Care or Coercion: A Critical Phenomenological Study of the Embodied Experience of Involuntary Civil Commitment in Early Adulthood

Background: Within the mental health service delivery system, inpatient hospitalization is the most restrictive level of care; some access it involuntarily. Involuntary civil commitment in the U.S. is a subjective process with potentially devastating costs.  Much of the literature focuses on the paternalistic duty of the state without giving much consideration to the impact on the individual.  Some experiencing involuntary civil commitment have been known to be treated inhumanely, and stripped of their basic human right to freedom. We know that involuntary civil commitment disproportionately affects vulnerable populations, including the poor and those who are powerless and under-served.

The impact of involuntary commitment is particularly salient in early adulthood, a crucial period in identity development, as well as when most serious mental health disorders emerge. This age group is more likely to experience involuntary civil commitment as a response to newly identified mental illness, and have higher rates of psychiatric readmission within 30 days. The literature that exists on involuntary civil commitment has restricted its focus to provider perspectives. Few research studies have explicitly included the voices of those with lived experience.

A critical phenomenological study rooted in theoretical concepts of narrative identity, embodiment, and culture of risk are used to gain an in-depth understanding of how individuals embody the experience of involuntary commitment and what impact this has on their identity. The study also seeks to gain understanding of the socio-political context in which these policies and practices thrive.

Methods: Fifteen in-depth, minimally structured interviews were conducted with individuals in early adulthood (18-35) who experienced involuntary civil commitment (core participants). For contextual purposes, ten interviews were conducted with professionals (key stakeholders) working in private, public, for profit, and nonprofit mental health, legal, advocacy, and human rights organizations in Massachusetts. Participants were recruited through outreach letters and flyers distributed in the community, and emails sent to local and state agencies. Interviews were digitally audio recorded, transcribed verbatim and coded thematically. Analysis was guided by principals grounded in hermeneutic phenomenology.

Findings: The overarching theme which united the data was the identification of the iatrogenic effects of being involuntarily committed.  Core participants described “painful,” “humiliating,” and “dehumanizing” experiences during the commitment process and the impact this has had on their identity. Multiple participants noted they could not share who they were without talking about being involuntarily committed; the experience was too intertwined into their personal narrative.  Several participants described feeling one dimensional and struggled with repeatedly sharing a pathologized version of themselves.  Despite recalling such negative experiences, participants believe involuntary commitment should exist but emphasize the need for changes to how and when it is utilized.

Implications: This study is focused on improving the functioning and well-being of individuals with serious mental illness. It aims to develop knowledge that can inform both state and national mental health policy, practice, and education. In turn, this will help to alleviate and ultimately prevent care that is deemed inadequate and potentially harmful, while also informing and promoting best practices.