Involuntary commitment

Involuntary commitment is the practice of placing a person to a psychiatric hospital or ward against his or her will, in compliance with mental health laws of the country. Commitment is normally time-limited and requires reevaluation at fixed intervals.

Most countries require a formal court hearing if the individual is hospitalized involuntarily more than briefly. Commonly, the commitment process begins when a law enforcement officer or a designated mental health professional determines that a person is in urgent need of psychiatric evaluation. If this evaluation indicates a need for further hospitalization, a court order must be obtained. Physicians, psychologists and/or psychiatrists present written reports to the court and in some cases testify before the judge. The person who is involuntarily hospitalized may be provided with legal counsel, and may challenge the commitment through habeas corpus rules.

There have been alternating trends towards the abolition or substantial reduction of involuntary commitment via stricter standards for its imposition, and the greater use of involuntary commitment with more lax standards for its imposition. Alternatives include voluntary commitment in hospitals, and involuntary treatment outside of a hospital.

Purpose
Involuntary commitment has been used for a variety of purposes over the years and in different jurisdictions. There has been considerable debate about these purposes and this has been a factor in leading to the various laws. A number of individuals and groups remain strongly opposed to either all these laws, some of these laws, or some aspects of their application.

In most jurisdictions involuntary commitment is specifically directed at people claimed or found to be suffering from a mental illness which impairs their reasoning ability to such an extent that the laws state or courts find that decisions must or should be made for them under a legal framework. (In some jurisdictions this is a distinct proceeding from being "found incompetent.") This decision requires a subjective opinion and is therefore open to error or abuse, both of which have been documented as occurring at different times in various places. There have been numerous official enquiries into such matters around the world and these have often led to legal and system reforms, but there have also been allegations that the requirements for involuntary commitment are "too lenient," with a consequential strengthening of such laws.

Involuntary commitment is used to some degree for each of the following headings although different jurisdictions have different criteria. Some allow involuntary commitment only if the person both appears to be suffering from a mental illness and that the effects of this produce a risk to themselves or others. Other jurisdictions have criteria that are broader.

Observation
Observation is sometimes used to determine if a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person is psychotic or otherwise warrants commitment and so sometimes people are admitted for a period to observe their behavior. This period of observation can be helpful in determining the actual diagnosis but can tend to produce an expectation of disease which can alter the perceptions and behavior of the staff. David Rosenhan's paper, "On being sane in insane places",1 demonstrated a variety of problems. In this study a number of volunteers mimicked illnesses (pretending to hear a voice in their head that simply said "thud") to obtain admission to hospital and then subsequently behaved normally. The staff continued to perceive that they were exhibiting signs of the illness diagnosed on admission and treated them as such. Rosenhan's results were criticized by psychiatrist Robert Spitzer2 who argued that given the initial "symptoms" presented that the mindset of the staff was not only understandable but that it did not invalidate an ability to diagnose conditions as Rosenhan had claimed. Rosenhan's experiment remains a cautionary tale that informs the teaching of trainee psychiatrists.

Containment of danger
A common reason given for involuntary commitment is to prevent danger to the individual or society. People with suicidal thoughts may act on these thoughts and harm or kill themselves. People with psychoses are occasionally driven by their delusions or hallucinations to harm themselves or others. People with personality disorders are occasionally violent and can be a danger to the disabled patients as well as the elderly.

This concern has found expression in the standards for involuntary commitment of a number of jurisdictions in the U.S. and other countries as the "danger to self or others" standard if someone has a "mental illness" or "mental disorder" (though sometimes explicit exceptions are made, as in Arizona law, in which "drug abuse, alcoholism or mental retardation" and "the declining mental abilities that directly accompany impending death" are specifically excepted), sometimes supplemented by the requirement that the danger be "imminent". However, it has come under criticism from two directions. Those who are concerned that the "danger to self or others" standard is too narrow and will not permit the commitment of those for whom it is necessary have occasionally advocated that it be replaced by the "gravely disabled" standard. There are others who are concerned that the "danger to self or others" standard is vague and not precisely defined, which could lead to abuse of involuntary commitment. However, some people find that the increasingly narrow definition of "danger to self or others" provided by statute and court rulings have to some degree mitigated these concerns.

Some of the same people who are concerned about the overbreadth of the "danger to self or others" standard are more concerned about the "gravely disabled" standard, as they find it broader still. The First District Court of Appeal in California, however, held in Conservatorship of Chambers (1977) (71 Cal.App.3d 277, 139 Cal.Rptr. 357), that the standard was not unconstitutional due to overbreadth or vagueness, and excluded commitment of people whose lifestyles were simply eccentric or unusual. In Wetherhorn v. Alaska Psychiatric Institute (2007), the Supreme Court of the State of Alaska found that a person could not be involuntarily committed under the statute unless their "level of incapacity [is] so substantial that the respondent is incapable of surviving safely in freedom." In In re Maricopa County, (Ariz. Ct. App. 1992, 840 P.2d 1042), the court held that "persistently or acutely disabled" was not an unconstitutionally vague standard.

The Michigan Mental Health Code provides that a person "whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others" may be subjected to involuntary commitment, a provision paralleled in the laws of many other jurisdictions. These types of provisions have been criticized as a sort of "heads I win, tails you lose". Understanding one's "need for treatment" would cause one to agree to voluntary commitment, but the Bazelon Center has said that this "lack of insight" is "often no more than disagreement with the treating professional" and this disagreement might form part of the evidence to support one's involuntary commitment.

In Oregon the standard that the allegedly mentally ill person "Peter [h]as been committed and hospitalized twice in the last three years, is showing symptoms or behavior similar to those that preceded and led to a prior hospitalization and, unless treated, will continue, to a reasonable medical probability, to deteriorate to become a danger to self or others or unable to provide for basic needs" may be substituted for the danger to self or others standard.

In Utah the standard is that "the proposed patient has a mental illness which poses a substantial danger," where "Substantial danger" means the person, by his or her behavior, due to mental illness: (a) is at serious risk to: (i) commit suicide, (ii) inflict serious bodily injury on himself or herself; or (iii) because of his or her actions or inaction, suffer serious bodily injury because he or she is incapable of providing the basic necessities of life, such as food, clothing, and shelter; (b) is at serious risk to cause or attempt to cause serious bodily injury; or (c) has inflicted or attempted to inflict serious bodily injury on another.

Treatment of illness
It has been established through O'Connor v. Donaldson that an individual cannot be involuntarily committed unless he is a danger to himself or others and that while committed, he must receive appropriate treatment. The case of Rennie v. Klein established that an involuntarily committed individual has a qualified constitutional right to refuse psychotropic medication. In California under the Lanterman–Petris–Short Act each involuntarily detained person has the right to refuse psychosurgery for the purpose of mind control but not prefrontal sonic treatment wherein there is no destruction of brain tissue.

Community treatment as an alternative
There have been some criticisms of the efficacy or appropriateness of inpatient treatment. For example, the "Pan American Health Organization (PAHO) Caracas Declaration of 1990 [...] identified inpatient psychiatric treatment as isolating individuals from the community and thus as an obstacle to recovery." Community treatment is now generally accepted as an alternative.

Deinstitutionalization
Starting in the 1960s, there has been a worldwide movement toward deinstitutionalization of patients from psychiatric hospitals into community care centers, and this has been matched with efforts at reform of involuntary commitment laws. (In the U.S. from the 1970s onwards a relatively small number of ex-mental patients and former "consumers of psychiatric services" have promoted what they call the "psychiatric survivors movement", often calling for the abolition of involuntary commitment.)

In the U.S. in the 1980s there was a return to institutionalization and less stringent commitment laws. However, Michael L. Perlin3 has claimed that throughout this entire period psychiatrists have frequently and as a practice committed perjury during commitment hearings in order to make it more likely that a patient they believe would benefit from commitment will be committed. E. Fuller Torrey, a prominent proponent of involuntary commitment, has stated: ''It would probably be difficult to find any American psychiatrist working with the mentally ill who has not, at a minimum, exaggerated the dangerousness of a mentally ill person's behavior to obtain a judicial order for commitment [...]. Thus, ignoring the law, exaggerating symptoms, and outright lying by families to get care for those who need it are important reasons the mental illness system is not even worse than it is.''

Torrey also quotes psychiatrist Paul Applebaum as saying when "confronted with psychotic persons who might well benefit from treatment and who would certainly suffer without it, mental health professionals and judges alike were reluctant to comply with the law," noting that in "the dominance of the commonsense model, the laws are sometimes simply disregarded."4

The general trend worldwide remains one of closing large mental hospitals, increasing the integration of psychiatric treatment into general hospitals and of increasing community care at times using involuntary community treatment where in the past involuntary admission would have been used.

United Nations
United Nations General Assembly (resolution 46/119 of 1991), "Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care" is a non-binding resolution advocating certain broadly-drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programs in some countries to assist in this process.

Australia
In Australia, court hearings are not required for involuntary commitment. Mental health law is constitutionally under the state powers. Each state thus has different laws, many of which have been updated in recent years.

Referral for service
The usual requirement is that a police officer or a physician determine that a person requires a psychiatric examination, usually through a psychiatric hospital. If the person is detained in the hospital, they usually must be seen by an authorized psychiatrist within a set period of time. In some states, after a further set period or at the request of the person or their representative, a tribunal hearing is held to determine whether the person should continue to be detained. In states where tribunals are not instituted, there is another form of appeal.

Some Australian states require that the person is a danger to the society or themselves; other states only require that the person be suffering from a mental illness that requires treatment. The Victorian Mental Health Act (1986) specifies in part that:
 * "(1) A person may be admitted to and detained in an approved mental health service as an involuntary patient in accordance with the procedures specified in this Act only if—
 * (a) the person appears to be mentally ill; and
 * (b) the person's mental illness requires immediate treatment and that treatment can be obtained by admission to and detention in an approved mental health service; and
 * (c) because of the person's mental illness, the person should be admitted and detained for treatment as an involuntary patient for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and
 * (d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and
 * (e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of that person's freedom of decision and action.

There are additional qualifications and restrictions but the effect of these provisions is that people who are assessed by doctors as being in need of treatment may be admitted involuntarily without the need of demonstrating a risk of danger. This then overcomes the pressure described above to exaggerate issues of violence to obtain an admission.

Treatment
In general, once the person is under involuntary commitment, treatment may be instituted without further requirements. Some treatments such as electroconvulsive therapy (ECT) often require further procedures to comply with the law before they may be administered involuntarily.

Community treatment orders can be used in the first instance or after a period of admission to hospital as a voluntary or involuntary patient. With the trend towards deinstitutionalization this is becoming increasingly frequent and hospital admission is restricted to people with severe mental illnesses.

Germany
In Germany there is a growing tendency to use the law on legal guardianship, instead of mental health law, to justify involuntary commitment or treatment. The ward's legal guardian decides that he/she must go into mental hospital for treatment, and the police will act on this decision. This is simpler for the government and family members than the formal process for commitment under mental health laws.

In German criminal law a person that was convicted of certain crimes can also be sentenced to be kept in preventive detention; see article on preventive detention.

Netherlands
In Dutch criminal law a convict can be sentenced to involuntary psychiatric treatment in a special institute called a TBS-clinic. TBS is an abbreviation for "Ter Beschikkingstelling," meaning literally "being placed at disposal." Legally, such a sentence is not regarded as punishment like a prison sentence, but as a special measure. In the Netherlands, it is common practice to sentence criminals to a combination of a normal prison term and TBS. The convict will then be placed in a TBS-clinic after serving time in prison (usually two-third of the original prison sentence, although this practice is under discussion).

According to Dutch law, meeting three conditions is required for a convict to be sentenced to TBS. These conditions are:
 * the crime committed must have been directly related to a psychiatric disorder,
 * recidivism must be likely, and
 * the convict can not, or only partially, be held accountable for the crime.

To determine if these conditions are met, the suspect is observed in a forensic psychiatric detention center, the Pieter Baan Centre. Neither the prosecution or the defense can effectively challenge the Pieter Baan Centre's report, since it is the only institution that can conduct such investigations. Fatal mistakes have occurred, for instance, when a child molester regarded by the Pieter Baan Center as "not dangerous" killed a child upon release. The conclusions in the centre's report are not binding, the judge can decide to ignore, or only partially accept them.

Every convict detained in a TBS-clinic may get temporary leave, after serving a certain time or after some progress in treatment. This is regarded as an essential part of treatment, as the convict will be gradually re-entering society this way. At first the convict will be escorted by a therapist, and will be allowed outside the clinic for only a few hours. After evaluation, time and freedom of movement will be expanded until the convict can move freely outside the clinic without escort (usually for one day at a time). At that time, the convict will find work or follow an education. Generally, the convict is released after being in this situation for one or two years without incident.

The time to be served in TBS can be indefinite, and it may be used as a form of preventive detention. Evaluation by the court will occur every one or two years. During these evaluations the court determines if any progress is made in treatment of the convict, and if it will be safe to release the convict into society. In general, the court will follow conclusions made by the TBS-clinic.

Average time served in a TBS-clinic by a convict is slightly over eight years.

In the Netherlands there are currently 12 institutions regarded as TBS-clinics:
 * Dutch TBS-clinics
 * AMC de Meren/Arkin, Amsterdam
 * Dr. Henri van der Hoevenstichting, Utrecht
 * Dr. S. van Mesdagkliniek, Groningen
 * Hoeve Boschoord, Boschoord
 * FPC Veldzicht, Balkbrug
 * Pompestichting, Nijmegen
 * Oostvaarderskliniek, Almere
 * De Kijvelanden/FPC Tweelanden, Poortugaal
 * FPC Oldenkotte, Rekken
 * FPC De Rooyse Wissel, Venray
 * GGz Drenthe, Assen
 * GGz Eindhoven/De Woenselse Poort, Eindhoven

These institutions combined currently are holding about 1840 convicts.

By the end of the 20th century, it was concluded that some convicts could not be treated and therefore could not be safely released into society. For these convicts, TBS-clinics formed special wards, called "long-stay wards". Transfer to such a ward means that the convict will no longer be actively treated, but merely detained. This is regarded as more cost-effective. In general, the convicts in these wards will be incarcerated for the rest of their lives, although their detention is eligible for regular review by the court.

Controversy
Since the latter half of the 1990s considerable controversy has grown among Dutch society, about the TBS-system. This controversy has two main reasons. The first reason is the media increasingly reported cases of convicts committing crimes while still in, or after, treatment in a TBS-clinic.

Some examples of these cases are:
 * During 1992, a truck driver was convicted for raping and murdering three young children. Eight years earlier he was released from a TBS-clinic after being treated for child molestation.
 * A convict, about to be released from a TBS-clinic, murdered the owner of a garage in 1996 while under the influence of drugs.
 * An ex-convict, treated in a TBS-clinic, murdered two women in 1994 and 1997.
 * A convict, still treated by a TBS-clinic, randomly killed a man in the city of Groningen in 1999.
 * Between 2000 and 2004, an ex-convict tortured several animals and killed a homeless man. He had been treated in a TBS-clinic.
 * In 2002 an ex-convict was sentenced for triple murder. He also was released earlier.
 * In 2005 a convict escaped his escort during leave. He was arrested several days later after killing a man.

Political and social commotion increased, and debate started about the effectiveness of the TBS-system and if convicts should be granted leave from TBS-clinics. Especially right-wing politicians pleaded the TBS-system should be discarded altogether. Numerous articles in newspapers, magazines, television and radio programs and a revealing book written by an ex-convict (which for the first time openly questioned the effectiveness of the TBS-system) boosted discussion. Prior to that, any problems had been mostly denied by TBS-clinics themselves.

The center of attention became a highly renowned TBS-clinic, Dr. S. Van Mesdagkliniek in the city of Groningen. Events that took place there, by the end of the 1990s and the first years of the 21th century, initiated the second reason for controversy. Concern rose about signs of unprofessional behavior by staff working in TBS-clinics, and the Dr. S. Van Mesdagkliniek proved to be among the most infamous for these problems. This TBS-clinic has been plagued with unprofessional and even criminal acts by its staff since 1999. During that year, the Dr. S. Van Mesdagkliniek came under investigation by Dutch police after rumors about female staffmembers committing sexual offenses against convicts. Five such cases were discovered during the investigation, and also numerous cases of drug-abuse, smuggling and trading of contraband such as: alcohol, mobile phones, pornographic material and hard drugs. It became apparent that staff members did not have the required education, had not been informed about rules and regulations, disregarded legal procedures, gave false testimonies, tampered with evidence, uttered false accusations against convicts, and intimidated colleagues. At least one psychiatrist, employed as such by the Dr. S. Van Mesdagkliniek, proved to be not qualified, and treatment of convicts was in many cases simply non-existent. These problems had been known for long by the management, but were always kept hidden. After public outcry about this situation, management was replaced and all of the nine (at the time) TBS-clinics in the Netherlands were subjected to investigation. Six of them proved to be below the required legal standards. However, problems for the expensive Dutch TBS-system did not end there. In spite of many measures taken by the government, convicts still were released without proper treatment. As a consequence, numerous crimes were committed by convicts that were regarded as treated by TBS-clinics. Also, sexual offenses against convicts by staff members and smuggling of contraband did not cease in several TBS-clinics. In 2006, the Dutch government formed a committee to investigate the TBS-system. Some, however not the worst, problems were recognized and measures were proclaimed. One of the known actual results is that fewer convicts escape during temporary release.

Controversy regarding the, often praised, Dutch TBS-system does not cease to exist. In 2005, a staff member working in the Dr. S. Van Mesdagkliniek was caught while smuggling liquor to convicts suffering from alcohol-related problems. In 2007, a female staff member committed sexual offenses against a convict, and had smuggled contraband. She was sentenced to three months in prison in 2009. That same year, investigation proved convicts still had ample access to illicit drugs and four inmates from the Dr. S. Van Mesdagkliniek were arrested for possession of child pornography. Many crimes committed by released convicts treated in TBS-clinics, escape statistics because of occurring in other countries, or because they differ from the crime the convict was originally convicted for (many convicts released from TBS-clinics find their way in illegal drug trade and related crimes). Because there seems to be no acceptable alternative available, political support for the much plagued TBS-system remains, in spite of controversy.

United Kingdom
In the United Kingdom, the process known in the United States as involuntary commitment is informally known as "sectioning," after the various sections of the Mental Health Act 1983 (covering England and Wales), the Mental Health (Northern Ireland) Order 1986 and the Mental Health (Care and Treatment) (Scotland) Act 2003 that provide its legal basis.

In England and Wales, Approved Mental Health Professionals have a lead role in coordinating Mental Health Act assessments, which they conduct in cooperation with usually two medical practitioners. Under the Mental Health Act, detention is determined by utility and purpose. Ward-based patients can be detained for periods of up to 3 days while further assessments are arranged. In the community, mentally ill individuals may be detained under Section 2 for a period of assessment lasting up to 28 days or Section 3 for a period of treatment lasting up to 6 months. Separate sections deal with mentally ill offenders. In all cases detention needs to be justified on the basis that the person is mentally ill and constitutes a risk of deterioration and/or of risk to themselves or others.

Under the amended Mental Health Act 2007, which came into force in November 2008, to be detained under Section 3 for treatment, treatment that is appropriate must be available in place of detention. Supervised Community Treatment means people can continue to be detained and discharged on extended conditional leave to the community in accordance with a Community Treatment Order.

United States
Involuntary commitment is governed by state law and procedures vary from state to state. In some jurisdictions, laws regarding the commitment of juveniles may vary, with what is the de facto involuntary commitment of a juvenile perhaps de jure defined as "voluntary" if his parents agree, though he may still have a right to protest and attempt to get released. However, there is a body of case law governing the civil commitment of individuals under the Fourteenth Amendment through U.S. Supreme Court rulings beginning with Addington v. Texas in 1979 which set the bar for involuntary commitment for treatment by raising the burden of proof required to commit persons from the usual civil burden of proof of "preponderance of the evidence" to the higher standard of "clear and convincing" evidence.

In 1977, the U.S. Supreme Court ruled that involuntary hospitalization and/or treatment violates an individual's civil rights in O'Connor v. Donaldson. This ruling forced individual states to change their statutes. For example, the individual must be exhibiting behavior that is a danger to himself or others in order to be held, the hold must be for evaluation only and a court order must be received for more than very short term treatment or hospitalization (typically no longer than 72 hours). This ruling has severely limited involuntary treatment and hospitalization in the U.S. In the U.S. the specifics of the relevant statutes vary from state to state.

This was the case in a famous United States Supreme Court decision in 1975, O'Connor v. Donaldson, when Kenneth Donaldson, a patient committed to Florida State Hospital, sued the hospital and staff for confining him for 15 years against his will. The decision means that it is unconstitutional to commit for treatment a person who is not imminently a danger to himself or others and is capable to a minimal degree of surviving on his own.

An example of involuntary commitment procedures is the Baker Act used in Florida. Under this law, a person may be committed only if they present a danger to themselves or others. A police officer, doctor, nurse or licensed mental health professional may initiate an involuntary examination that lasts for up to 72 hours. Within this time, two psychiatrists may ask a judge to extend the commitment and order involuntary treatment. The Baker Act also requires that all commitment orders be reviewed every six months in addition to insuring certain rights to the committed including the right to contact outsiders. Also, a person under an involuntary commitment order has a right to counsel and a right to have the state provide a public defender if they cannot afford a lawyer. While the Florida law allows police to initiate the examination, it is the recommendations of two psychiatrists that guide the decisions of the court.

In the 1990s, involuntary commitment laws were extended under various state laws commonly recognized under the umbrella term SVP laws to hold some convicted sex offenders in psychiatric facilities after their prison terms were completed. (This is generally referred to as "civil commitment," not "involuntary commitment," since involuntary commitment can be criminal or civil). This matter has been the subject of a number of cases before the Supreme Court, most notably Kansas v. Hendricks and United States v. Comstock in regard to the Adam Walsh Child Protection and Safety Act, which does not require a conviction on sex offences, but only that the person be in federal custody and be deemed a "sexually dangerous person".

Controversy about liberty
The impact of involuntary commitment on the right of self-determination has been a cause of concern. Critics of involuntary commitment have advocated that "the due process protections... provided to criminal defendants" be extended to them. The Libertarian Party opposes the practice in its platform. Thomas Szasz and the anti-psychiatry movement has also been prominent in challenging involuntary commitment.

A small number of individuals in the U.S. have opposed involuntary commitment in those cases in which the diagnosis forming the justification for the involuntary commitment rests, or the individuals say it rests, on the speech or writings of the person committed, saying that to deprive him of liberty based in whole or part on such speech and writings violates the First Amendment. Other individuals have opposed involuntary commitment on the bases that they claim (despite the amendment generally being held to apply only to criminal cases) it violates the Fifth Amendment in a number of ways, particularly its privilege against self-incrimination, as the psychiatrically examined individual may not be free to remain silent, and such silence may actually be used as "proof" of his "mental illness".

Although patients involuntarily committed theoretically have a legal right to refuse treatment, refusal to take medications or participate in other treatments is noted by hospital staff. Court reviews usually are heavily weighted toward the hospital staff, with the patient input during such hearings minimal. In Kansas v. Hendricks, the US Supreme Court found that civil commitment is constitutional regardless of whether any treatment is provided.

Alternatives
Accompanying deinstitutionalization was the development of laws expanding the power of courts to order people to take psychiatric medication on an outpatient basis. Though the practice had occasionally occurred earlier, outpatient commitment was used for many people who would otherwise have been involuntarily committed. The court orders often specified that a person who violated the court order and refused to take the medication would be subject to involuntary commitment.

Involuntary commitment is distinguished from conservatorship and guardianship. The intent of conservatorship or guardianship is to protect those not mentally able to handle their affairs from the effects of their bad decisions, particularly with respect to financial dealings. For example, a conservatorship might be used to take control of the finances of a person with dementia, so that the person's assets and income are used to meet his basic needs, e.g., by paying rent and utility bills.

Advance psychiatric directives may have a bearing on involuntary commitment.

Politically motivated abuses
At certain places and times, the practice of involuntary commitment has been used for the suppression of dissent, or in a punitive way.

In the former Soviet Union, psychiatric hospitals were used as prisons in order to isolate political prisoners from the rest of society. The official explanation was that no sane person would declaim against Soviet government and Communism. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals.

The government of the United States once employed involuntary commitment against political dissenters. In 1927 after the execution of Sacco and Vanzetti a demonstrator named Aurora D'Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists.