CHPR: Many of us in inpatient psychiatry often feel helpless when we work with patients who cycle in and out of involuntary hospitalization often without real progress, so I’m glad you’re writing about this issue (Zhong R and Wasser T, Psychiatric Services 2024;75:1279–1281). What drew you both to focus on it?
Dr. Zhong: As medical director at a community mental health agency, I saw many individuals with serious mental illnesses who were repeatedly hospitalized. They’d be discharged, only to return within days or weeks, often brought in by police after causing a public disturbance. It wasn’t clear that hospitalization was helping them. 

Dr. Wasser: I’ve seen the same pattern across emergency rooms (ERs) and inpatient units, both in the private sector and in state institutions. We use the tools available to us, but for some patients, those interventions simply don’t work. Meanwhile, we deprive these patients of liberty and erode their trust in treatment. Dr. Zhong and I are both board-certified forensic psychiatrists, and our experiences have led us to wonder: How can we find the right balance between patients’ rights, safety, and the legal and ethical responsibilities of care? And, given the resource-constrained world we live in, are we making the best use of our resources? 

Dr. Zhong: Our inpatient and outpatient clinicians often felt compelled to admit these patients, even though they knew it wasn’t really going to make a difference. So, we wanted to explore why.

CHPR: But what alternatives exist for individuals with chronic mental illnesses who might be found living on the streets in rags and malnourished?  
Dr. Wasser: We’re not arguing against civil commitment for grave disability. But we believe there’s a subset of patients for whom inpatient care has proven futile. The issue isn’t just ethical; it’s also pragmatic. Psychiatric beds are a scarce resource, and their availability has declined dramatically over the past several decades. Since 1970, there’s been a nearly 80% decline in inpatient and other residential treatment beds (www.tinyurl.com/2dujc3tn). One alternative would be a massive expansion of inpatient services. If beds were abundant, resource constraints wouldn’t be a reason to rethink hospitalization. However, that still wouldn’t make inpatient care any more effective or respectful of patient autonomy. Another option is significantly investing in involuntary outpatient commitment (IOC). While 46 states and Washington, DC, have IOC statutes, fewer than half have implemented them in ways that lead to meaningful improvements in outcomes, often due to limited funding, insufficient community-based infrastructure, and inconsistent enforcement mechanisms. (Meldrum ML et al, Psychiatr Serv 2016;67:630–635). And too often, funding for IOC comes at the expense of other mental health services—robbing Peter to pay Paul and leaving other vulnerable populations underserved. 

CHPR: Have any states implemented IOC more successfully despite those challenges?
Dr. Wasser: New York and North Carolina have shown the most success, largely because they’ve paired IOC with robust community services and made dedicated investments rather than reallocating funds from other programs (Phelan JC et al, Psychiatr Serv 2010;61(2):137–142).

“As physicians, our job is to recommend treatments that help. For a subset of patients, hospitalization no longer provides meaningful benefit. At some point, any clinician will recognize that repeated admissions aren’t helping. Whether that’s after 5, 30, or 100 stays, we must ask: If hospitalization isn’t helping, why keep doing it?”

Rocksheng Zhong, MD, MHS

CHPR: In addition to outpatient commitment, what about conservatorships?
Dr. Wasser: Conservatorships or guardianships are an option in many states for individuals who are chronically gravely disabled with repeated hospitalizations and a clear inability to manage their own health care decisions. In some states, conservatorship can sometimes lead to long-term hospital care. But in many other states, it doesn’t actually affect whether someone can be hospitalized or how long they stay.

CHPR: One strategy that’s often discussed to reduce repeated hospitalizations is expanding the use of long-acting injectables (LAIs)—possibly even on an involuntary outpatient basis. What are your thoughts on the feasibility and ethics of that approach?
Dr. Wasser: While many jurisdictions allow forced LAIs on an outpatient basis, implementing these laws is another matter. LAIs can reduce repeated hospitalizations, especially for individuals who disengage from care. At the same time, this approach raises serious questions about autonomy, consent, and coercion. While we recognize their potential benefits, especially in improving stability for some patients, compulsory use remains ethically fraught. And practically speaking, such mandates are unlikely to gain the political support or funding needed for broad implementation.

CHPR: Some patients don’t show significant clinical improvement from inpatient care, yet benefit from, and seem to appreciate, basic necessities like warm meals, clean clothes, and a shower. But hospitalizing them for those services, if they’re not also going to improve clinically, does seem excessive.
Dr. Zhong: That’s at the heart of our argument. Our society places a high value on personal liberty, yet we detain people preemptively for not functioning well in the community. If hospitalization provides only temporary shelter and basic needs, with no lasting benefit, we must question its ethics and utility. Compelling someone into care for minimal gain imposes major costs on systems and autonomy. There are few other areas where we detain someone simply for living in a way we disapprove of.

CHPR: What feedback have you received for your arguments?
Dr. Zhong: Most of the feedback has fallen into two camps. One group, largely from the substance use recovery community, including individuals with lived experience of serious mental illness and those who provide direct services, has been generally supportive, appreciative, and eager to explore how we can further engage with these ideas. 

CHPR: What concerns do psychiatrists raise about your approach?
Dr. Zhong: Many psychiatrists strongly disagree. Some reference the phrase “letting people die with their rights on,” which emerged in the 1970s when mental health laws were reformed to require stricter legal standards, such as demonstrating dangerousness, before someone could be involuntarily hospitalized. The concern then, as now, is that these protections are well-intentioned but may leave vulnerable individuals on the streets without adequate care or support. We understand that concern; no one wants to see people suffer due to a lack of care. But as physicians, our job is to recommend treatments that help. For a subset of patients, hospitalization no longer provides meaningful benefit. At some point, any clinician will recognize that repeated admissions aren’t helping. Whether that’s after 5, 30, or 100 stays, we must ask: If hospitalization isn’t helping, why keep doing it?

CHPR: Might clinicians risk liability if they avoid hospitalization and a bad outcome occurs? 
Dr. Zhong: We do live in a very litigious society, and there is always a risk of being sued for a bad outcome. In the long run, our goal is to start a conversation that shifts professional expectations so that clinicians will feel less obligated to admit patients who are unlikely to benefit from hospitalization even if they technically meet criteria for commitment. And if everyone is doing it—that is, not admitting people who won’t benefit from admission—then the standard of care changes and legal liability decreases. When a person dies of cancer, people usually don’t blame the oncologist for failing to administer every possible chemotherapy because there is no expectation that an oncologist should administer every possible chemotherapy.

CHPR: What practical steps can clinicians take to protect themselves legally when choosing not to hospitalize? 
Dr. Zhong: In the short run, effective documentation of clinical reasoning is critical to protecting yourself legally. The clinician’s duty is to perform an adequate risk assessment and implement reasonable interventions, not to predict the future with perfect accuracy. So long as you do conduct that risk assessment and then make a reasonable judgment that hospitalization is not medically appropriate, while explaining all this in your documentation such that someone reading your note can understand your decision, you’ll be well prepared to defend yourself in a lawsuit.

CHPR: How do you handle family pushback when you recommend against admission?
Dr. Zhong: It can be challenging, but as with any other disagreement between clinicians, patients, and families, it’s important to communicate the decision and rationale behind it in a compassionate and caring way. Clinicians can emphasize that the outcome, while different from what the family had in mind, is nonetheless arrived at with the patient’s interests at heart—given that involuntary hospitalization is not likely to help and may actually harm the patient. Then they can offer outpatient resources.

Dr. Wasser: Some pushback stems from the language we’ve used. Terms like “palliative psychiatry” and “futility” make people uneasy, but these concepts already exist in medicine. In other fields, when treatments no longer help, we shift focus. We stop chemo for terminal cancer patients. Why don’t we think the same way in psychiatry? We’re not calling for the end of civil commitment, but we are asking the field to consider whether there’s a point where continued involuntary hospitalization causes more harm than good. If so, we need to explore alternative approaches that might actually help these patients.

“Terms like ‘palliative psychiatry’ and ‘futility’ make people uneasy, but these concepts already exist in medicine. In other fields, when treatments no longer help, we shift focus. We stop chemo for terminal cancer patients. Why don’t we think the same way in psychiatry?”

Tobias Wasser, MD

CHPR: Right. Like with a terminal illness, at some point, continuing aggressive care can do more harm than good. 
Dr. Zhong: Exactly. Instead of forcing people into ineffective hospital stays, let’s invest in community-based care, like assertive community treatment (ACT) teams, outreach programs, social services, housing, employment support, and education. These interventions are far more likely to provide meaningful, lasting benefits. But these interventions require voluntary participation, and many patients, especially those with co-occurring substance use disorders, are reluctant to engage. 

Dr. Wasser: I won’t pretend there’s an easy solution. Substance use comorbidity complicates everything. It affects motivation, willingness, and sometimes even the ability to engage in care. One promising approach is greater investment in recovery-oriented services. We need to see these individuals as people with mental illness, not just “mentally ill people.” That means focusing on the same things that matter to all of us—safe housing, a sense of community, meaningful work, and educational opportunities.

CHPR: What specific strategies have shown promise in engaging these hard-to-reach patients? 
Dr. Wasser: Peer support is huge. When you hire individuals with lived experience, there’s strong evidence showing that peer support specialists can engage patients in ways that clinicians often cannot (Lee SN and Yu HJ, Healthcare (Basel) 2024;12(12):1179). Think about it—seeing someone who has been through similar struggles and found stability can be deeply motivating. If we could fund and co-locate these services, providing mental health care alongside housing, employment, and social engagement opportunities, we’d have a much better chance of connecting with patients and improving outcomes.

CHPR: What can us frontline clinicians do when we feel hospitalization may be futile?
Dr. Zhong: Make sure to document your reasoning. A good resource is the blog post “How to Write a Suicide Note” (www.tinyurl.com/y7fvtu93). It’s framed around discharging a suicidal patient from the ER, but it applies just as well to other contexts and for people with treatment-resistant disease and grave disability for whom the clinician doesn’t believe hospitalization is helpful. The more clinicians choose not to hospitalize patients when they don’t think it’s appropriate and are able to explain why, the more we can shift expectations over time among care providers, patients, families, administrators, and litigators.

Dr. Wasser: Also, collaborate. Contact outpatient providers or community teams. They may be able to engage the patient more effectively, or at least help develop a community-based plan. And even if ACT or housing isn’t immediately available, advocating for those options in your notes and treatment team meetings helps build a case for systemwide changes. These steps might seem small, but they lay the groundwork for broader reform.

CHPR: Thank you for your time, Dr. Zhong and Dr. Wasser.