America Already Has Extremely High Rates of Civil Commitment

A new study confirms that rates of psychiatric incarceration have been rising for many years

In this issue: Land (of pain) acknowledgement; Everyone has anosognosia, you idiot; Foxy Rob; New study on rates of civil commitment in U.S. (12 mins reading time)

I frequently feel like I should begin every post now with a pained acknowledgement to the fallen—recognition of the continued movement of the United States deeper into authoritarianism and extrajudicial policing. How extensive the undermining of democratic processes will become remains unclear, but one thing we know: It will almost certainly come with ever-expanding uses of involuntary commitment powers, because it’s simply too easy to use these to diagnose, discredit, incarcerate, and tranquilize virtually any “public enemy.”

A relatively minor but telling example of what’s to come is Brian Stettin’s remark to journalists this week

Everyone has anosognosia, you idiot

Stettin was a long-time policy director of the pro-force lobby group Treatment Advocacy Center and is now “senior advisor on serious mental illness” to Mayor Eric Adams in New York City. Stettin was justifying the incarceration of drug users in psychiatric facilities, even when clinicians don’t believe the person has any mental disorder whatsoever: “We’re talking about introducing the possibility of a really short-term hold in a hospital to get somebody through the physical withdrawal that often prevents them from recognizing their own need for substance abuse treatment,” said Stettin.

There’s a lot of inanity in that statement, but I’ll focus on one part: Stettin and TAC have long claimed that “anosognosia” or an alleged “lack of insight” and “inability to recognize” one’s need for psychiatric treatment is caused by “biological” damage to the brain that has developed from untreated schizophrenia or bipolar disorder. For decades, they’ve used this idea to justify forced treatment. Yet here, we see Stettin suggesting that anyone having trouble withdrawing from any drug whatsoever has anosognosia, too—which can then be miraculously, instantaneously cured through forced withdrawal!

As I wrote in Your Consent Is Not Required, aside from the contradictions and pseudoscience behind this whole idea, saying someone has anosognosia is conceptually no different than saying, “You’re too stupid to know how stupid you are.” It’s a humorous, effective, and indeed compelling argument—until we realize it could just as easily apply to us, and so consequently has little practical relevance beyond being a good reminder that we could all stand to be more humble, self-questioning, and respectful towards others.

Unfortunately, as the political situation worsens, we can expect ever more attempts to use the idea in Stettin’s way—to justify detaining and forcibly “treating” people whose behaviors are not illegal but are vehemently disliked by those holding power.

I tried to get an inkling of some of this across when I appeared on the popular (and sometimes notorious) morning show “Fox & Friends” last week for about three minutes. Everyone I trust has told me that I did okay; for reasons I may explore in a future post, I haven’t yet been able to go back and watch it myself. And I’m still frustrated thinking about all of the important things I didn’t manage to squeeze in!

However, I did read and was struck by many of the comments below the clip, where a stream of Fox News viewers called me “insane” and “delusional”—which is surely a necessary rite of passage for anyone who passes through the public spotlight these days? I also noted there and elsewhere many social media responses drenched in openly vitriolic hatred and name-calling targeted at homeless people, users of drugs, and those labeled with mental disorders. This base hatred is surely driving a lot of policies right now and cannot lead anywhere good.

Expand Commitment, Hide the Data

Once again, it’s confirmed: The U.S. has one of the highest known rates of civil commitment in the western world. And if we ever get the complete numbers, the rates will likely be orders of magnitude higher.

Last week the American Psychiatric Association journal Psychiatric Services released a new study of the numbers of people detained each year under civil (non-criminal) mental health laws in the United States. It was led by a team from the professional research services company Westat and funded by the federal Substance Abuse and Mental Services Administration (Karakus et al, “Involuntary Inpatient Civil Commitment: Trends From 2010 to 2022”).

It’s the second such study that’s been done—the first was by UCLA’s Gi Lee and David Cohen several years ago, and the latter of whom was a consultant on this study. In large part, this second study affirms the key, most important findings from the first.

Karakus et al did searches on government and court websites and e-mailed staff at State Mental Health Authorities (SMHAs) and state civil courts to gather recent data on civil commitment.

The result: Only 32 states and the District of Columbia (less than two-thirds of the country) provided any data at all about how many people are being committed.

Wherever data was found, the rates of psychiatric incarceration per 100,000 people did not decrease in any state between 2010 and 2022—all state detention rates were rising in sync with their population growth, or rising faster still. (I’ve posted one of Karakus et al’s supplements because it provides useful reference web links to this publicly accessible state data.) Nevertheless, only a handful of states gathered even just the most rudimentary demographic data on age, sex, or race-ethnicity—making it impossible to get any reasonable large-scale view into who is being committed or why.

Rates of psychiatric detentions varied enormously from state to state—ranging from 13.5 civil commitments per 100,000 people in Tennessee to 875.98 per 100,000 in Florida.

Overall, Karakus et al calculated a “grand mean rate” of 213.84 involuntary inpatient civil commitments per 100,000 people across all 32 states and DC from 2010-2022.

Notably, even though Karakus et al found stable or ever-increasing rates per 100,000 over time, their 213.84 rate is lower than the various averages from Lee and Cohen’s earlier study, which found between 309 and 357 detentions per 100,000 people. This somewhat confusing result mainly came about because Karakus et al included a handful of states with very dubious, extremely low numbers (see the discussion of data sources below). In any case, even at 213.84, this is still twice the rate in the UK and higher than virtually every other European country.

How many are missing?

Aside from more than a third of the country missing, there are some other important missing elements in this data and study.

Karakus et al’s data sources consisted of 6 SMHAs and 27 court systems. However, in many states, as Karakus et al rightly note, the vast majority of people get detained in hospitals on “emergency holds” and never get flagged to the courts before they’re released. Typically, only the much smaller percentage of detainees being considered for longer-term commitments get registered with the courts for a hearing. Therefore, in 27 of the 33 states where Karakus et al found data, what they obtained were almost certainly vast undercounts—perhaps even just small fractions of the true totals. (Karakus et al’s data show the rates of detentions recorded by SMHAs indeed tend to be vastly higher than from state courts—but it’s not clear if even the SMHAs are recording all of the emergency holds, since several years ago Colorado’s numbers jumped significantly when they finally started doing so.)

And importantly, these holds can themselves be long. Karakus at al state (perhaps reassuringly to some) that these many emergency holds are in any case never longer than seven days—however, in fact, some states’ holds are longer. For example, Rhode Island involuntary holds can last ten days (they also have ten-day involuntary holds for alcoholics.) More significantly, emergency psychiatric holds in many states exist in fuzzy quasi-legal grey areas and often easily get stretched into longer detentions. For example, a “preliminary” courtroom discussion or “pre-hearing” can take place up to five days after the ten-day hold in Rhode Island, and then the actual hearing can be scheduled 7-21 days after that. So in effect, a psychiatric detainee in Rhode Island can arguably be detained up to 36 days in total on an emergency hold—longer than an initial long-term commitment in some states.

Mainly, this highlights that, even where there is some basic numbers data, in most of these states we still know virtually nothing about how long most people are being detained, or if they’re being forcibly treated during these periods.

So, Karakus et al rightly describe their data as “incomplete and inconsistent,” and argue that the “wide variability” in rates between states likely do not reflect different realities on the ground so much as differences “in how states collect, define, and manage their data on civil commitments.”

Who can support this?

In summary, we now have a second study confirming that we have very little reliable information—and virtually no details—about how many Americans are currently being civilly committed, who they are, why they’re being committed, and what’s happening to them. It’s not the way we treat people or track medical results if we’re truly trying to help.

In this context, how can any reasonable person advocate for further expanding commitment criteria and increasing the numbers of people being committed—as is currently happening in many states? Especially when, conversely, there is one type of “data” that we do have in droves—studies showing that civil commitment leaves many people harmed and traumatized by the experience.

Karakus et al similarly concluded that “the lack of standardized processes, definitions, and data across states hinders the ability to examine the contributing and explanatory factors that may guide policy decisions.” As a result, “no definitive conclusions can be drawn about the reasons for these trends or their impact on individuals or systems,” and therefore “policy makers and practitioners are left without the information needed to guide reforms to protect individual rights and to ensure access to appropriate mental health care.”

What do Karakus et al advocate? “Our findings underscore the need for states to adopt more consistent and transparent reporting standards,” they wrote. Unfortunately, there’s a lot already here to suggest that governments and mental health institutions won’t agree to this—which raises sharp questions about what the purposes of commitment powers really are, why these purposes are being disguised, and why virtually no major news media report on it critically.

Have you seen an important study or interesting article about involuntary commitment? Please let me know in the comments or in an email to news@robwipond.com