Illegal Fraud is the Norm for Psychiatric Commitment

Two more investigations again reveal systemic abuses of patients’ rights

A psychiatrist in a prominent trade journal recently expressed “horror” about the mass-scale involuntary commitment fraud perpetrated by Acadia Healthcare Corporation in psychiatric facilities across at least twenty-four U.S. states. I found this heartening—profiteers, under false pretenses, depriving people of their most basic rights and liberties is indeed horrifying. And I found it still more heartening to see him express concern about the evident lack of any similar, widespread outrage among his fellow psychiatrists.

However, as two new, systemic investigative reports reveal, the real, underlying problem is this: Even when there’s no major financial motive, illegality and psychiatric fraud are the norm in the practice of involuntarily committing people. And though under-reported and under-discussed with respect to mental health laws, it’s not surprising: When society gives any group authoritarian powers without strong accountability, dividing lines between using and abusing those powers quickly evaporate. And the last ones to protest, or even see the true scope of the problems, are usually the people who hold those powers.

The key components of commitment fraud

First, a brief review of what blatant involuntary commitment fraud looks like.

According to the September, 2024 settlement agreement between Acadia and the U.S. Department of Justice, America’s second largest chain of psychiatric hospitals (valued at about $7 billion) “admitted ineligible patients”—that is, detained people who were not diagnosed with mental disorders and/or did not meet legal criteria for involuntary commitment. Acadia then “submitted false statements and claims”—that is, made fanciful medical records about how crazy these people allegedly were and how much mental health care they allegedly needed. Acadia then “billed for services not rendered” and “kept patients longer than medically necessary”—that is, locked people up for long periods and often just drugged them into submission while claiming comprehensive therapeutic help was being provided.

The list of states where this happened drives home the scale of the fraud: California, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, Tennessee, Texas, Vermont, Virginia, and Washington.

And note that these involved fraudulent claims to both Medicare and Medicaid—even impoverished people without good insurance can be cash cows for corporations in the involuntary commitment industry. Which is likely why America’s largest chain of psychiatric hospitals has also settled with the Department of Justice for conducting similar practices.

Direct link to this post: https://robwipond.substack.com/p/illegal-fraud-is-the-norm-for-psychiatric

Also notably, although their own employees testified against them, in neither settlement did these corporations admit wrongdoing—instead, they claimed they’re actually excelling in best practices. That is, these corporations give us every reason to suspect they’ll simply continue on doing the same. (Indeed, it’s likely these corporations regard such settlements as merely part of the cost of doing business—not uncommonly, their stock price rises afterwards.)

The Acadia story was well fleshed-out in a New York Times report, “How a Leading Chain of Psychiatric Hospitals Traps Patients—Acadia Healthcare is holding people against their will to maximize insurance payouts”:

“A social worker spent six days inside an Acadia hospital in Florida after she tried to get her bipolar medications adjusted. A woman who works at a children’s hospital was held for seven days after she showed up at an Acadia facility in Indiana looking for therapy. And after police officers raided an Acadia hospital in Georgia, 16 patients told investigators that they had been kept there “with no excuses or valid reason,” according to a police report.”

“Acadia, which charges $2,200 a day for some patients, at times deploys an array of strategies to persuade insurers to cover longer stays, employees said. Acadia has exaggerated patients’ symptoms. It has tweaked medication dosages, then claimed patients needed to stay longer because of the adjustment. And it has argued that patients are not well enough to leave because they did not finish a meal.”

One psychiatrist speaks out

In the wake of the NYT article, psychiatrist Daniel Morehead wrote an op-ed in the prominent trade journal Psychiatric Times. Morehead said that he supports involuntary psychiatric hospitalization for “a life- and health-threatening medical emergency”; however, he describes locking up a “well” person as “horrific and grossly unjust.”

He then expressed dismay about the evident lack of any widespread, publicly visible concern by psychiatrists and other mental health professionals in response to the revelations about Acadia. “[W]e as a community should be very worried,” commented Morehead. “[W]e psychiatrists ought to stand up and demand better… Where is the accountability here?”

Morehead thoughtfully added:

“It is our sacred duty to speak up for the needs and interests of our patients, and we should be every bit as energetic about defending their rights to refuse treatment as we are in advancing their right to access treatment. Anything less amounts to a kind of passive corruption of our profession, turning the other way to avoid facing inconvenient and painful wrongs within our field. Anything other than an energetic response to such reports implicitly tells the public that we as psychiatrists are not particularly interested in the way patients are treated.”

I agree. And I applaud Morehead for giving public voice to these perspectives, and for beseeching other psychiatrists to speak out. However, if Dr. Morehead wants to better understand how and why this kind of fraud gets perpetrated and not called out by most psychiatrists, he could start by re-reading some of his own previous writings.

After all, Morehead also shared in his op-ed that he actually works for a “nonprofit” health system that is one of twenty that has “joint ventures” with Acadia—yet he made no mention of bringing his concerns directly to his employers. And why not? Perhaps because, in his other articles, Morehead frequently vigorously defends the same kinds of highly subjective ways of assessing mental illness and mental wellness that underpin both honest and fraudulent psychiatric diagnosing.

In one essay, Morehead endorsed a widespread tendency among psychiatrists to simply mock and dismiss critics who suggest some of psychiatry’s subjective, “pseudoscientific” practices can sometimes be dangerous. “As psychiatrists, the fundamentally benign nature of what we do has been too obvious for words. Few of us have wasted time debating it amongst ourselves,” wrote Morehead. In another essay on the same topic, Morehead speaks directly to his fellow professionals: “I submit that you, as a practicing psychiatrist or other mental health professional, intuitively know that you are practicing legitimate and scientifically based medicine.”

But as Philip Hickey, a retired psychologist and dogged critic of psychiatry, dryly comments in his own response essay, “intuition seldom alerts us to our own prejudices and distortions, which is why we have this very different thing called science.”

My point is this: When there’s no solid, objective scientific grounding for psychiatric assessments, the “slippery slope” from well-meaning but highly subjective commitments of “mentally ill” people to fraudulent commitments of “mentally well” people is essentially a cliff over which anyone can fall in any moment.

And these problems are compounded when psychiatrists believe in their own intuitive determinations more than in science, patients’ views and rights, and the very rule of law. Which, study after study has shown, they often do.

Seek help, get locked up

Consider, for example, an August 2024 Veterans Administration Office of Inspector General (OIG) report of its investigation into involuntary psychiatric commitments occurring across twenty-six Veteran’s Health Administration (VHA) medical facilities in the Florida area.

The OIG investigation was apparently prompted by a complaint from a family member about the treatment of an unnamed man, described as an honorably discharged veteran in his thirties with a history of depression and PTSD. In 2021, the man sought care with a VHA telehealth provider and was prescribed an antidepressant. He also began attending therapy sessions at a VHA outpatient clinic. However, over the next year a variety of therapists started work with him and then kept moving on to other positions. Frustrated with this inconsistent care, in 2023 the man went to a veterans’ mental health clinic and asked if he could be admitted to a hospital for an inpatient stay.

The man was referred to a VA hospital. And of note, through all of the mental health records, the man was repeatedly described by VHA practitioners as logical, goal-oriented, alert, “without hallucinations or delusions, and without impairment of insight or judgment.” He just wanted some consistent help with his mental health. So, he went to the hospital emergency room and requested admission—and instead of being admitted as the voluntary patient he was, the attending physician locked him up on a 72-hour hold under Florida’s mental health law “Baker Act.”

The sudden, unexpected incarceration and loss of his rights made the man immediately feel shocked, confused, betrayed, and afraid—and he vehemently protested. On the second day of his incarceration, a psychiatrist finally converted him back to voluntary status—but the damage had been done.

The man promptly left the hospital. Immediately and over the ensuing months, he canceled all of his mental health appointments, and would never seek mental health care again. And he lodged a slew of formal and informal complaints about the involuntary commitment.

None of his complaints prompted any responses from anyone in the VHA mental health system. And about half a year after the incarceration, he killed himself.

Repeated fraudulent incarceration of veterans

After its investigation, the OIG determined that, “staff incorrectly applied the involuntary inpatient Baker Act examination hold criteria set forth by state law when admitting the patient.”

The man, the OIG said, had never met the legal criteria for being committed. He should never have been committed. And much like the DOJ found in the Acadia case, the OIG determined that the VHA’s routine involuntary commitment processes were in many ways fundamentally illegal. VHA staff were detaining people who didn’t meet criteria for commitment and holding them for illegal lengths of time, while making false statements in medical records about them. This, even as the OIG report summarized across pages the abundant research showing how traumatizing and suicidogenic involuntary commitment often is.

The details of this man’s case, and of this broader system of illegal, fraudulent commitment are revealing—though there was no suggestion any large financial motives were at play.

At admission, the emergency department records described the man as “calm and cooperative,” and “feeling better,” and glad to be getting admitted to the hospital for treatment. Nevertheless, the attending physician checked off boxes indicating that the man was refusing voluntary admission, lacked insight into his disorder, and was unable to understand his need for treatment, and therefore needed to be committed against his will. The man was also not notified, as required by law, of his right to appeal.

And it appears that VHA doctors routinely lie and mislead in these ways to commit people. The OIG did a random review of 61 involuntary commitment cases at one facility, and found that in nearly a third of cases “the rationale” for detaining the person was not properly noted and/or the staff’s own documentation showed staff held people longer than they were legally allowed to hold them. Further, the OIG found that, at Florida VHA hospitals, “patients are often admitted through the Baker Act involuntary examination process… despite requesting voluntary admission.” Staff claimed they did it in case patients changed their minds—but there’s no policy or law allowing that. The OIG found the VHA even had written policies that were in clear conflict with the Baker Act—such as requiring any patient with suicidal thoughts, whether seeking help or not, to be immediately put on an involuntary hold.

Meanwhile, VHA policies outlined a hierarchical system of checks and balances, accountability and oversight, for mental health inpatient care, leading up from the facility-level ward clerks and associate chiefs of psychiatry to the regional System Director and the Veterans Integrated Service Network right to the national VHA Office of Mental Health Operations. Yet the OIG found that, from top to bottom, VHA staff “lacked clarity regarding who was responsible for providing oversight” and that “system leaders did not have an oversight process in place… related to involuntary admissions.”

Ironically, even the VHA “patient advocate” office, responsible for managing and resolving patient complaints, did not follow up on or resolve the man’s complaints—and this appeared to be common. All of the medical staff at every level of the VHA told the OIG that they rely on the patient advocate’s office to handle complaints--but the patient advocate’s office said that, when they couldn’t immediately provide a simple resolution themselves, they didn’t actually have any established ways to “escalate concerns to a higher level” within the VHA. Furthermore, the OIG determined that the patient advocate office was not completing the required monthly reviews of involuntary admissions—consequently, the VHA had absolutely no records of “any complaints or concerns” from patients committed against their will.

How many people have been victimized by these illegal incarcerations by VHA staff with no legitimate opportunities for redress? No one knows. The OIG found that VHA staff have not been submitting forms and data about involuntary commitments to Florida’s Baker Act Reporting Center—though doing so is required by law. And the OIG also found that, across the nation, the VHA’s electronic health record systems don’t track involuntary commitments. However, the numbers could be huge: The OIG found that 61% of the patients at one veterans’ inpatient facility were involuntarily detained.

Across the border, the same lack of boundaries

So, similar illegal, fraudulent involuntary commitment practices occur at U.S. government-funded VA hospitals as occur in for-profit, private psychiatric hospitals. How about in Canada, a completely different health system?

In November of 2024, the Prince Edward Island (PEI) Office of the Auditor General (OAG) released a report of an investigation that began after the OAG “received a complaint from a concerned citizen that involuntary patients in psychiatric facilities were not being treated in accordance with the Mental Health Act.”

PEI is Canada’s smallest province and home to less than 180,000 people—yet the OAG found many of the same systemic abuses and organized disdain for the rule of law among psychiatric staff as in two of America’s largest health systems.

The OAG didn’t investigate whether people were being detained for legitimate reasons—only if people were being properly afforded their legal rights once they were detained.

Right away, the OAG identifed a serious “scope limitation”—the OAG often couldn’t find sufficient documentation anywhere to adequately investigate and assess what was actually happening to involuntary patients in these psychiatric wards and hospitals. Nevertheless, some of the findings that the OAG did arrive at included:

• The government oversight agency Health PEI “did not maintain documentation that demonstrated involuntary patients were informed of their rights.”

• There were no policies or procedures in place to ensure patients’ rights were upheld or that patients were properly informed of their rights.

• Patients’ rights were required by law to be prominently displayed in psychiatric facilities—these displays did not exist.

• From a sample of 15 records of involuntary patients, only four patients were informed by hospital staff about their right to appeal their incarceration.

• From another sample of 13 records of patients who were detained for an involuntary psychiatric assessment, more than half were detained for illegally long periods.

When patients did know about and request hearings to appeal their incarcerations, hospital staff often illegally stalled processing the requests—on average for a week, and sometimes as many as several weeks. Worse, according to the OAG, the Mental Health Review Board (MHRB)—the agency specifically charged with holding these appeal hearings and ensuring patients’ rights are upheld—was also seriously remiss in its legal responsibilities.

For example, in a sample of 20 cases, the MHRB had only recorded the date on which it had received the patient’s request for appeal in 10 of them—making it impossible to truly determine how often patient requests for hearings were being illegally delayed and for how long. But the OIG did determine that the MHRB itself didn’t always hold hearings and make decisions within the required, legislated timeframes.

The MHRB also had no processes in place to ensure the identifying and notifying of all of the legally relevant parties for a hearing. For 47 percent of the patients, the MHRB couldn’t even show that these patients had ever been notified of the MHRB decision in their cases. Even the Public Guardian said their office was “often not informed” of Board hearings or decisions related to people under the Public Guardian’s care.

And finally, the MHRB was not gathering the data on its own hearings and reporting results, as required by law, to the PEI government department that has accountability and oversight responsibility.

Commitment powers are inherently corrupt

These reports add to the mounting evidence examined in my book that illegal fraud is a routine norm in the practice of involuntary commitment across very different health systems, no matter how much or how little money-making is a factor.

So why does it happen? Because, in the same breath as psychiatrists like Morehead express concern about subjective, fraudulent uses of mental health law powers, they’ll express support for using these same powers in situations that they personally believe are right and good. Most psychiatrists never protest the very principle of the existence of these extremist, subjective powers with little accountability. And whatever the intentions behind it, that’s a fascistic framework of thinking—not a democratic, rational, ethical, fair and accountable framework of thinking.

Drawing from the tremendous scholarly work of lawyer Michael Perlin, I discussed this further in Your Consent Is Not Required:

While these broad, vague laws already give psychiatrists immense discretionary powers, Perlin states that psychiatrists and judges often anyhow ignore them, and commit anyone “whom they believe should be committed.” For example, Perlin quotes various prominent psychiatrists in trade journals encouraging colleagues to resist “tyrannical laws” and let decisions about what’s best for patients be guided instead by their own “wise and benevolent paternalism.” In his book Out of the Shadows: Confronting America’s Mental Illness Crisis, prominent pro-force psychiatrist E. Fuller Torrey acknowledges approvingly, “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.” Paul Applebaum, today a member of the American Psychiatric Association’s Council on Psychiatry and the Law, has also written that “mental health professionals and judges alike” are “reluctant to comply with the law.”

Perlin calls such attitudes a “blatant attempt” by psychiatrists to “aggregate power.”

I believe this is one major reason why we’re not hearing psychiatrists rise up en masse in protest about blatant abuses of involuntary commitment powers. They know the lines are blurry between uses and abuses of such authoritarian powers—and they aren’t willing to see their own powers challenged.