ED boarding and inpatient harms

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Dinah Miller, psychiatrist, writer, and author of Committed: The Battle Over Involuntary Psychiatric Care, for a rigorous examination of civil commitment and involuntary treatment in modern psychiatry.

The conversation explores the legal structures underlying involuntary hospitalization, medication over objection, and outpatient civil commitment, while highlighting the profound ethical tensions between patient autonomy, public safety, and clinical responsibility. Dr. Miller traces the historical evolution of involuntary care, examines why state systems vary so widely, and explains why outcomes data remain limited and difficult to interpret.

Listeners will gain a framework for understanding the competing advocacy groups shaping policy, the real-world consequences of emergency department boarding and bed shortages, and the psychological impact involuntary care can have on patients long after discharge. The episode also addresses language, stigma, and how psychiatrists can practice humane, ethically grounded care even when coercion is unavoidable.

This is a sober, thoughtful discussion of one of psychiatry’s most challenging responsibilities.

Takeaways:

Civil commitment is distinct from forensic commitment, yet often conflated in public discourse and policy discussions.

Evidence linking involuntary treatment to improved public safety is limited, in part due to ethical and methodological constraints on research.

System failures (bed shortages, ED boarding, lack of housing) amplify the harms of coercive care, even when clinically justified.

Outpatient commitment models vary widely, with New York’s AOT program offering one of the most studied but resource-intensive approaches.

How psychiatrists communicate, document, and set boundaries during involuntary care profoundly affects patient trust and future engagement.

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