I do have one underlying question, though, and I’m curious how you think about it. When we compare detention rates across countries, how confident can we be that we’re comparing the same form of coercion rather than different institutional ways of managing risk and social breakdown? In other words: to what extent might lowr rates elsewhere reflect displacement of control (policing , incarceration, family burden, non-care) rather than less coercion overall?
Not a challenge to the concern, just a question about whether we’re actually seeing less coercion in some countries, or the same coercion pushd into different institutions.
Very reasonable question, Kali -- and yet another reason I keep saying we need better data. And better means, even some basic, rudimentary efforts on the part of governments would be nice, rather than their current demonstrable efforts to avoid tracking and hide data.
So my reply here is qualified by the above remark.
First, I don't think it's reasonable to classify "non-care" or "family burden" as forms of involuntary commitment or state coercion. If we go there, then we're getting further from understanding how many people are actually being subjected to legal coercion, not closer. I'm not saying cultural analyses of different ways that families or employers or others might put pressure on people isn't valuable and important to understand -- I explore some of this in my book. And I think some of those are measurable (e.g. employer threats/requirements) and some are less so (family functioning). But generally, even most of those exist primarily because of the backbone of state mental health laws that buttress them.
Second, we actually have good data on policing and criminal incarceration, and we know the US has by far the most of that in the world. So the fact that the U.S. is ALSO a leader in mental health incarceration is significant, and very revealing in the comparisons.
Third, the bigger issue for comparing is just that the mental health laws and processes do vary, so more granular analysis is really needed to feel more confdent in what we're seeing. Generally, I look to the places with the best data, and they tell an even more extreme story than this broader one, but the same basic story.
Thanks for your response! Toally agree on the point about non-care and family burden , I was too loose in how I framed it for sure.
One example that keeps nagging at me: in countries with lower formal detention rates, crisis response oftn happens earlier via medication, police “welfare checks,” or nominally voluntary hospital pathways where refusl is, in practice, nearly impossible. On paper, it looks less coercive; empirically, it may just mean coercion is front-loaded, informal, and largely invisible to the datasets.
This doesn’t undermine the differences you highlight, like the U.S. clearly overusing all formal coercive channels, and the policing/ incarceration data are unambiguous. But it does flag a tricky measurement problem: are we seeing genuinely less coercion elsewhere, or just coercion upstream of formal commitment that’s hidden from view (like in Netherland or Deutschland and North europe globally) ?
The challenge is, of course, is designing data collection that captures these pressures without collapsing everything into a vague moral category.. while still retaining the legal specificity that makes the analysis actionable. So, Clinician report? Patient report? Institutional data? Each has trade-offs for sure.... I’m curious how you’d approach that in an ideal way.
Addendum: I think the core data point for involuntary commitment in institutions is, "person who is in a hospital and is not going to be allowed to leave immediately." Every patient of that status should be identified and recorded, and that is a medical staff decision. It usually is, in fact, I believe, already recorded in some way somewhere in most EHR records, but they're often just not gathering and/or releasing that information. Currently, they choose what data point they want to gather or release, if any, eg when a court process starts.
Good example! Indeed, I have little doubt that, if we tracked it, the number of people in psychiatric hospitals who are technically "voluntary" but actually there under coercive threat ("if you don't stay, we'll make you involuntary") is massive. Virtually every patient I've ever spoken with has experienced it.
Another example: A study in five US cities found that about half of people accessing "voluntary" community services had experienced coercive threats of losing housing, losing supports etc if they did not comply with treatments.
These and other practices like them need to be tracked and reported on. However, interviews and sometimes even studies show these informal and untracked types of coercion are common practice in all the countries with modern mental health systems that we're discussing here. There's no strong evidence to suggest otherwise. Maybe if we delved into one country in particular in depth, we might find something to support your speculation in that country that's really interesting and significant--but as of now, I've not seen any evidence that the systems work "fundamentally" differently in that way. (The one notable exception being Italy, where they set out explicitly to change the system to lower commitment rates, and did so. Their lessons, in fact, might answer some of your questions about key pinch points that make big differences. I'll be writing something about them soon btw, there was a webinar recently.) So, that presumably brings a degree of consistency to the numbers and allows for (relatively) meaningful comparisons.
All of that said, the “missing data” again is the single biggest issue. E.g. In Colorado, they weren’t counting people in legally “undesignated” facilities—numbers doubled overnight. In Maryland, they weren’t counting people BEFORE the formal court process kicked in—numbers doubled overnight. In San Francisco, a formal audit was done—numbers were nine times higher overnight.
So I think we can comfortably agree the data isn’t very reliable, and there may be big surprises if it gets better here and in other countries. But it is the best we’ve got right now, and I think it can therefore be reasonably used to make arguments, raise flags, and push for better data collection.
I have lots of ideas, but I think your final question merits interdisciplinary consultations and discussions and planning and ongoing iterative development. For the very reasons we’re discussing. The main thing I’d personally like to see captured, more than the sheer numbers, is WHO, and what the impacts and outcomes look like for the patients based strongly on their own testimony. The lack of meaningful data on real-life outcomes is incidentally a systemic problem in mental health care, not just in coercive mental health care. As if we were doing heart surgeries and not tracking how many people lived or died from them—it’s ridiculous.
Thanks for this! your last point really resonates...
For what it’s worth, I currently work within the French hospital system, and many of the dynamics you describe around “ voluntary” status, upstream coercion, and undocumented threats are very much present here too, despite France often beig framed as comparatively less coercive in international discussions....
Whats striking is how the system has, over time, reproduced a number of well documented failures seen elsewhere (early medication first crisis responses, police mediated entry into care, blurred voluntary/ involuntary boundaries) , while also developing its own institutional quirks that complicate tracking and accountability. On paper, some indicators look better; in practice, a lot of pressure simply operates earlier and more informally.
I’m actually planning to write a comparative piece looking at how the French system fits into this broader international pattern, not to claim it’s uniquely bad, but to show how similar structural incentives tend to generate similar outcomes, even under different legal frameworks.
Obviously I can’t share identifiable data, but if it’s ever useful , I’d be happy to share system level observations or help think through what is and isnt realistically capturable from inside hospital workflows. Just putting it out there.
Interesting -- why would France be framed as less coercive? (although internally it seems practically every country has a narrative of 'we hardly detain anyone!' Except not in the UK--they do some public handwringing over their numbers.) Do you have recent data from France? The most recent data I've seen was from 2016, and it was, at 140 per 100,000, one of the higher rates internationally. See:
I was admitted for almost 2 weeks at LHSC, without ANY questions being asked of me? No physical or psych assessment? I never spoke once, with a Psychiatrist, they just locked me up on the 7th floor? The Dr they gave me, couldn’t answer my questions? No diagnosis was given. Schizo, they said. No DSM criteria was met? No other reasons. Just admitted, and heavily medicated with antipsychotics? Withheld food at times? I was not psychotic? I knew exactly what was happening but couldn’t do anything about it. I had no choice! I was quiet and waited things out. How can one be admitted without any assessment? I was not a danger to myself or others? My husband left me unexpectedly, no family Dr, I was upset and wanted some mild meds…I went to the hospital, got put on antipsychotics and locked in, for 11 days? Very Bizarre and disturbing.
You are totally free now, I hope? Yes, sadly, I know from extensive research that what you're describing is not uncommon. In BC, for example, two successive Ombudsperson studies found that less than half of psychiatric detentions were actually legal -- the proper paperwork of diagnoses, determinations of risk, etc weren't even done.
Oh! Really appreciate this piece!
I do have one underlying question, though, and I’m curious how you think about it. When we compare detention rates across countries, how confident can we be that we’re comparing the same form of coercion rather than different institutional ways of managing risk and social breakdown? In other words: to what extent might lowr rates elsewhere reflect displacement of control (policing , incarceration, family burden, non-care) rather than less coercion overall?
Not a challenge to the concern, just a question about whether we’re actually seeing less coercion in some countries, or the same coercion pushd into different institutions.
Very reasonable question, Kali -- and yet another reason I keep saying we need better data. And better means, even some basic, rudimentary efforts on the part of governments would be nice, rather than their current demonstrable efforts to avoid tracking and hide data.
So my reply here is qualified by the above remark.
First, I don't think it's reasonable to classify "non-care" or "family burden" as forms of involuntary commitment or state coercion. If we go there, then we're getting further from understanding how many people are actually being subjected to legal coercion, not closer. I'm not saying cultural analyses of different ways that families or employers or others might put pressure on people isn't valuable and important to understand -- I explore some of this in my book. And I think some of those are measurable (e.g. employer threats/requirements) and some are less so (family functioning). But generally, even most of those exist primarily because of the backbone of state mental health laws that buttress them.
Second, we actually have good data on policing and criminal incarceration, and we know the US has by far the most of that in the world. So the fact that the U.S. is ALSO a leader in mental health incarceration is significant, and very revealing in the comparisons.
Third, the bigger issue for comparing is just that the mental health laws and processes do vary, so more granular analysis is really needed to feel more confdent in what we're seeing. Generally, I look to the places with the best data, and they tell an even more extreme story than this broader one, but the same basic story.
Thanks for your response! Toally agree on the point about non-care and family burden , I was too loose in how I framed it for sure.
One example that keeps nagging at me: in countries with lower formal detention rates, crisis response oftn happens earlier via medication, police “welfare checks,” or nominally voluntary hospital pathways where refusl is, in practice, nearly impossible. On paper, it looks less coercive; empirically, it may just mean coercion is front-loaded, informal, and largely invisible to the datasets.
This doesn’t undermine the differences you highlight, like the U.S. clearly overusing all formal coercive channels, and the policing/ incarceration data are unambiguous. But it does flag a tricky measurement problem: are we seeing genuinely less coercion elsewhere, or just coercion upstream of formal commitment that’s hidden from view (like in Netherland or Deutschland and North europe globally) ?
The challenge is, of course, is designing data collection that captures these pressures without collapsing everything into a vague moral category.. while still retaining the legal specificity that makes the analysis actionable. So, Clinician report? Patient report? Institutional data? Each has trade-offs for sure.... I’m curious how you’d approach that in an ideal way.
Addendum: I think the core data point for involuntary commitment in institutions is, "person who is in a hospital and is not going to be allowed to leave immediately." Every patient of that status should be identified and recorded, and that is a medical staff decision. It usually is, in fact, I believe, already recorded in some way somewhere in most EHR records, but they're often just not gathering and/or releasing that information. Currently, they choose what data point they want to gather or release, if any, eg when a court process starts.
Good example! Indeed, I have little doubt that, if we tracked it, the number of people in psychiatric hospitals who are technically "voluntary" but actually there under coercive threat ("if you don't stay, we'll make you involuntary") is massive. Virtually every patient I've ever spoken with has experienced it.
Another example: A study in five US cities found that about half of people accessing "voluntary" community services had experienced coercive threats of losing housing, losing supports etc if they did not comply with treatments.
These and other practices like them need to be tracked and reported on. However, interviews and sometimes even studies show these informal and untracked types of coercion are common practice in all the countries with modern mental health systems that we're discussing here. There's no strong evidence to suggest otherwise. Maybe if we delved into one country in particular in depth, we might find something to support your speculation in that country that's really interesting and significant--but as of now, I've not seen any evidence that the systems work "fundamentally" differently in that way. (The one notable exception being Italy, where they set out explicitly to change the system to lower commitment rates, and did so. Their lessons, in fact, might answer some of your questions about key pinch points that make big differences. I'll be writing something about them soon btw, there was a webinar recently.) So, that presumably brings a degree of consistency to the numbers and allows for (relatively) meaningful comparisons.
All of that said, the “missing data” again is the single biggest issue. E.g. In Colorado, they weren’t counting people in legally “undesignated” facilities—numbers doubled overnight. In Maryland, they weren’t counting people BEFORE the formal court process kicked in—numbers doubled overnight. In San Francisco, a formal audit was done—numbers were nine times higher overnight.
So I think we can comfortably agree the data isn’t very reliable, and there may be big surprises if it gets better here and in other countries. But it is the best we’ve got right now, and I think it can therefore be reasonably used to make arguments, raise flags, and push for better data collection.
I have lots of ideas, but I think your final question merits interdisciplinary consultations and discussions and planning and ongoing iterative development. For the very reasons we’re discussing. The main thing I’d personally like to see captured, more than the sheer numbers, is WHO, and what the impacts and outcomes look like for the patients based strongly on their own testimony. The lack of meaningful data on real-life outcomes is incidentally a systemic problem in mental health care, not just in coercive mental health care. As if we were doing heart surgeries and not tracking how many people lived or died from them—it’s ridiculous.
Thanks for this! your last point really resonates...
For what it’s worth, I currently work within the French hospital system, and many of the dynamics you describe around “ voluntary” status, upstream coercion, and undocumented threats are very much present here too, despite France often beig framed as comparatively less coercive in international discussions....
Whats striking is how the system has, over time, reproduced a number of well documented failures seen elsewhere (early medication first crisis responses, police mediated entry into care, blurred voluntary/ involuntary boundaries) , while also developing its own institutional quirks that complicate tracking and accountability. On paper, some indicators look better; in practice, a lot of pressure simply operates earlier and more informally.
I’m actually planning to write a comparative piece looking at how the French system fits into this broader international pattern, not to claim it’s uniquely bad, but to show how similar structural incentives tend to generate similar outcomes, even under different legal frameworks.
Obviously I can’t share identifiable data, but if it’s ever useful , I’d be happy to share system level observations or help think through what is and isnt realistically capturable from inside hospital workflows. Just putting it out there.
Interesting -- why would France be framed as less coercive? (although internally it seems practically every country has a narrative of 'we hardly detain anyone!' Except not in the UK--they do some public handwringing over their numbers.) Do you have recent data from France? The most recent data I've seen was from 2016, and it was, at 140 per 100,000, one of the higher rates internationally. See:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30090-2/fulltext
(Low compared to the US and Canada, of course.)
And yes, this study and another review highlighted how the rates don't seem to map onto the laws at all.
I'd be very interested to hear some of your thoughts and research. Drop me an email sometime!
I know way too many people whose lives have been and/or are currently being ruined by the powers of psychiatric force and coercion. Sickening.
I was admitted for almost 2 weeks at LHSC, without ANY questions being asked of me? No physical or psych assessment? I never spoke once, with a Psychiatrist, they just locked me up on the 7th floor? The Dr they gave me, couldn’t answer my questions? No diagnosis was given. Schizo, they said. No DSM criteria was met? No other reasons. Just admitted, and heavily medicated with antipsychotics? Withheld food at times? I was not psychotic? I knew exactly what was happening but couldn’t do anything about it. I had no choice! I was quiet and waited things out. How can one be admitted without any assessment? I was not a danger to myself or others? My husband left me unexpectedly, no family Dr, I was upset and wanted some mild meds…I went to the hospital, got put on antipsychotics and locked in, for 11 days? Very Bizarre and disturbing.
You are totally free now, I hope? Yes, sadly, I know from extensive research that what you're describing is not uncommon. In BC, for example, two successive Ombudsperson studies found that less than half of psychiatric detentions were actually legal -- the proper paperwork of diagnoses, determinations of risk, etc weren't even done.