Involuntary Psychiatric Commitment Jumps 60 Percent in 10 Years

Health ministry and justice officials say they are worried by what they call 'criminalization' of the psychiatric system in Israel

Ido Efrati
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File photo: A doctor walks through the psychiatric ward Tel Aviv's Ichilov Hospital, January 10, 2016.
File photo: A doctor walks through the psychiatric ward Tel Aviv's Ichilov Hospital, January 10, 2016.Credit: David Bachar
Ido Efrati

A few days before Passover, A., in his 20s, mentally ill and handicapped, tried to commit suicide by overdosing on pills, and was hospitalized. A few days later it was decided to send him home. “The psychiatrist came, saw him for five minutes and pronounced him fit,” A.’s mother said. By the time she got to the hospital to pick him up, he was gone, she said. “It turned out that he had left the ward. We looked around. We found him half naked.” When they tried to get him into the car, he attacked his mother and pulled her hair. A. was later arrested, and taken before a judge to determine whether he should be forcibly committed to a psychiatric institution.

Over the last decade, according to Health Ministry figures reported here for the first time, involuntary commitment to psychiatric wards by court order has jumped by about 60 percent, while the population grew by only 22 percent in that same period.

Involuntary commitment by court order has become the most convenient way to hospitalize psychiatric patients who are belligerent or agitated and refuse to enter the hospital voluntarily. Helpless family members, neighbors and others who call the police to complain that laws are being broken are aware of the advantage of this action. The police arrive immediately, arrest the person and bring him or her to court. In this procedure, known as the criminal procedure, with the appropriate psychiatric opinion, the judge issues an order of involuntary commitment for a relatively lengthy period compared to the “civil procedure” of commitment by order of the Health Ministry’s district psychiatrist.

But the moment a person is committed this way, not only is he or she labeled mentally ill, they are also treated like an offender. They are arrested, cuffed and taken away in a police car. They might have to remain in lockup for a night or two before seeing a judge, sometimes together with regular criminal offenders. And if the court does issue an involuntary commitment order, only a psychiatric committee headed by a lawyer can order the patient released.

Health ministry and justice officials say they are worried by what they call “criminalization” of the psychiatric system in Israel – dealing with the mentally ill with tools from the criminal justice system rather than medical tools.

Involuntary psychiatric commitment occurs on a daily basis in Israel, whether by civil or criminal procedure and is a matter of ongoing debate.

Also according to Health Ministry statistics, between 2006 and 2015, there was a 45 percent increase in the number of suspects placed under psychiatric observation by court order to determine whether they are fit to stand trial. A similar increase was seen in the percentage of suspects sent for observation as out-patients.

Tragic stories of the mentally ill having to face a judge for breaking the law have been heard with ever greater frequency in Israel’s courts.

In the case of A., who attempted suicide but was released a few days later and subsequently attacked his mother, she told the judge: “He hurt me badly, he scalped me.” When the judge asked the mother whether she thought he should release A. and ban him from going home, the mother said: “I don’t know. Do you want to see me completely scalped? We can’t stand it, my husband and I. We need someone to do the job for us, a therapist.” Eventually, with the agreement of all parties, the judge released A. to his parents’ home.

In attacking his mother, thus committing a crime, is A. an offender to be treated like a criminal, or is he mentally ill, with the attack a symptom of his illness, and in need of urgent treatment? The line is becoming increasingly blurred.

As for concerns over the criminalization of the mentally ill, according to central district public defender Dorit Nahmani-Albek, who is in charge of psychiatric criminal cases in the district, a mentally ill person who commits a serious crime should indeed be dealt with in criminal proceedings. But in all other cases, she says, the civil system should and can deal with the matter, whether in an out-patient clinic or, if there is no choice, by involuntary commitment. “In many cases, there is no real assault but rather letting off steam or throwing some object. In cases of assault or injury, the police will come in any case. Those cases could be dealt with in emergency psychiatric treatment or by the district psychiatrist.” If a mentally ill person is arrested, Nahmani-Albek says, their mental state declines further, as some of them find themselves behind bars for the first time, together with criminals.

In the past the pendulum swung the other way – commitments by district psychiatrists proliferated as they used their authority sometimes to forcibly hospitalize people without justification. They were criticized by patients, their families and social action groups, as well as the courts. “The criticism was that the voice of the patients was not heard. During one period, the district court even reprimanded district psychiatrists. They were very harshly criticized and moved to a defensive position,” Nahmani-Albek said.

According to the 1991 law governing the treatment of the mentally ill, the district psychiatrist can order the involuntary commitment of a person when as a result of the person’s illness, his or her judgement and perception of reality are impaired, and they might do imminent harm to themselves or others. The district psychiatrists do use their authority, but in light of the criticism leveled at them, they have become more cautious, some say too cautious.

“Instead of acting in the framework of the defined criteria of the law, they prefer to give way in some cases to the police and the criminal procedure,” Nahmani-Albek said. “As a result, we see many more mentally ill people who were once dealt with in the civil system but as a result of some minor act, find themselves in the criminal system. The police come and investigate, and the family, because they realize that [commitment] is much harder in the civil system, exaggerate what happened and even make things up so the police will intervene,” she added.