Sectioned Research Articles

Developing and testing Advance Choice Document implementation resources for Black African and Caribbean people with experience of compulsory psychiatric admission.

Advance Choice Documents (ACDs) have been recommended for use in England and Wales based on evidence from trials that show that they can reduce involuntary hospitalisation, which disproportionately affects Black African and Caribbean people. Our aim was therefore to develop and test ACD implementation resources and processes for Black people who have previously been involuntarily hospitalised and the people that support them. Resource co-production workshops were held to inform the development of the ACD template and two types of training for all stakeholders, comprising a Recovery College course and simulation training. An ACD facilitator then used the ACD template developed through the workshops to create personalised ACDs with service users and mental health staff over a series of meetings. Interviews were then conducted with service user and staff participants and analysed to document their experience of the process and opinions on ACDs. Other implementation strategies were also employed alongside to support and optimise the creation of ACDs. Nine ACDs were completed and were largely reported as appropriate, acceptable, and feasible to service users and staff. Both reported it being an empowering process that encouraged hope for better future treatment and therefore better wellbeing. Uncertainty was also expressed about the confidence people had that ACDs would be adhered to/honoured, primarily due to staff workload. The information provision training and the skills training were generally considered to be informative by trainees. The project has developed an ACD creation resource that was reported as agreeable to all stakeholders; however, the generalisability of the findings is limited due to the small sample size. The project also highlights the importance of staff and ACD facilitator capacity and good therapeutic relationships in ACD completion. Further research is needed to determine the adjustments needed for large scale use, including for those under age 18 and those under the care of forensic mental health services; and how to include carers/supporters more in the process.

Compulsory treatment at home: an interview study exploring the experiences of an early group of patients, relatives and mental-health workers

BackgroundWhen introduced in 2020, the Netherlands’ Compulsory Mental Healthcare Act included provisions for compulsory community treatment (CCT) and compulsory treatment in patients’ homes (CTH). Although CCT has been incorporated into mental health care in many countries, its effectiveness is debated. We know of no other countries in which CTH has been adopted.The aim of this study is to evaluate how an early group of participants experienced CTH. They were drawn from three stakeholder groups: patients, relatives and mental-health workers.MethodsIn total, 17 open interviews were conducted with six patients, five relatives and six mental-health workers. All had experience with CTH. Thematic analysis was used to analyze the interviews.ResultsFive themes were identified: 1). Reasons for applying for a court order with options for CTH. The reasons included preventing harm, avoiding hospitalization, and providing a safety net. 2.) Participants’ experiences with CTH in practice. The four most noteworthy experiences were related to the process of applying for a court order; compulsory home visits and the compulsory use of medication; the involvement of relatives during treatment; and the influence of CTH on the relationship between patients and relatives. 3.) The advantages and disadvantages of CTH. The most important advantages were avoiding hospitalization; improving medication adherence; facilitating easy access to care; early signaling of deterioration; early intervention; and regained autonomy. The most important disadvantages were restricted autonomy; fewer options for monitoring compared to hospitalization; and problems regarding control of patient behavior. 4.) Participants’ preferences. All preferred CTH to hospitalization. 5.) Participants’ suggestions for improving CTH. These included the need not only to provide patients with better information, but also to improve the involvement of relatives during treatment.ConclusionThe interviewees found that CTH might help to avoid hospitalization by providing stakeholders with more options for arranging effective care at home. Although this suggests that initial experiences of CTH under the new Dutch mental health law were positive, it is still uncertain whether CTH as currently implemented really differs from CCT.

Understanding Involuntary Hospitalization Applications Submitted to an Urban Police Department.

To improve understanding of the application process for temporary involuntary hospitalization (Section 12 of the Massachusetts General Laws) in Boston, the authors focused on cases involving the Boston Police Department (PD) and the information shared about the individuals involved. A retrospective analysis was conducted on all Section 12 applications submitted to the Boston PD by external clinicians from July 14, 2021, to June 30, 2022. The authors analyzed 488 applications processed by the Boston PD's Street Outreach Unit, examining demographic information, reasons for requests, information provided by petitioners, and the status of the applications (completed vs. not). The analysis revealed racial disparities: 41% of involuntary hospitalization applications were for individuals identified as Black or African American, but this racial group represents only 23% of Boston's population. Racial-ethnic data were based on police perceptions, and 21% of cases lacked race-ethnicity data. Seventy-six percent of applications were submitted without a direct clinical examination by petitioners, who did not justify the omission. The Boston PD completed 70% of the requested involuntary hospitalization orders. This study identified substantial racial disparities in Section 12 applications, which disproportionately involved Black or African American individuals. The frequent absence of direct clinical examinations before application submissions and the lack of justification indicated a need for regulatory oversight and enhanced petitioner training. Incomplete demographic data underscored the need for improved data collection and reporting practices. These findings highlight the need for reforms to ensure equitable, transparent, and best practice-aligned involuntary hospitalization processes.

Involuntary commitment and medical education on mental health diseases across Europe

Abstract Background Psychiatric diseases are projected to become one of the greatest contributors to the global burden of disease by 2030, already presenting as one of the principal causes of DALYs lost in Europe. Given the particular nature of psychiatric disorders, national legislatures have been enacted by each European country regarding the possibility of involuntary psychiatric treatment. As practical implementations vary greatly from country to country, we wish to analyse how different attitudes to involuntary treatment affect health outcomes, so as to propose a uniform guideline for European medical practitioners. We also wish to analyse whether medical education targeted at communication with psychiatric patients has an effect on involuntary treatment rates and general mental well-being. Methods We conducted a systematic review on PubMed to identify studies pertaining to how legislature on involuntary commitment varies between European countries, as well as to what extent it is utilised. We also looked at the extent of medical education on psychiatric diseases. Results Preliminary results show that involuntary hospitalisation rates vary greatly within Europe, with certain countries being almost 20 times more likely to utilise such measures than others, notwithstanding similar mental illness prevalence. Results do not seem correlated to legislation types. Conclusions Given the vastly different use of involuntary commitment, a more standardised European approach should be implemented, especially in sight of the growing prevalence and burden of disease of psychiatric illnesses. Furthermore, an often-overlooked aspect of medical education is how to understand and communicate effectively with patients dealing with mental diseases: we advocate for continuous education, regardless of medical specialty. Key messages • Involuntary hospitalisation rates vary greatly across Europe, but the effects of this phenomenon have been poorly studied. We propose a more unified approach to maximise the efficacy of such a law. • We advocate for a more thorough education of health professionals on mental illnesses, regardless of medical specialty, in sight of the growing prevalence of such diseases.

Improving the rights of people with mental disorders in the Republic of Croatia

Abstract The mental health care system in the Republic of Croatia, despite the ongoing reform, is still based on hospital treatment. Hospitalizations due to mental disorders are in first place according to the length of stay. According to the annual report of the Ombudsman in the Republic of Croatia, 2% of hospitalizations due to mental disorders are involuntary hospitalization. Coercive measures and deprivation of business capacity are also often used. In order to reduce the number of coercive measures, involuntary hospitalizations and deprivation of professional capacity, it is necessary to increase mental health literacy and knowledge about human rights and the rights of persons with mental disorders, both among mental health experts and among patients and their families, as well as the general public. In order to increase knowledge and skills related to the rights of people with mental disorders, the Croatian Institute of Public Health, has been conducting WHO Quality Rights workshops in Croatian counties since 2019. The two-day workshops include all stakeholders: local politicians and decision-makers, associations of people with mental disorders and their families, employees in the mental health care system with the involvement of the media. So far, the training has been conducted in five major Croatian counties. The Quality Rights e-training platform has been translated into Croatian and the link to access the training is available online. In order to ensure the sustainability of the program and expand knowledge and skills, obtaining a certificate of completed Quality Right training became a requirement for passing the specialist exam in public health and in psychiatry. In five years of implementation of the program, the number of coercive measures in psychiatric hospitals decreased by 58%. Respect for human rights is a prerequisite for improving the mental health care system and the mental health. of both patients and the entire population. Key messages • Respect for human rights is necessary for the mental health of the population. • Knowledge and skills about the rights of patients with mental disorders reduce the rate of coercive measures.

Use and perceptions of involuntary civil commitment among post-overdose outreach staff in Massachusetts, United States: A mixed-methods study.

Involuntary civil commitment (ICC) is a legal process by which people are compulsorily admitted to substance use treatment. This study explored views about and promotion of ICC procedures for substance use disorders among public health-public safety post-overdose outreach programs and their outreach team members in Massachusetts, USA. In this mixed-methods study, survey data were collected from post-overdose outreach programs in 2019, and semi-structured interviews were conducted with outreach team members in 2019 and 2020. Massachusetts, USA. We received 138 survey responses and conducted 38 interviews with post-overdose outreach team members (law enforcement officers, recovery coaches, social workers and harm reductionists) who were majority male (57%) and white (66%). We used the survey instrument to categorize programs as more (discussed ICC at 50% or more of outreach encounters) or less ICC focused (discussed ICC at less than 50% of outreach encounters) and to identify program characteristics that corresponded with each categorization. Semi-structured interviews explored staff perceptions of ICC effectiveness. Among 138 programs, 36% (n = 50) discussed ICC at 50% or more of outreach encounters. Discussing ICC at a majority of visits was positively associated with abstinence-only program philosophies (36% v. 6%, P < 0.001) and collaborating with drug courts (60% v. 30%, P < 0.001), but negatively associated with naloxone distribution (48% v. 75%, P < 0.001) and referring to syringe service programs (26% v. 65%, P < 0.001). Qualitative interviews identified three themes: 1) some programs viewed ICC as a first line tool to engage overdose survivors in treatment; 2) other programs considered ICC a last resort, skeptical of its benefits and concerned about potential harms; 3) families commonly initiated discussions about ICC, reportedly out of desperation. Promotion of involuntary civil commitment (ICC) appears to vary widely across post-overdose outreach programs in Massachusetts, USA, with approaches ranging from seeing it as a first step to treatment to being a tool of last resort. Demand for ICC among family members may relate to inadequate access to voluntary treatment. Family interest in ICC appears to be driven by inadequate availability of treatment and other services. ICC at post-overdose outreach visits should be limited, if used at all.

The Forgotten Feminist

Kate Millett (1934–2017) is best known for her text Sexual Politics (1970). Despite her sudden rise to popularity in the women’s liberation movement, she was quickly dismissed and forgotten, even while continuing to produce new works. Victoria Hesford and Sheila Jeffreys have, respectively, examined the role of homophobia and shifts in feminist theory on Millett’s cataclysmic rise and fall. Expanding on these accounts, the article addresses how sanist discourse pathologized Millett’s bisexuality and polyamory as symptomatic of mental illness to delegitimize her critiques of heteronormative patriarchal psychiatry. It draws a connection between Millett’s public outing in 1970, her first involuntary psychiatric hospitalization in 1973, and the unfavourable and problematic literary responses to her memoirs Flying in 1974 and The Loony-Bin Trip in 1990. Relying on Maria Rovito’s Madwoman theory, the article argues literary critics participate in the silencing and pathologization of Millett by continuing to frame her as mentally ill, instead of as a survivor of psychiatric abuse. It seeks to demonstrate that Madwoman theory is an ethical feminist disability methodology for literary criticism that restores Millett’s voice by unveiling the intersections of heteronormative monosexism and sanism that functions to silence queer Madwomen through epistemic violence and social death.

Cochrane meta-analysis fuels invalid skepticism about compulsory community treatment effectiveness

BackgroundQuantitative research on non-randomized-samples, focused on statute-mandated-outcomes, has found positive results favoring compulsory-community-treatment (CCT) in jurisdictions fully supporting its implementation. In contrast, three randomized-studies “failed-to-find” a difference between randomly-assigned-CCT and control-groups–each study repeatedly summarized in revisions of a Cochrane-meta-analysis reporting this failure. Considering the potential health and safety threats to people with severe-mental-illness and those with whom they interact, there is a critical need for this investigation to resolve these conflicting results. MethodUsing data and procedural-descriptions from the involved-studies, this validity-focused-analysis addressed six questions. Two external-validity focused-questions addressing generalizability of study findings: 1. Did the Cochrane-meta-analysis select studies focused on the CCT-target population? 2. Assuming valid population focus did the Cochrane meta-analysis enroll individuals from among this population fitting the CCT criteria? Four internal-validity-questions: 1. Did the study-designs address the intervention's purpose? 2. Were the outcome-criteria used in the selected-studies valid-indicators of the intervention's intended-outcomes? 3. Were the studies reviewed in the Cochrane-meta-analysis, controlled-trials? And 4. Were the prescribed-Cochrane-Database-statistical-procedures appropriate for evaluating the reviewed-randomized-trials? ResultsFocused on completing randomized-investigations, two outpatient-commitment and one CTO-study failed to validly represent the CCT-population, failed to enroll qualifying-subjects, conflated their primary outcome-measure with a required-intervention-procedure, failed to control for post-randomization experiences directly related to their primary-outcome-measure, and conflated the study conditions. Two trials continuously misrepresented themselves as “randomized-controlled-trials”. All relied on univariate-contrasts in evaluating their outcomes, while without post-randomization-control the studies required multivariate-controls for contrasting the outcomes of their intervention-groups. The Cochrane-review, while listing the short-comings of these studies, placing an over-emphasis on prescriptive-methodology, without addressing study substantive-validity, has yielded spurious-conclusions suborning an invalid political-narrative regarding CCT-effectiveness. ConclusionsThe “failure-to-find” results from the Cochrane-reviewed-studies can be attributed to research shortcomings rather than intervention-ineffectiveness. The Cochrane-review has promoted undue controversy and skepticism re the use of CCT, a potentially lifesaving-procedure.

Mental healthcare in South Tyrol

Mental healthcare in South Tyrol, as everywhere in Italy, is still characterized by Law 180, which came into force in 1978 under the leadership of Franco Basaglia and Bruno Orsini. The Ministry of Health subsequently set atarget number of beds of 10/100,000 inhabitants. Unlike in other parts of Italy, private clinics play aminimal role in South Tyrol. The "Psychiatric Services" are part of the state healthcare system responsible for all citizens and are also responsible for compulsory outpatient care. According to the concept of community care, also due to the small number of inpatient beds, agreat deal of care is provided on an outpatient basis. Coercive measures can only be used in the case of an illness requiring urgent treatment that the patient refuses, without recourse to endangering circumstances (self-endangerment or danger to a third party). Inpatient hospitalization is only possible if treatment also takes place and the principle of "outpatient before inpatient" also applies in this context, i.e., coercive treatment can only take place as an inpatient if it cannot be carried out as an outpatient. Forensic psychiatry has very few places and mentally ill offenders are often in prison or occupy beds in general psychiatric wards. Compared to Germany there are fewer beds available but staffing levels are better, particularly for nursing. In relation to the number of inhabitants, compulsory treatment is more frequent than in Germany, whereas involuntary hospitalization and physical restraint are much rarer (only possible in Italy by court order).

Examining legal challenges in involuntary hospitalisation proceedings: insights from judicial analysis in China

Since the implementation of China’s Mental Health Law, there has been a notable increase in involuntary hospitalisation cases involving individuals with mental health conditions across many provinces, leading to significant social controversy. Moreover, in the process of involuntary hospitalisation litigation, patients with mental health conditions have experienced difficulty initiating legal proceedings, presenting their cases effectively, and prevailing in court, to name a few of the many challenges they face. These obstacles, by impeding them in safeguarding their lawful rights and interests against this legal measure, substantially restrict their personal freedom. To establish a more accessible judicial relief mechanism, a number of steps need to be taken: enhancing the relevant provisions governing the acceptance of involuntary hospitalisation cases, ensuring a balanced distribution of the burden of proof between both parties, and strengthening judicial scrutiny of the legality of involuntary hospitalisation.

The effect of legal representation on clinical measures in involuntarily admitted psychiatric patients: a retrospective study

BackgroundMost western countries provide funded legal representation (LR) for involuntarily admitted psychiatric patients appearing before judicial committees. In 2004, an amendment to the Israeli Mental Health Act granted this right to involuntarily committed psychiatric patients. Psychiatrists then voiced concerns that LR may increase rates of premature discharge and compromise patients’ safety and well-being. These worries have not been sufficiently addressed to date. This study aimed to provide answers to their concerns.MethodsThis study included 3124 and 3434 inpatients involuntarily admitted to psychiatric facilities in 2000 and in 2010 (respectively), prior to and after the introduction of LR in Israel. Data were acquired from the Israeli National Psychiatric Hospitalization Registry. Clinical measures included percentage of discharges by the District Psychiatric Board (DPB), duration of involuntary hospitalization and rates of readmissions within thirty days and six months of discharge by treating psychiatrists (TP) or DPB.ResultsThe odds ratio (OR) of discharge by a DPB in 2010 (n = 221) compared to 2000 (n = 93) was 2.2 [95%CI 1.72–2.82]. The OR was similar for readmissions within thirty days or six months among patients discharged by TP and a DPB (OR = 1.08, p = 0.697 and OR = 0.92, p = 0.603, respectively) as well as between the two time points (p = 0.486 and p = 0.618). The duration of hospitalizations terminated by a DPB was significantly shorter than those terminated by TP, with no difference between the study time points. The mean hospitalization duration in 2010 was 21% shorter compared to 2000 among patients discharged by TP.ConclusionsThe number of DPB proceedings and the number of involuntarily hospitalized psychiatric patients discharged by DPBs increased considerably after the advent of state-funded legal representation in 2004. We found that this did not compromise beneficence and non-malfeasance of patient care. Our results emphasize the feasibility of affording even the most severely mentally ill patients the rights to due process. These findings may relieve concerns about state-funded LR procedures in involuntary psychiatric hospitalizations.

The perspectives of Māori on community treatment orders: A thematic analysis.

To understand the themes for Māori subjected to compulsory community treatment orders. The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms. Thematic analysis of a purposive sample of Māori in Hawke's Bay, New Zealand. Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant. Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially 'slippery slope' towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective.

Compulsory Community Treatment Orders and health outcomes for Ma-ori in New Zealand.

We have previously analysed outcomes for all community treatment orders commenced during a 10-year period in New Zealand. Given Te Tiriti O Waitangi obligations to scrutinise health and consider equity for Māori, we completed this analysis to consider community treatment-order outcomes according to ethnicity. Ministry of Health databases provided demographic, service use and medication dispensing data for community treatment-order recipients between 2009 and 2018. As non-Māori on community treatment orders are older, less deprived and less likely to be diagnosed with a Psychotic Disorder, data were categorised according to age (<35/⩾35 years), level of deprivation (New Zealand Dep levels ⩽3, 4-6 and ⩾7) and diagnosis (Psychotic Disorder/non-Psychotic Disorder). The incidences of key outcome measures (admissions, community care, medication dispensing) were calculated for periods on/off community treatment orders for Māori and non-Māori to consider the differential impact of community treatment orders according to ethnicity. Māori have high rates of community treatment order utilisation and are younger, more likely to be diagnosed with a Psychotic Disorder and spend longer receiving compulsory treatment than non-Māori. Non-Māori are more likely to receive more additional depot antipsychotic medication on-community treatment orders compared with periods off-community treatment order than Māori but other clear patterns of response distinguishing between Māori and non-Māori were not present. The differences between Māori and non-Māori for community treatment-order utilisation suggest the presence of structural inequity in underlying mental illness distribution and treatment provision. Māori cultural expertise at all levels of healthcare including healthcare planning and delivery is required to make advances and reduce disparity.

Impact of Comorbid Personality Disorder on the Risk of Involuntary Hospitalization in Patients Referred for Urgent Forensic Assessment: A Cross-Sectional Study.

In Belgium, involuntary psychiatric hospitalization is authorized in the presence of certain criteria governed by the law relating to the protection of the mentally ill. The number of involuntary hospitalizations has been increasing continuously in recent years. Since personality disorders are frequent comorbidities in involuntarily hospitalized patients, the aim of this study was to investigate the potential role played by comorbid personality disorders in the decisions about involuntary hospitalization made during urgent forensic assessment. A total of 565 individuals were retrospectively recruited from the database of urgent forensic assessment carried out in the Psychiatric Emergency Department. Logistic regression analyses were performed to investigate the risk of involuntary hospitalization associated with comorbid personality disorders in patients referred for urgent forensic assessment. 66.7% of urgent forensic assessments resulted in involuntary hospitalization. In addition, comorbid personality disorders (especially borderline personality disorder) were associated with a lower risk of involuntary hospitalization in patients referred for urgent forensic assessment. In this study, we demonstrated that urgent forensic assessments frequently result in involuntary hospitalizations. Furthermore, this study highlighted that comorbid personality disorders (especially borderline personality disorder) appeared to have a major impact on the decision not to involuntarily hospitalize patients referred for urgent forensic assessment. These elements therefore justify the establishment of adequate clinical reflection to avoid the stigmatization related to these frequent comorbidities in patients at risk of involuntary hospitalization.

Insights from California on Involuntary Commitment for Substance Use.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

Involuntary Commitment #3

Involuntary Commitment #3

Area-level factors associated with variation in involuntary psychiatric hospitalisation across England: a cross-sectional, ecological study.

Involuntary hospitalisations for mental health care are rising in many high income countries, including England. Looking at variation between areas can help us understand why rates are rising and how this might be reversed. This cross-sectional, ecological study aimed to better understand variation in involuntary hospitalisations across England. The unit of analysis was Clinical Commissioning Groups (CCGs), NHS bodies responsible for delivering healthcare to local areas in England. 205 CCGs were included in the analysis. Demographic, clinical, and socioeconomic variables at CCG-level were extracted from national, open access data bases. The outcome variable was the rate of involuntary hospitalisation for psychiatric care under the 1983 Mental Health Act in 2021/22. There was a four-fold difference between the CCGs with the highest and lowest involuntary hospitalisations. In an adjusted analysis, CCGs with a higher percentage of severe mental illness in the population, higher percentage of male population, and higher community and outpatient mental health care use showed a higher rate of involuntary hospitalisation. Depression, urbanicity, deprivation, ethnicity, and age were not strongly associated with involuntary hospitalisation after adjustment. These variables explained 10.68% of the variation in involuntary hospitalisations across CCGs. Some demographic and clinical variables explained variation in involuntary hospitalisation between areas in England, however, most of the variance was unexplained. Complex relationships between urbanicity, deprivation, age, and ethnicity need to be further explored. The role of other influences, such as variation in service organisation or clinical practice, also need to be better understood.

Development of a Vignette-Based Instrument to Assess Psychiatric Involuntary Hospitalization Decision-Making

The decision to hospitalize a psychiatric patient against their will is an ethically and clinically complex problem. While there is variation in rates of involuntary hospitalization (IH) across different settings, we lack a tool to measure individual differences in IH decision-making. This study used a mixed-methods approach to develop and validate a vignette-based instrument designed to assess the decision to hospitalize psychiatric cases and confidence in IH decision-making. The instrument was tested locally inn= 31 psychiatrists, and the results were replicated in a national sample (n= 238). The results showed variation in IH rates across the eight vignettes. Mixed-effects models found significant variability in confidence ratings across both vignettes and participants, supporting the validity of this instrument to assess IH decision-making.

Views and experiences of involuntary civil commitment of people who use drugs in Massachusetts (Section 35)

BackgroundInvoluntary civil commitment (ICC) is a court-mandated process to place people who use drugs (PWUD) into substance use treatment. Research on ICC effectiveness is mixed, but suggests that coercive drug treatment like ICC is harmful and can produce a number of adverse outcomes. We qualitatively examined the experiences and outcomes of ICC among PWUD in Massachusetts. MethodsData for this analysis were collected between 2017 and 2023 as part of a mixed-methods study of Massachusetts residents who disclosed illicit drug use in the past 30-days. We examined the transcripts of 42 participants who completed in-depth interviews and self-reported ICC. Transcripts were coded and thematically analysed using inductive and deductive approaches to understand the diversity of ICC experiences. ResultsParticipants were predominantly male (57 %), white (71 %), age 31–40 (50 %), and stably housed (67 %). All participants experienced ICC at least once; half reported multiple ICCs. Participants highlighted perceptions of ICC for substance use treatment in Massachusetts. Themes surrounding ICC experience included: positive and negative treatment experience’s, strategies for evading ICC, disrupting access to medications for opioid use disorder (MOUD), and contributing to continued substance use and risk following release. ConclusionsPWUD experience farther-reaching health and social consequences beyond the immediate outcomes of an ICC. Findings suggest opportunities to amend ICC to facilitate more positive outcomes and experiences, such as providing sufficient access to MOUD and de-criminalizing the ICC processes. Policymakers, public health, and criminal justice professionals should consider possible unintended consequences of ICC on PWUD.

Involuntary Commitment: Opinions Regarding Patient Autonomy, Legal Parameters, and Behavioral Services Care Delivery.

Involuntary Commitment: Opinions Regarding Patient Autonomy, Legal Parameters, and Behavioral Services Care Delivery.