Scoping Review Process

The initial database search yielded 29,313 evidence sources. Figure 1, the review’s flow diagram, shows the stepwise screening process which resulted in a final sample of 162 evidence sources. The final citation list and a table containing data about each evidence source are in the supplemental results.

Figure 1

Prisma flow diagram for a scoping review of how U.S. healthcare clinicians define “involuntary” in psychiatric, behavioral, and mental healthcare

Characteristics of Evidence Sources

Table 1 shows characteristics of the final 162 evidence sources, of which the most common types were research articles (n = 53), review articles (n = 39), and book excerpts (n = 32). Source years were between 1966 and 2023 (median = 2005). The most common author credential was M.D./D.O. (n = 113) followed by Ph.D. (n = 82).

Table 1 Characteristics of included sources of evidence (N = 162)Number of (In)Voluntary Definitions and the Specific Terms Defined

Among the 162 evidence sources, there were 203 definitions provided (hereafter referred to as the definitions reviewed), with 40 for “voluntary” terms and 163 for “involuntary” terms. There were 126 sources with one definition, 31 sources with two definitions, and 5 sources with three definitions.

Among the definitions reviewed, (in)voluntary was a standalone word for 21 terms and part of a multi-word term for 182 terms. There were a variety of concepts that were described as (in)voluntary multi-word terms, including interventions (hospitalization, mental hospitalization, outpatient commitment, outpatient treatment, civil commitment, commitment, admission, admission for treatment, treatment, mental health treatment, treatment decision, admission to a mental hospital, discharge, medication, inpatient civil commitment, hold, psychiatric hold, mental health holds psychiatric examination, and electroconvulsive therapy [ECT]), people (clients, patients, psychiatric patient, inpatients, and subjects), clinical process concepts (involuntary beds in state hospitals, the involuntary treatment system, and voluntary service agreement), and legal references (legal status, involuntary and voluntary statuses, involuntary treatment laws, substance use laws for involuntary commitment, voluntary participation in mental health court, involuntary outpatient commitment statutes, civil commitment laws, and civil commitment cases).

Table 2 shows definition dimensions (legal, ethical, and safety; see methods section for explanation), key definition words for “involuntary,” and the most frequently defined terms. Illustrative definitions for the most defined terms are found in supplemental results.

Table 2 Definition dimensions and definition words for most frequently defined (in)voluntary terms among scoping review included sources (1966–2023)

The earliest evidence sources identified were two from the 1960s. One defined involuntary hospitalization as “hospitalized without consent,” 20(p. 53) and the other defined “involuntary hospitalization, or commitment” as “the legal procedure which confines the mentally ill to an appropriately designated hospital” 21(p. 1267).

Among the (in)voluntary terms, involuntary outpatient commitment had the most consistent definition. The most common key words in the definition were: order, adhere, comply, mandate, compel, coercion, force, protested, and reluctant. The least consistent definitions were found for involuntary treatment, whose most frequent key (in)voluntary definitions words were three mentions each of consent, against a patient’s will/wishes, coercion, and refusal.

(In)Voluntary As a Standalone Word Defined

The term (in)voluntary was defined in isolation or as the focus of the concept in 17 definitions: 11 for involuntary and 6 for voluntary. There were different definitions for (in)voluntary depending on the context. The most common key definition words for involuntary were against the patient’s will/wishes (3 uses) and legally/civilly committed (2 uses).

Examples of involuntary definitions were a decision made by someone other than the patient when describing a “decision to commit” 22(p. 130); patients committed against their will when describing “beds in state hospitals” 23(p. 13); patients having no choice in some aspect of treatment (e.g., location, treatment site, or psychiatrist), non-compliance resulting in commitment, and could not easily modify treatment plan when discussing “treatment” 24(p. 83); against the patient’s will 25; and civil commitment 26. Voluntary examples definitions include self-referred when discussing “clients,” 27(p. 189) and an individual not coerced in the context of a “treatment decision.” 28(p. 105).

Four definitions directly contrasted voluntary and involuntary. The difference was said to hinge upon on an individual’s consent with respect to treatments (specifically ECT) 29; “of their own accord” versus “against the patient’s will” regarding arrival at the hospital 30(p. 122); and initiated by the patient versus another adult for mental hospital admissions within North Carolina statutes 31.

Definition Citations

Among the evidence sources, 48 (30%) cited a reference for the definition. There were no single definition or group of definitions that were highly cited for the definition of (in)voluntary. In other words, many different sources were cited infrequently.

Multiple (In)Voluntary Terms Within One Evidence Source

Most evidence sources (135/202, 67%) used at least one additional (in)voluntary term without defining it. For example, an article would define “involuntary hospitalization” and then later refer to “involuntary treatment” without defining it.

Specific Laws or Legal References

Some definitions referred to specific laws, regulations, or legal cases. Involuntary psychiatric examination was used interchangeably with Baker Act examination, which refers to the Florida Mental Health Act of 1971 32. Specific state laws or regulations were used as references to define (in)voluntary admission, 31,33,34,35 informal voluntary admissions, 36 involuntary patients, 37(p.200) voluntary agreement as part of assisted outpatient treatment, 38 involuntary legal status, 39 and involuntary commitment for alcoholism 40. U.S. Air Force regulation was used to define involuntary treatment 41.

Professional Societies

A total of 9 evidence sources were found from the hand search review of the professional societies, organizations, and the U.S. VA/DoD websites. Two definitions were found from the American Psychological Association’s Dictionary of Psychology. “Voluntary admission” was said to occur at the patient’s request, without coercion, and ends when the patient sees fit unlike involuntary hospitalization 42. “Involuntary hospitalization” was defined as “confinement of a person with a serious mental illness to a mental hospital by medical authorization and legal direction (as in involuntary civil commitment)” 43.

Four evidence sources were found from the American Psychiatric Association. “Non-emergency involuntary medication” was defined as a “clinical and legal process by which a psychiatric patient is administered medication after they have declined acceptance of prescribed medication” 44(p. 1). “Involuntary outpatient commitment” was described in a position statement as “mandated under state involuntary commitment statutes… a judge orders a person with severe mental illness to adhere to an outpatient treatment plan” 45(p. 1). A resource document provided three definitions for “involuntary outpatient commitment”: “court-ordered… unlikely to adhere without such a program,” “judge orders… to adhere,” and a list of interchangeable terms 46(p. 5).

One source was found from the Academy of Consultation-Liaison Psychiatry, which was a collaborative care guide that included “involuntary psychiatric hold” defined by synonym as “civil commitment” by placing it in parenthesis after the term 47(p. 4).

The Veterans Health Administration defined “commitment and involuntary mental health treatment” in a healthcare handbook as “the totality of applicable state laws governing involuntary mental health evaluation and treatment, including time limited holds for evaluation, involuntary outpatient treatment, and forced administration of psychotropic medication” 48(p. 3). In a Veterans Affairs mental health nursing orientation guidebook, “voluntary hospitalization” was said to “allow the person to freely choose to discharge from the facility by utilizing the proper process,” while “involuntary hospitalization” was said to “[result] in a period of commitment established in compliance with state legal guidelines” 49(p. 107).

Two notable uses of (in)voluntary terms without clear definitions were in the American Psychiatric Glossary 50 and The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry 51.

Specific Definition Words for (in)Voluntary Terms

Across all (in)voluntary terms (n = 163), the most frequently used key definition words were order (found in 25 definitions), coercion (23 definitions), and against or opposed to a patient’s will/wishes (23 definitions). The ethical concept of autonomy versus beneficence was used in 6 definitions, and the concepts of capacity and competence were mentioned in 4 and 7 definitions, respectively.

Order

Forms of order appeared in 25 definitions, all of which were for involuntary terms. The term with order found most frequently in the definition was “involuntary outpatient commitment” which was defined as “court-ordered” 46(p. 1), 52(p. 863), 53(p. 36), 54(p. 7) ordered by a judge [some sources also add: to comply/adhere], 45,46,55,56,57,58,59,60,61 “ordered to seek,” 62(p. 339) and ordered/orders to adhere 63,64. Involuntary commitment was said to be “court-ordered,” 65(p. 181), 66(p. 65), 67(p. 65) and involuntary inpatient treatment was defined with “court-ordered to receive” 68(p. 57).

Coercion

There were 23 definitions in which coercion was included in the definition of (in)voluntary. Of these, 10 definitions presented coercion dichotomously as either present or absent. Four definitions presented coercion in a more nuanced way. One definition of “involuntary legal status” stated that patients were not necessarily coerced, 39 while other definitions stated that “involuntary treatment,” “involuntary mental hospitalization,” “involuntary outpatient commitment,” “involuntary outpatient treatment,” and “involuntary civil commitment” were coercive. “Voluntary” terms (“treatment,” “treatment decision,” “clients,” “situated,” and “admission”) were said to be not coerced, uncoerced, no coercion permissible, without coercion, or without improper inducement or coercion. Sources with more specific concepts related to coercion distinguished between “coerced voluntaries” 69(p. 167) as patients who were coerced to be a voluntary patient (“sign themselves in as voluntary patients”), “uncoerced involuntaries” to mean those involuntary patients who were “actually seeking hospitalization,” 69(p. 168) “coerced involuntary retention” to mean “patients who clearly expressed the wish to avoid hospitalization” 70(p. 516).

A Patient’s Will/Wishes

There were 23 definitions that explained an involuntary intervention as something that was against/opposed to the will/wishes of a patient; no definitions of voluntary included this language. Among these, as examples, one definition term was “involuntary” alone, 25 three were involuntary treatment, 71,72,73 four were hospitalization derivatives, 30,74,75,76 one was patient, 77 one was intervention, 78 and five were [civil] commitment 40,79,80,81,82.

Consent

Consent was mentioned in 18 definitions, 11 of which were involuntary terms, and seven were voluntary terms. Voluntary treatments 29 and medications 83 were said to be done with patient consent, and another definition stated that voluntary interventions were done with patient informed consent 78. A “voluntary” civil commitment was said to be one in which consent could be withdrawn and lead to discharge 84(p. 321). Voluntary inpatients were said to be persons who presented, requested, and consented to treatment of illness 85. For involuntary terms, most commonly, involuntary treatments, hospitalization, and confinement were said to be done without patient consent. Involuntary legal status was defined using “without consent” and “non-consenting,” although not necessarily coerced 39(p. 89). The involuntary admissions process was defined as one where the patient is “unwilling” to consent to hospitalization 86(p. 872). Patients were said to, in many instances, lack the capacity to consent in one definition of involuntary treatment 87. The term “involuntary voluntary” was defined as a patient who is labeled as admitted voluntarily but actually is coerced into the decision and therefore repression of true informed consent is concealed 88.

Autonomy Versus Beneficence

The medical ethics concepts of autonomy and beneficence were listed as part of six explicit definitions, all of which were involuntary interventions. The most common terms were involuntary hospitalization (n = 2) and involuntary commitment (n = 2). Specific phrasings were that doctors, with the help of the state, deprived patients of autonomy and liberty for the purpose of beneficence 89; autonomy and beneficence were values in conflict 66,67,86; patient autonomy was precluded for beneficial treatment