Above: Emergency responders reach out to a person sleeping on a bench in the Manhattan subway system. In New York City’s latest effort to address a mental health crisis on its streets and subways, Mayor Eric Adams announced in November 2022 that authorities would more aggressively intervene to help people, even if it means providing care to those who don’t ask for it. (John Minchillo / AP Photo, File)
Cities across the country are grappling with the intersecting, pandemic-exacerbated crises of housing, mental illness, and substance abuse. Pressured to act swiftly, policymakers this year jumped to pass new laws and regulations lowering the threshold for emergency intervention, even if it means forcing people into treatment for mental illness or substance use disorders.
It’s tempting to see forced treatment, also known as involuntary commitment, as in the best interest of everyone involved—but we are health care providers who treat involuntarily committed patients in Boston, Massachusetts. We’ve rarely seen the practice achieve good outcomes for patients.
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Instead, policymakers and public health professionals should be asking themselves whether the investment in involuntary commitment might be better spent on housing, case management, and expanding availability of voluntary treatment for substance use disorders. All of that is difficult, but relying on involuntary commitment is a dangerous and convenient distraction from real solutions.
Politicians often bill involuntary commitment as a measure of last resort, but in fact it’s been used for years, and much more often than we like to admit. In Boston, it’s even been weaponized to clear encampments of people living on the streets as part of police “clean sweep” operations.
Massachusetts involuntarily commits more than 6,000 individuals each year for substance use disorders under Section 35, a statute allowing family members, medical providers, and law enforcement to forcibly detain individuals for up to 90 days when they pose “a clear and convincing risk of harm” to themselves or others as the result of a substance use disorder. These statutes have expanded in recent years, and now 38 states have similar laws on their books.
In Boston, involuntary commitment has only gotten easier. In 2017, the Boston municipal court launched a pilot program allowing health care providers to fax their Section 35 affidavits instead of physically appearing in court. Emergency departments could send patients directly from the hospital to involuntary treatment. As a result, the number of petitions in Boston exploded—increasing by 272% from 2016 to 2018.
To be fair, hospitals are ill-equipped to provide comprehensive care for patients with substance use disorders, and placement in residential or outpatient treatment programs can take days or weeks, if it happens at all. Section 35 petitions almost always result in patients being prioritized for a treatment bed, sometimes in just a few hours.
For example, we treated an elderly man (we’ll call him Richard) and regular visitor to our emergency department. Richard, a former construction worker injured on the job, struggled with severe alcohol use disorder, and had recently lost a loved one. We saw Richard more than 100 times in a single year, mostly because of complications from alcohol use. He almost always came to the hospital intoxicated, with injuries from falling while impaired. Although we encouraged him to consider treatments for his alcohol use, he frequently left the hospital against medical advice. Eventually, we used Section 35 to involuntarily commit him.
The police escorted him to a treatment facility and we lost contact with him. Because Section 35 programs operate independently (and are often located in correctional facilities), they rarely share information about patient treatment with other providers. We received no details of Richard’s stay. Less than two months after he was committed, we saw him in our emergency department again, intoxicated.
We used Section 35 to commit Richard to inpatient treatment no fewer than nine times over three years. Every time treatment failed, and Richard’s health continued to deteriorate. Eventually, Richard began to leave the hospital before courts opened for the day, because he knew the staff would file a Section 35 petition against him.
Clearly, forcing Richard into treatment failed him. Richard is just one of the 22 patients we followed as part of a new study published in Community Health Journal. We found that every single one of those patients relapsed within a year of being released from involuntary commitment, and continued to have serious medical complications. Two patients died.