it would hurt worse the way I was thrashing. I panicked in that moment and I begged them not to when I realized that they weren’t listening while I was trying to explain. It’s a memory that’ll stay with me for a long time.

    I also managed to pick up a bit of a stalker while I was there. After the first day, I was forced to socialize and participate in meals. This allowed a male patient to follow me around because he was allowed everywhere except my room during the day — just like me. I was sexually harassed by someone who I could tell was just a lot less stable than everyone else there, and I was trapped. After a few days, someone noticed and he wasn’t allowed to be near me anymore, but he would find me anyway and it just made him very… upset. I just wanted to leave.

    I fed the staff what they wanted to hear, gradually ‘improving’, and left that place with more problems than I entered it with.

    I know this is long, but I was never exactly able to talk with anyone about my experience there afterwards.

  5. Leigh says:

    From my experience, it IS certainly illegal to express the wish to commit suicide in Los Angeles. An ex-boyfriend called the police, believing I was going to try. I was calm by the time the police arrived, but as I had stated I was suicidal, I was arrested, handcuffed, and taken to jail, where I sat for several hours.

    After being admitted to a lock-down ward of a hospital, I was ignored for 5 days. Originally, it had been three days, but I complained to the psychiatrist (who occasionally wandered in), he was angry, and gave me 2 more days.

    There were ward staff, but other than to call us for meals and medications, or tell us to get away from the door, they did not speak to us. There was nothing to do except watch TV, or read one of the few books on the ward.

    I was asked to cover a cigar box with material.

    It was a hideous experience. Had I had minor children, they would have been taken to DPSS…had a I had job, I would have been fired. The phones did not work consistently enough to call out.

    I was more suicidal when I got out.

  6. Mari says:

    Treat me without permission, incarcerate me, and when I got out I swear I would take you with me, and anyone else who helped put me there.

    • Stacey Freedenthal, PhD, LCSW says:

      Mari, I have known people who similarly felt very angry about having been involuntarily hospitalized, but who felt very differently when they were in a better state emotionally.

      Many years ago, I worked at a crisis hotline where one of these people was legendary. The person had called the hotline and described plans to kill someone and then die by suicide. The hotline counselor passed a note to another counselor, who called the police. The police went to the person’s house, where they found loaded firearms in a gym bag beside the front door.

      The hotline caller was involuntarily committed to a psychiatric hospital. Months later, after being discharged, the person called the hotline director to say thank you. The caller was grateful for having been stopped from killing another person and then himself.

      That is only one story, of course. But it is a good one. Generally speaking, for someone to be involuntary hospitalized, they have to be at grave risk of doing violence to themselves or to others. I am certain there are others out there who recognize that the trauma of being committed involuntarily to a hospital prevented an even greater trauma from occurring.

  7. Anonymous says:

    It is never okay to remove control away from someone. It is a lack of control over their lives that produces depression. You act as God. And have no right to do so. Because of YOUR beliefs I will die. Under no circumstances will I try to get help again. The risk to my self and my children is far too great. You are monsters. Every one of you…I hope that those, like yourself rot…but it will not happen. You do not care about the patient. You said it yourself…you would be subject to malpractice. Merry Christmas to the most untrustworthy, powerful segment in society. Hope you rot.

    • Stacey Freedenthal, PhD, LCSW says:

      “Anonymous,” from your anger I can only conclude that you have been hurt deeply by mental health professionals. Perhaps you have even experienced involuntary hospitalization.

      I am sorry you have had negative experiences. I hope you will keep in mind that there are hundreds of thousands of mental health professionals and thousands of psychiatric hospitals in the United States. While some professionals might not help you, there are others who can help.

      Yes, to seek help again would mean taking a risk.

      Yes, depending on what you disclose about your mental state and your level of danger, you might risk being hospitalized against your will.

      It is terribly difficult for me to believe that your children would be hurt more by your being hospitalized than by your dying by suicide.

      I wish for you hope and healing amid your great pain.

    • prettyangelboi says:

      Unfortunately Stacey as long as there is a risk of patients being neglected, abused. or otherwise exploited by mental health professionals due to a lack of safeguards, then this is not an issue to be taken lightly. We cannot justify involuntary civil commitment — that is taking away people’s personal freedoms — on the basis that it “usually” works out okay. Until the system protects mentally ill people first and foremost, and there is adequate oversight and accountability then I don’t think that a person’s fundamental human rights should be denied just because sometimes the mental health system function correctly.

    • michael says:

      Yes indeed controlling others lives is never ok….

      Mental illness industry is a disgrace, and the dsm iv has proven to be fake, voted upon like a candy factory

      Controlling others is intruding on others private space, it is a universal sin. People doing it, or helping doing it, will get their karma back one day.
      They will become very sad people, who neversmile for real, only fake smile

      Ever seen a psychiatrist smile? nope, they are in love with Control

  8. Cat says:

    I expressed thoughts that I was having to a therapist and they wanted me to commit myself. I didn’t have any intent but I had tried to commit suicide a month ago. I felt very betrayed by this therapist because I wanted someone to talk me through the thoughts and help calm me down. I’m afraid that they still want to have me committed.

    • Stacey Freedenthal, PhD, LCSW says:

      Cat, that must have been very frightening. I’m sorry that you are not able to trust your therapist. Is this something you could to him or her about? As a therapist myself, I would certainly want to know if my client did not trust me. And I would want to know what I needed to do, within limits, to rebuild that trust.

      Best wishes for you in your healing. I hope that you are able to talk through your thoughts and be helped.

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