Liberty versus Need — Our Struggle to Care for People with Serious Mental Illness

Of 9.8 million U.S. adults with serious mental illness, an estimated 40% receive no treatment in any given year, often with dire consequences. But the structural impediments to care can’t be addressed without reconciling the conflicting ideals underlying them. In 1985, when internist Jim O’Connell, cofounder of the Boston Health Care for the Homeless Program, 1 began doing outreach to homeless people, one of the toughest questions he faced was whether to commit someone to the hospital for involuntary psychiatric treatment. States vary in their criteria for involuntary commitment: some permit consideration of psychiatric need, whereas others allow such infringement of civil liberties only if one is believed to pose an immediate physical danger to self or others. Nevertheless, the application of legal criteria to the unique circumstances of someone’s life requires subjective interpretation. So despite 30 years of navigating . . .