How Did This Happen? Youth Perceptions of Factors Associated with Their Involuntary Psychiatric Hospitalizations

Background and Purpose: All states in the US allow for involuntary psychiatric hospitalizations (IH) for individuals who are deemed an immediate threat to themselves or others. Although these policies provide for important protections, they are easily overused or misused. Many individuals who experience them report that they are harmful; in particular many youth who have experienced IH report that the experience is traumatizing, reduces trust in the system, and makes them less likely to seek treatment in the future. There is widespread agreement that involuntary hospitalization should be avoided when possible. Prevention efforts can be aided by understanding perceptions of the causes of hospitalization from the point of view of the youth who have experienced them; however, there has been virtually no research documenting these perspectives in the United States.

Methods: Forty in-depth semi-structured interviews were conducted with youth and young adults in Florida, the state with the highest rate of IH, who experienced an involuntary hospitalization. Youth described their perceptions of the distal, proximal, and immediate factors associated with their hospitalization. Participants were recruited with flyers posted at community colleges and universities, cafes, outpatient treatment centers and other community hubs. Data collection was closed when thematic saturation was reached, operationalized as no major new themes introduced across ten successive interviews. Interviews were transcribed and coded using a constructivist approach informed by grounded theory. Youth interviewed include 28 females, 11 males and one non-binary individual, 18 white, 12 Latinx, 4 African American, 5 Asian and 1 multiracial individual. Individuals were aged 16-27, and ranged in age from 11 – 23 at the time of the hospitalization.

Results: Youth reported that distal precipitants included the rejection of important aspects of their identities by family or peers, denigration of mental health needs and services in their family or peer reference group, and histories of abuse. Proximal factors included significant disruptions in important personal relationships, developmental and academic stressors, and substance use. Immediate events leading up to IH involved in-the-moment emotional volatility and/or arguments and conflicts with family or peers. It was common for youth to experience escalation in multiple factors before IH. No youth reported attempts to de-escalate emergency situations when they occurred.

Conclusions and Implications: Youth perceptions of distal and proximal causes broadly align with the relatively small extant literature, which has mostly focused on various objective or survey measures of risk factors. Many of these factors could be addressed if youth could access timely and appropriate support. Even immediate circumstances, which are often dramatic, could often be successfully addressed if de-escalation efforts were understood and practiced. Anecdotally, providers and policy makers express concern that youth may not recognize their need for help, buttressing the need for coercion in the entry to mental health services. Importantly, this group of individuals who experienced involuntary hospitalizations reported that they both needed and wanted help. Continued, sustained, attention to the enactment of involuntary hospitalization is needed to contain the considerable risk for harm that can be experienced when this event occurs.