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In various movies, most recently Unsane (2018), a scenario is painted in which a healthy person gets committed and trapped in an insane asylum and the caretakers there are more or less indifferent to whether she is actually sane or not.

In the movie she "voluntarily" commits herself by signing a form, so presumably she will not be afforded the protections some states give to involuntarily committed people.

Is this scenario realistic in the United States? Can a person who "voluntarily" commits themself, be turned into a medicated prisoner with no recourse for freeing themself?

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    $\begingroup$ There's a readable, current (2018) US-based discussion of involuntary commitment here: slatestarcodex.com/2018/03/22/… $\endgroup$ – steveLangsford Mar 29 '18 at 2:28
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    $\begingroup$ The United States is particularly notorious among developed nations for underfunded mental health institutions. It's far more likely for such institutions to discharge patients prematurely than to hold them longer than necessary, and it appears that many patients end up trapped in the penal system rather than the mental health system (researchgate.net/publication/…). $\endgroup$ – Arnon Weinberg Apr 14 '18 at 20:04
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It all boils down to the Duty of Care

Duty of Care

The duty of care is the responsibility of a mental health professional to protect patients and others from foreseeable harm. If a client makes statements that suggest suicidal or homicidal ideation, the clinician has the responsibility to take steps to prevent harm where reasonably practicable, and if necessary, initiate involuntary commitment.

The same goes when a person has been assessed as suffering from one or more severe mental health conditions which has a high chance of resulting in any other physical harm to the individual or others.

Voluntary Commitment

Getting committed either voluntarily or involuntarily is not straight forward. In both the US and here in the UK, you can't just go into a hospital, sign a form and then be taken in as a mental health patient. You can go into a hospital and ask to be committed, but you need to be assessed in order for the committal to be accepted.

Involuntary Commitment

With voluntary committal, you are free to discharge yourself by signing a discharge form and leave at any time, however, if at any time it is deemed that you would be a danger to yourself or others, the voluntary committal can change to involuntary committal.

Aside from an unscrupulous group of psychiatrists it is practically impossible to trap a mentally healthy person in a psychiatric unit against their will. For a person to be held against their will, it needs the co-ordinated efforts of more than one psychiatrist. Where it happens that a mentally healthy individual is held against their will, there is possible legal redress and the psychiatrists involved could have their practice licenses removed.

In the US

Voluntary Committal

As pointed out by psychiatrist, Scott Alexander, in his Slate Star Codex post, you are not guaranteed admission to a psychiatric unit on a voluntary basis just because you want it. You might be turned down if the psychiatrist thinks you aren’t sick enough to need it, or if your insurance refuses to pay for it. Insurance companies are very reluctant to pay for hospitalisations unless there is a clear risk involved.

Involuntary Committal

The laws governing this seems to differ depending on which state you are in.

For example:

  1. In California

    According to the Lanterman-Petris-Short Act (Section 5150 of the California Welfare and Institutions Code)

    When a person, as a result of a mental health disorder, is a danger to others, or to himself or herself, or gravely disabled, a peace officer, professional person in charge of a facility designated by the county for evaluation and treatment, member of the attending staff, as defined by regulation, of a facility designated by the county for evaluation and treatment, designated members of a mobile crisis team, or professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment in a facility designated by the county for evaluation and treatment and approved by the State Department of Health Care Services.

  2. In Florida

    According to the Florida Mental Health Act

    A person may be placed in involuntary inpatient placement for treatment upon a finding of the court by clear and convincing evidence that:

    (a) He or she is mentally ill and because of his or her mental illness:

    1.a. He or she has refused voluntary placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment; or

    b. He or she is unable to determine for himself or herself whether placement is necessary; and

    2.a. He or she is manifestly incapable of surviving alone or with the help of willing and responsible family or friends, including available alternative services, and, without treatment, is likely to suffer from neglect or refuse to care for himself or herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; or

    b. There is substantial likelihood that in the near future he or she will inflict serious bodily harm on himself or herself or another person, as evidenced by recent behavior causing, attempting, or threatening such harm; and

    (b) All available less restrictive treatment alternatives which would offer an opportunity for improvement of his or her condition have been judged to be inappropriate.

In the UK

The whole issue of committal, voluntary and involuntary, is governed by the Mental Health Act 1983 and the Mental Health Act 2007.

Involuntary Committal in the UK

To be involuntarily committed (also known as sectioned), it needs to be founded on the written recommendations in the prescribed form of two registered medical practitioners, including in each case a statement that in the opinion of the practitioner:

  1. The individual is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period; and
  2. The individual ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons. (See Sections 2 and 3 of the Mental Health Act 1983)

For voluntary committal in the UK

It needs to appear to the registered medical practitioner or approved clinician in charge of the treatment of the patient that an application ought to be made under Section 5(2) of the Mental Health Act 1983, for the admission of the patient to hospital, he or she may furnish to the managers a report in writing to that effect; and in any such case the patient may be detained in the hospital for a period of 72 hours from the time when the report is furnished. By which time the patient should be assessed by the two registered practitioners prescribed in Section 2 of the Act.

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  • $\begingroup$ This does not really answer the question. The question is whether a mentally healthy person could get trapped against their will in a scenario like in "Unsane". Simply quoting rule books does not answer this question. $\endgroup$ – Tyler Durden Apr 4 '18 at 8:56
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    $\begingroup$ @TylerDurden - I encourage you to carefully read the answer - it does target your question heads on $\endgroup$ – AliceD Apr 4 '18 at 9:07
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    $\begingroup$ To add about the UK - there is also a possibility to appeal against being sectioned. Within 2 weeks from appealing there must be a tribunal hearing consisting of 1 independent doctor, judge and a lay member. Patient can be represented by a lawyer. For longer term sections tribunal will be convened within a month. In addition even quicker there can be managers hearing - but that discharges from section only if procedure used was done wrongly. $\endgroup$ – r0berts Apr 7 '18 at 12:56
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    $\begingroup$ There is always possibility to appeal against being sectioned. Hence "Where it happens that a mentally healthy individual is held against their will, there is possible legal redress and the psychiatrists involved could have their practice licenses removed." — Second paragraph of 3rd section of my answer $\endgroup$ – Chris Rogers Apr 7 '18 at 13:02
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I think in current times this is hardly possible.

It has happened in the late 1800's that a sane person gets themselves admitted purposefully in a New York mental institution in order to reveal the poor conditions in which the admitted people have to live.

More recent cases have been listed by popular sources such as this one on the internet. Given the questionable reputation of such sites, it is hard to say in as how far they reflect reality.

A cursory search on Google Scholar (e.g. "admission+of+healthy+individuals+in+mental+ institutions) yields no relevant hits, other than those pertaining to involuntary admissions, i.e., admissions of folks against their own will. There the debate starts whether people should be admitted in institutions against their will, and when it is deemed necessary for their own good, or for the safety of others. That, however, is a discussion outside the scope of this question though.

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Yes and no.

It depends a lot on the legislation of a country. For example, in Germany, if you are admitted involuntarily by social workers, the police or doctors, you must see a judge in the following 48 hours after your admission. Furthermore, you may not be treated or kept in mental care against your will if a judge has not ruled so. Meaning if you are admitted involuntarily, there must be pretty strong evidence suggesting that you actually need to be admitted.

However, it does look quite different if you admit yourself voluntarily: In the year 1973, Rosenhan conducted a experiment, investigating how voluntarily admitted pseudo patients are treated in closed mental care institutions. He wrote a paper about it, called "On being sane in Insane Places" Let me cite some passages from a summary of the study, published on dowellwebtools.com:

[Rosenhan] put together a team of eight perfectly healthy and sane "pseudo patients" [...] to have themselves committed in one of several psychiatric hospitals across the United States. In order to make this experiment work, the pseudo patients had to lie about [...] the fact that they heard a voice in their heads.

Immediately after admission, the pseudo patients acted normally [...] while discreetly taking notes for the experiment. They could not be released without staff corroboration of their sanity, which took from 7 to 52 days [...] to get.

When the pseudo patients were eventually discharged, none of them were seen as normal, but all with "schizophrenia in remission."

Searching for it on Wikipedia reveals that there is a second part to Rosenhan's study which is even more interesting:

The second part of his study involved an offended hospital administration challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 250 new patients the staff identified 41 as potential pseudopatients, with 2 of these receiving suspicion from at least one psychiatrist and one other staff member. In fact, Rosenhan had sent no pseudopatients to the hospital.

The core of your question can be answered with no: It's very unlikely for a person to be kept in mental care for a very long time without showing actual symptoms of a mental disorder. If you read Rosenhan's study carefully, you will find a passage that says that other patients got suspicious of the pseudo patients as they seemed "too normal".

During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. "You're not crazy. You're a journalist, or a professor [referring to the continual note-taking]. You're checking up on the hospital."

So, sooner or later, someone would raise a concern.

Nevertheless, it is not unrealistic to be kept in mental healthcare for a shorter duration even though you show no symptoms or whatsoever. Rosenhan explains this as follows:

The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood.

But before storming off now, saying that mental healthcare institutions can't diagnose properly, it's important to note that I couldn't find any replication of Rosenhan's study in our time, nearly 50 years later, and that his pseudo patients wanted to be admitted. The fact that they stopped showing symptoms right after they were admitted would probably leave anyone wondering what is going on, meaning that most would make closer and longer observations. (Why did he stop showing symptoms? Maybe a new disorder appeared?)

Conclusion: His findings don't necessarily have to hold true nowadays (at least to the extent he found), but it may be helpful to take them into account.

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  • $\begingroup$ Welcome and thanks for your answer. I think the question is not so much on involuntary admission, but admission of healthy folks. $\endgroup$ – AliceD Mar 28 '18 at 11:32
  • $\begingroup$ Did you even read my question? The question is about psychologically healthy patients admitted voluntarily in the United States. $\endgroup$ – Tyler Durden Mar 28 '18 at 12:06
  • $\begingroup$ Thank you for referencing Rosenhan‘s work, a hallmark of putting the finger on a fundamental problem not only in the institutions, but the very definitions of sanity / insanity. $\endgroup$ – michi Apr 4 '18 at 20:17
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    $\begingroup$ see the case of Gustl Mollath, a German man who was kept in forensic mental hospital with a court order for several years without justification: en.m.wikipedia.org/wiki/Gustl_Mollath. Involuntarily admitted, though. $\endgroup$ – michi Apr 4 '18 at 20:25
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    $\begingroup$ @TylerDurden a little background can‘t hurt, don‘t you think? $\endgroup$ – michi Apr 4 '18 at 20:27

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