CLINICAL HANDBOOK OF SCHIZOPHRENIA

518 VII. POLICY, LEGAL, AND SOCIAL ISSUESTABLE 49.1. WHO Criteria for Involuntary Committment1. A person may be admitted involuntarily to a mental health facility . . . if . . . a qualified mentalhealth practitioner authorized by law determines . . . that the person has a mental illness andconsidersa. that because of that mental illness, there is a serious likelihood of immediate or imminentharm to that person or other persons; orb. that in the case of a person whose mental illness is severe and whose judgment is impaired,failure to admit . . . is likely to lead to serious deterioration . . . or will prevent the giving ofappropriate treatment that can only be given by admission.2. In the case referred to in subparagraph (b) above, a second such mental health practitioner,independent of the first, should be consulted where possible.3. A mental health facility may receive involuntarily admitted patients only if the facility has beendesignated to do so by a competent authority prescribed by domestic law.Note. From World Health Organization (2005). Copyright 2005 by the World Health Organization. Adapted by permission.titioner and the concept of impaired judgment (also known as impaired capacity to makedecisions). It has been argued that if impaired judgment (assessed by a doctor or by anotherlegal process) is present, then the criterion of diagnosed mental illness is redundant.By this argument, people with mental illness, but without impaired judgment, should beallowed to determine their own treatment, whereas people with impaired judgment maybe treated involuntarily, in their own best interests, regardless of diagnosis.The criteria allow wide latitude for clinical judgment, about not only the presence ofmental illness but also the seriousness or imminence of risk (notoriously hard to assess accurately),the likelihood of deterioration without treatment, or what treatment is appropriate.Legal criteria provide a framework for clinical decisions but do not determinethem.NATURE AND IMPORTANCE OF INVOLUNTARY COMMITMENTInvoluntary commitment is widely used, with an estimated 2 million uses in the UnitedStates per year (0.8%, 800 per 100,000 population), somewhat higher than the total incarcerationrate in the criminal justice system (500 per 100,000 per year). In England,26,000 people were committed to hospital in 2004, and a further 3,000 were detained afterentering a hospital voluntarily (a total of 58 per 100,000 per year), somewhat lessthan the total incarcerated by the criminal justice system (220 per 100,000 in 2002).These numbers, although they demonstrate the scale of involuntary commitment, donot convey the importance of the issue to consumers of mental health care, for many ofwhom the use of forced treatment is a key issue in determining their attitude towardtreatment and the professionals who provide it. They also cannot convey the extent towhich the perceived threat of involuntary treatment may affect people receiving treatmentvoluntarily, even when compulsion is not actually threatened, or even considered,by the psychiatrist.Studies of this perception that psychiatric treatment is coercive by researchers in theUnited States and Europe have shown that it is indeed widespread, and that althoughinvoluntary commitment is, as expected, an important factor in determining perceivedcoercion, patients who are treated “voluntarily” in the strict legal sense may perceive coercivepressures to take treatment from a number of sources, including family, housingorganizations or the welfare system, as well as mental health professionals.