Holding the Guardrails on Involuntary Commitment.

In response to the increasing number of mentally ill people experiencing homelessness, some policy-makers have called for the expanded use of involuntary commitment, even for individuals who are not engaging in behaviors that are immediately life-threatening. Yet there is no evidence that involuntary commitment offers long-term benefits, and significant reasons to believe that expanding the practice will cause harm. In addition, these proposals ignore research showing that most people with mental illness have the capacity to make medical decisions for themselves. Rather than expanding the use of involuntary commitment, policy-makers should support approaches proven to decrease the prevalence of homelessness, such as supportive housing. In addition, states should reevaluate their commitment standards for persons who pose no risk of harm to others. One promising approach is Northern Ireland's Mental Health Capacity Act of 2016, which establishes a uniform standard for imposing nonconsensual health care interventions, without any distinction between mental illnesses and other conditions in which capacity might be compromised.

Detention of children and adolescents under mental health legislation: a scoping review of prevalence, risk factors, and legal frameworks.

BACKGROUND: For individuals with severe mental illness, involuntary assessment and/or treatment (hereafter detention) can be a necessary intervention to support recovery and may even be lifesaving. Despite this, little is known about how often these interventions are used for children and adolescents. METHODS: This global scoping review set out to: (1) map the current evidence around mental health detentions of children and adolescents (< 18 years); (2) identify the clinical, sociodemographic, and behavioural factors associated with detention; and (3) document the views of professionals and young people on the implementation of mental health legislation. RESULTS: After searching databases of peer-reviewed literature and citation chaining, 42 articles from 15 jurisdictions were included. About one fifth of psychiatric admissions in national register data were detentions, however trends were only available for a few high-income Western countries. The circumstances justifying detention and the criteria authorising detention varied between studies, with a mix of clinical factors and observed behaviours reported as the reason(s) warranting/precipitating a detention. Particular groups were more likely to experience detention, such as children and adolescents from minority ethnic communities and those with a documented history of abuse. There was a notable absence of qualitative research exploring the views of professionals or children and adolescents on detention. CONCLUSION: Further research is needed to explore the impact of detention on those aged < 18 years, including national register-based studies and qualitative studies. This is particularly relevant in nations currently undergoing legislative reform.

The Other Infodemic: Media Misinformation about Involuntary Commitment for Substance Use.

BACKGROUND: As drug-related deaths have surged, the number and scope of legal mechanisms authorizing involuntary commitment for substance use have expanded. Media coverage of involuntary commitment routinely ignores documented health and ethical concerns. Prevalence and dynamics of misinformation about involuntary commitment for substance use have not been assessed. METHODS: Media content mentioning involuntary commitment for substance use published between January 2015 and October 2020 was aggregated using MediaCloud. Articles were redundantly coded for viewpoints presented, substances mentioned, discussion of incarceration, and mentions of specific drugs. In addition, we tracked Facebook shares of coded content. RESULTS: Nearly half (48%) of articles unequivocally endorsed involuntary commitment, 30% presented a mixed viewpoint, and 22% endorsed a health-based or rights-based critique. Only 7% of articles included perspectives of people with lived experience of involuntary commitment. Critical articles received nearly twice as many Facebook shares (199,909 shares) as supportive and mixed narratives combined (112,429 shares combined). DISCUSSION: Empirical and ethical concerns about involuntary commitment for substance use are largely absent from coverage in mainstream media, as are voices of those with lived experience. Better alignment between news coverage and science is vital to inform effective policy responses to emerging public health challenges.

Financial Equity in Involuntary Treatment for Substance Use Disorders.

Involuntary civil commitment for individuals who are chronically impaired as a result of their substance use remains highly controversial. At present, 37 states have legalized this practice. Increasingly, states are allowing private third-parties, such as friends or relatives of the patient, to petition courts for involuntary treatment. One such approach, modeled on Florida's Marchman Act, does not determine status based on the petitioning party's willingness to commit to pay for care. In contrast, Kentucky's approach, widely known as "Casey's Law," predicates such involuntary commitment on the third party's willingness to commit in advance to pay for the patient's treatment. This article reviews the history and current status of existing law on this subject and then argues that psychiatrists should advocate strongly against involuntary substance treatment laws that rely upon third-party pledges of payment.

Outcomes for Patients Discharged to Involuntary Commitment for Substance Use Disorder Directly from the Hospital.

To evaluate the outcomes of patients discharged to involuntary commitment for substance use disorders directly from the hospital. We performed a retrospective chart review of 22 patients discharged to involuntary commitment for substance use disorder from the hospital between October 2016 and February 2020. We collected demographic data, details about each commitment episode, and healthcare utilization outcomes 1 year following involuntary commitment. Nearly all patients had a primary alcohol use disorder (91%) and had additional medical (82%) and psychiatric comorbidities (71%). One year following involuntary commitment, all patients had relapsed to substance use and had at least one emergency department visit while 78.6% had at least one admission. These findings suggest that patients discharged to involuntary commitment directly from the hospital universally relapsed and experienced significant medical morbidity during the first year following their release. This study adds to a growing literature recognizing the harms of involuntary commitment for substance use disorder.

Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England.

BACKGROUND: Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. METHODS: Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. RESULTS: Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. CONCLUSIONS: We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Vivências de trabalho precoce de adolescentes em medida socioeducativa / Experience of child labor of adolescents complying with a social-educational measure / Vivencias de trabajo infantil de adolescentes en medidas socioeducativas

Este artigo tem como objetivo analisar a vivência de trabalho precoce de adolescentes e jovens em cumprimento de medida socioeducativa, no estado da Paraíba. Os instrumentos utilizados foram um Questionário Mosquito Diagnóstico e uma Entrevista Semiestruturada. A análise foi realizada com o software Iramuteq, (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), através da Análise Hierárquica Descendente, que gerou seis classes: significado do trabalho; infância e escola; condições objetivas de vida; trabalho, drogas e ato infracional; consequências do trabalho infantil; e trabalho infantojuvenil. A perspectiva teórica utilizada foi a psicologia histórico-cultural e os dados discutidos a partir do conceito de vivência. Conclui-se que as vivências e situações sociais de desenvolvimento foram caracterizadas pelo trabalho precoce que oportunizou o envolvimento com atos infracionais e as instituições responsáveis pela garantia de direitos em vez de garantir a proteção social, criminalizaram por meio de medidas socioeducativas.(AU)

This article aims to analyze the experience of child labor of adolescents and youngsters that are complying a social-educational measure, in the State of Paraíba. The instruments utilized were a Questionnaire Mosquito Diagnóstico and a Semi-Structured Interview. The analysis was performed by using the Iramuteq software (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), by using Descending Hierarchical Analysis, which generated six classes: meaning of labor; childhood and school; objective conditions of life; labor, drugs, and act of infraction; consequences of child labor; and child labor. The theoretical perspective used was historical-cultural psychology and the data were discussed from the concept of experience. It was concluded that the experiences and social situations of development were characterized by child labor, which enabled the involvement with acts of infraction; and the institutions responsible for guaranteeing rights, instead of guaranteeing social protection, criminalized by using social-educational measures.(AU)

Este artículo tiene como objetivo analizar la vivencia precoz de adolescentes y jóvenes que cumplen medidas socioeducativas en el estado de Paraíba (Brasil). Los instrumentos utilizados fueron un Cuestionario Mosquito Diagnóstico y una entrevista semiestructurada. El análisis se realizó con el software Iramuteq (Interface de R pour les Multidimensionnelles Analyzes de Textes et de Questionnaires), mediante análisis jerárquico descendente, que generó seis clases: Significado del trabajo; Infancia y escuela; Condiciones objetivas de vida; Trabajo, drogas y acto de infracción; Consecuencias del trabajo infantil; y Trabajo infantojuvenil. La perspectiva teórica que se utilizó fue la psicología histórico-cultural, y los datos se discutieron desde el concepto de vivencia. Se concluye que las vivencias y situaciones sociales de desarrollo se caracterizaron por trabajo infantil que permitió la participación en infracciones y que las instituciones responsables de garantizar los derechos en lugar de la protección social los criminalizaron mediante medidas socioeducativas.(AU)

Implications of deficit discourse in the conversations of a mother who requests forced treatment / Implicações do discurso do déficit nas conversas de uma mãe que solicita tratamento forçado / Implications du discours déficitaire sur les conversations d'une mère qui demande traitement forcé / Implicaciones del discurso del déficit en las conversaciones de una madre que solicita tratamiento forzado

Abstract This case study analyzes the implications of deficit discourse on the daily conversations of a mother who requested forced treatment for her son. Data were analyzed drawing on social construction, with an emphasis on positioning theory and deficit discourse. Two episodes displaying deficit discourse were analyzed: one about the son as someone who is powerless, coping with drug use and another about the mother as someone unable to help her son. A sample letter was constructed using relational discourse, which provided new understandings for practice. Results support the benefits of collaborative and relational approaches for people who use drugs and for the emotional support of families.

Resumo Este estudo de caso analisa as implicações do discurso do déficit nas conversas cotidianas de uma mãe que solicitou tratamento forçado para seu filho. Os dados foram analisados a partir da construção social, com ênfase na teoria do posicionamento e do discurso do déficit. Dois episódios foram analisados a partir do discurso do déficit: um sobre o filho como alguém que é impotente no enfrentamento do uso de drogas e outro sobre a mãe como alguém incapaz de ajudar seu filho. Foi construída uma carta ilustrativa a partir do discurso relacional, que proporcionou novos entendimentos para a prática. Os resultados corroboram os benefícios das abordagens colaborativas e relacionais para o suporte emocional de pessoas que usam drogas e suas famílias.

Résumé Cette étude de cas analyse les implications du discours déficitaire sur les conversations quotidiennes d'une mère qui a demandé traitement forcé pour son fils. Les données ont été analysées en s'appuyant sur la construction sociale, en mettant l'accent sur la théorie du positionnement et le discours déficitaire. Deux épisodes ont été analyses utilisant le discours déficitaire: l'un sur le fils en tant que personne impuissante face à l'usage de drogue, et l'autre sur la mère en tant que personne incapable d'aider son fils. Une lettre illustrative a été construit utilisant le discours relationnel, qui a fourni de nouvelles compréhensions pour la pratique. Les résultats confirment les avantages des approches collaboratives et relationnelles pour le soutien émotionnel des personnes qui consomment des drogues et leurs familles.

Resumen Este estudio de caso analiza las implicaciones del discurso del déficit en las conversaciones diarias de una madre que solicitó tratamiento forzado para su hijo. Los datos fueron analizados a partir de la construcción social, con énfasis en la teoría del posicionamiento y el discurso del déficit. Se analizaron dos episodios a partir del discurso del déficit: uno sobre el hijo como alguien que es impotente frente al uso de drogas y otro sobre la madre como alguien incapaz de ayudar a su hijo. Se construyó una carta ilustrativa utilizando el discurso relacional, que proporcionó nuevas comprensiones para la práctica. Los resultados respaldan los beneficios de los enfoques colaborativos y relacionales para el soporte emocional de las personas que usan drogas y sus familias.

Involuntary Civil Commitment for Substance Use Disorders in Puerto Rico: Neglected Rights Violations and Implications for Legal Reform.

Laws facilitating the involuntary civil commitment (ICC) of people with substance use disorders vary considerably internationally and across the United States. Puerto Rico, a colonial territory of the United States since 1898, currently harbors the most punitive ICC legislation in the country. It is the only place in the United States where self-sufficient adults who pose no grave danger to themselves or others can be involuntarily committed to restrictive residential facilities for over a year at a time without ever being assessed by a health care professional. The involuntary commitment of otherwise-able citizens-many of whom have never been diagnosed with a substance use disorder-continues to be ignored nationally and internationally. In this paper, we specify how Puerto Rican ICC law and procedures systematically violate rights and liberties that are supposed to be guaranteed by Puerto Rico's Mental Health Act, the US Federal Supreme Court, and the Universal Declaration of Human Rights. To ensure that Puerto Rico's ICC procedures conform to prevailing local, national, and international standards, we propose a series of legislative reforms. Finally, we highlight the importance of addressing the preponderance of poorly constructed ICC laws both within the United States and internationally.

Manifestaciones psicológicas y factores de riesgo en el adolescente durante confinamiento Covid-19, año 2022 / Psychological manifestations and risk factors in adolescents during Covid-19 confinement

La pandemia por COVID-19 ha marcado la historia como una de las pandemias que más ha impactado la vida de la población global. Siendo el virus SARS-CoV-2 altamente transmisible, los diferentes países adoptaron regímenes sanitarios estrictos para enfrentar la pandemia, mencionando el confinamiento como uno de los más notables. La población adolescente, particularmente, ha sido una de las más afectadas por la pandemia debido a todos los cambios obligados que han implementado en sus vidas durante esta etapa de transición en la que se encuentran. Se han descrito pérdidas de hábitos saludables, problemas de relaciones interpersonales e intrafamiliares, y el aumento del uso de tecnología durante el confinamiento como factores de riesgo relevantes que convierten a la población adolescente en blanco vulnerable a manifestar la importante sintomatología psicológica. La revisión bibliográfica tiene como objetivo conocer las manifestaciones psicológicas y factores de riesgo en el adolescente durante el confinamiento del COVID-19 2022. Esta revisión bibliográfica es de tipo descriptivo, en la cual se realizó una busqueda sistemati- ca de articulos científicos, consultando diversos sitios web y bases de datos, entre algunas; LATINDEX, LILACS, Google Académico, Camjol, ELSEVIER, PubMed, SCOPUS, NLM Catalog. En conclusión, es notable el impacto que ha tenido la pandemia en el adolescente. A pesar de que actualmente las estrictas medidas sanitarias se han revocado, la experiencia personal del adolescente durante el confinamiento es determinante en su vida poscon- finamiento. Es de especial importancia vigilar esta población por la etapa de tran- sición en la que se encontraba durante el confinamiento y la manera en que este impactó su vida, especialmente su salud mental...(AU)

Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists.

INTRODUCTION: Anorexia nervosa poses an important bioethical dilemma, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. METHODS: Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. RESULTS: The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. CONCLUSIONS: It is concluded that the difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

The Dramatic Decline of Civil Commitment in Oregon, 1972 to 2020.

The rate of civil commitment in Oregon fell from 53.2/100,000 in 1972 to 9.2/100,000 in 2020. The paper discusses this decline in civil commitment as related to statutory and case law changes and complex interactions including bed availability at Oregon State Hospital (OSH). The latter was in turn influenced by the significant increase in the last decade of hospitalization at OSH of competence to stand trial evaluation and restoration (CST) patients. Multnomah County, which contains the city of Portland, was responsible for the largest number of investigations and commitments and led the state in using a 14-day diversion alternative to commitment. This analysis may serve as a model for other states to engage in similar longitudinal research to shed light on the functioning of their involuntary commitment statutes.

Mental health professionals' attitudes towards mental competency and involuntary commitment in anorexia nervosa: Construction, validation and results of the ACINOVAN questionnaire.

INTRODUCTION: Anorexia nervosa is a serious disorder that causes high rates of morbidity and mortality. Involuntary treatments are only legally admissible if the patient is not competent. However, assessing their capacity can be really complex. This implies that the final decision can be influenced by the individual attitudes of the physician. OBJECTIVE: To create and empirically validate a questionnaire in Spanish that makes it possible to measure the attitude towards capacity and involuntary commitment and compare between categorical groups. METHODS: The sample consisted of 338 mental health professionals. The items were validated by groups of experts. An exploratory factor analysis and group comparisons were carried out. RESULTS: Favourable evidence was obtained of a 13-item model consisting of three factors: pro-intervention, lack of competence and chronicity. Professionals tend to believe in the lack of capacity and the need for involuntary interventions, as well as differential suitability due to chronicity. Support prior to involuntary interventions was significantly related to the pro-intervention and absence of capacity factors, and training in bioethics to chronicity. CONCLUSIONS: The resulting instrument is valid and reliable. Its use can be useful to professionals, patients and society.

Percepción de tiempo, salud mental en tiempos de pandemia por COVID-19 y cuarentenas / Perception of time and mental health during COVID-19 pandemic quarantines

Introducción: Debido a la pandemia por COVID-19 fue necesario implementar la cuarentena obligatoria, con el fin de contener la propagación del virus; situación que generó cambios en los estilos de vida y diversas respuestas que incluyen temor, ansiedad, monotonía e incertidumbre. Esto pudo alterar la capacidad en la percepción del tiempo de los individuos, y con ello afectar su salud mental. Objetivo: Sintetizar las bases neurológicas del fenómeno de percepción de tiempo, su importancia y la evidencia científica sobre posibles alteraciones en condiciones de cuarentena. Materiales y métodos: Revisión bibliográfica temática en bases de datos Pubmed, Medline, Scopus, y Google Scholar. Los términos de búsqueda en español e inglés incluyeron: percepción de tiempo, estimación de tiempo, pandemia, cognición, estados emocionales, salud mental. Resultados: Se describe el concepto de percepción del tiempo, sus bases neurológicas y las alteraciones que se pueden generar. Conclusión: La salud mental fue afectada por la pandemia, sin embargo, se desconoce con claridad la forma como se desarrolló dicha afectación a mediano y largo plazo.

Introduction: COVID-19 pandemic made it necessary to implement obligatory quarantine measures in order to contain viral spreading. This situation generated lifestyle changes and diverse responses such as fear, anxiety, monotony, and uncertainty. This affected the people's capacity to perceive time resulting in changes in mental health. Objective: Synthesize the neurological bases of the phenomenon of time perception, its importance and the scientific evidence regarding the possible alterations in the conditions of quarantine. Materials of methods: A thematic bibliographic review was carried out in Pubmed, Medline, Scopus, and Google Scholar databases. The Spanish and English keywords used were: perception of time, estimation of time, pandemic, cognition, emotional states, and mental health. Results: The concept of time perception, its neurological bases and the alterations that can be generated are described. Conclusions: Mental health was affected during pandemic, yet its effects in the short-term and long-term are not understood clearly.

Assessment Team Recommendations on the Continuation of Involuntary Commitment in Poland.

This study explores explicit justifications for recommendations regarding patients' continuing detention in forensic psychiatric wards. We are interested in what arguments are used in recommendations for the continuing detention of involuntarily committed patients made by assessment teams for legal proceedings. Our frequency analysis shows that assessment teams refer predominantly to arguments related to the mental state of the detainee. When recommending a change of security level, the assessment teams frequently refer to behavioural factors. However, very rarely does such argumentation appear in recommendations for continuation of detention at the same security level. Additionally, our qualitative analysis shows a very high level of certainty with which pronouncements about patients' behaviour are made, typically in the absence of any social/institutional context. Our study shows that assessment teams tend to opt for safe decisions that are unlikely to be challenged by legal proceedings and that allow them full control over the patient.

Involuntary Commitment as "Carceral-Health Service": From Healthcare-to-Prison Pipeline to a Public Health Abolition Praxis.

Involuntary commitment links the healthcare, public health, and legislative systems to act as a "carceral health-service." While masquerading as more humane and medicalized, such coercive modalities nevertheless further reinforce the systems, structures, practices, and policies of structural oppression and white supremacy. We argue that due to involuntary commitment's inextricable connection to the carceral system, and a longer history of violent social control, this legal framework cannot and must not be held out as a viable alternative to the criminal legal system responses to behavioral and mental health challenges. Instead, this article proposes true alternatives to incarceration that are centered on liberation that seeks to shrink the carceral system's grasp on individuals' and communities' lives. In this, we draw inspiration from street-level praxis and action theory emanating from grassroots organizations and community organizers across the country under a Public Health Abolition framework.

Migrant status and risk of compulsory admission at first diagnosis of psychotic disorder: a population-based cohort study in Sweden.

BACKGROUND: Minority ethnic and migrant groups face an elevated risk of compulsory admission for mental illness. There are overlapping cultural, socio-demographic, and structural explanations for this risk that require further investigation. METHODS: By linking Swedish national register data, we established a cohort of persons first diagnosed with a psychotic disorder between 2001 and 2016. We used multilevel mixed-effects logistic modelling to investigate variation in compulsory admission at first diagnosis of psychosis across migrant and Swedish-born groups with individual and neighbourhood-level covariates. RESULTS: Our cohort included 12 000 individuals, with 1298 (10.8%) admitted compulsorily. In an unadjusted model, being a migrant [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.26-1.73] or child of a migrant (OR 1.27; 95% CI 1.10-1.47) increased risk of compulsory admission. However after multivariable modelling, region-of-origin provided a better fit to the data than migrant status; excess risk of compulsory admission was elevated for individuals from sub-Saharan African (OR 1.94; 95% CI 1.51-2.49), Middle Eastern and North African (OR 1.46; 95% CI 1.17-1.81), non-Nordic European (OR 1.27; 95% CI 1.01-1.61), and mixed Swedish-Nordic backgrounds (OR 1.33; 95% CI 1.03-1.72). Risk of compulsory admission was greater in more densely populated neighbourhoods [OR per standard deviation (s.d.) increase in the exposure: 1.12, 95% CI 1.06-1.18], an effect that appeared to be driven by own-region migrant density (OR per s.d. increase in exposure: 1.12; 95% CI 1.02-1.24). CONCLUSIONS: Inequalities in the risk of compulsory admission by migrant status, region-of-origin, urban living and own-region migrant density highlight discernible factors which raise barriers to equitable care and provide potential targets for intervention.

Clinician's experiences with involuntary commitment for substance use disorder: A qualitative study of moral distress.

BACKGROUND: Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use. METHODS: Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews. RESULTS: Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services. CONCLUSION: Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.