Involuntary Civil Commitment & DSM: Medicine or Mechanism of societal Control?
Stories dictate reality. They shape our beliefs, uphold societal structures, and determine who holds power. Nowhere is this more evident than in the psychiatric-legal system, where storytelling becomes law, and law becomes control.
A diagnosis is more than words on a page; it is a tool that can strip a person of their autonomy, erasing their voice in an instant. The Diagnostic and Statistical Manual of Mental Disorders (DSM), widely accepted as psychiatry’s definitive guide, is not based on biological markers or measurable science. It is, instead, a document of consensus—where conditions are voted into existence by committees, not discovered in laboratories. Yet, these classifications carry the weight of law, justifying the forced confinement and treatment of individuals who, in another context, would still be considered citizens with rights.
Civil commitment hearings follow a script. A pre-written affidavit, a checked box, a few brief references to legal statutes (such as Minnesota’s 253B), and a judge’s signature—these are the thin layers of formality disguising a process that, in reality, offers little due process. A person can be forcibly detained, drugged, and indefinitely hospitalized without ever having committed a crime. And, perhaps most disturbingly, they often have no true defense.
The Psychiatric Story That Erases You
The civil commitment process does not operate on an individual’s lived experience, emotions, or truth. It operates on a story—a carefully constructed narrative written by those in power. The psychiatrist, the social worker, the court evaluator—each plays a role in crafting an official account, one that transforms a person from an autonomous individual into a psychiatric subject.
My doctoral dissertation, Separation from the Real: The Power of Story at the Heart of the Civil Commitment Process, explores how psychiatric labels become more powerful than the voices of the individuals they are assigned to. Once a diagnosis is recorded, it ceases to be a theory and becomes fact, no matter how little evidence supports it. This is the defining power of psychiatric storytelling: it does not require truth, only state-sanctioned authority.
A psychiatrist’s affidavit is rarely unique. It follows a standardized format, reducing human complexity into checked boxes:
✔ "Danger to self or others."
✔ "Unable to care for basic needs."
✔ "Lacks insight into their condition."
Each checkbox is an erasure, a dismissal of the individual’s reality in favor of a state-sanctioned script. The forms are so disturbingly simplistic that one wonders how such flimsy documentation can strip a person of all the rights they believe they have. And yet, they do.
Inventing Illness: How the DSM Defines Madness Without Science
Psychiatry insists on its scientific legitimacy, but the DSM (Diagnostic Statistical Manual) is not a medical document in the way the public may assume. It is a socially constructed narrative, shaped by politics, pharmaceutical influence, and the profession’s desire to maintain authority. Unlike medical diseases that can be identified through imaging, blood tests, or genetic markers, psychiatric disorders are categorized through subjective assessment.
Even those at the highest levels of psychiatry acknowledge this fundamental flaw. Dr. Thomas Insel, former director of the National Institute of Mental Health (NIMH), offered a rare admission of the DSM’s true nature:
“While the DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’—each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.” (Insel, April 29, 2013, Transforming Diagnosis).
This statement should have unraveled the foundation of modern psychiatry. It should have led to a mass reevaluation of the field’s authority. Instead, the DSM remains unquestioned in legal proceedings. Judges, attorneys, and mental health professionals treat its categories as absolute truths, despite the fact that they were never based on objective science.
And in the courtroom, the DSM diagnosic label applied is not treated as theory, but as biological, scientific fact of a major mental disorder required by law in order to civilly commit.
Legal Authority and the Illusion of Defense
In a criminal trial, the accused is granted a defense attorney, the presumption of innocence, and the right to challenge the evidence against them. In civil commitment proceedings, these protections exist in name only. The person facing involuntary confinement is often assigned a court-appointed defense attorney—a lawyer who, as in Dr. Nerad’s case, and others spent minimal time speaking with her/their client for more than a few minutes leaving their client ill-informed and unprotected. The illusion of defense exists, but the outcome is largely predetermined.
Psychiatrist Thomas Szasz starkly contrasts the fundamental principles of criminal law with the unchecked power of psychiatric authority:
"In the Anglo-American adversarial legal system, the accused is presumed innocent until proven otherwise, and the onus of proof of guilt is on the accuser. In the psychiatric-inquisitorial 'medical' system, this relationship is reversed: the person diagnosed as mentally ill is presumed insane until proven otherwise, and the onus of disproof of insanity is on the (usually powerless) individual incriminated as 'insane.' A priori, psychiatrists disqualify such claims of 'psychiatric innocence' as evidence of the 'insane patient's' denial of his illness,"—a circular argument known as "lack of insight."
Here, the accused does not stand a chance. The burden of proof is reversed. One is presumed unfit, irrational, and incapable of self-determination from the outset, and any attempt to argue otherwise only serves to validate the diagnosis. To speak in one’s own defense is to be labeled delusional. To refuse medication is to be labeled noncompliant. To fight for one’s freedom is to be seen as further proof of the need for confinement.
Defense attorneys in civil commitment hearings are not there to win. They are there to move the process along. The very structure of commitment hearings discourages true legal advocacy; the defense does not take time to review the case, and attorneys can often manipulate proceedings to further the desired outcome of commitment or “getting the client the treatment they need”. Resisting the process does not simply put one at odds with the court—it risks deeper entrenchment in the psychiatric system, where dissent itself is seen as pathology.
Historically when attorneys do fight they do so against a system rigged against them. They present cases to judges who have seen the same affidavits, the same forms, the same unchecked boxes over and over again. Judges who have learned, through practice and precedent, to defer to psychiatric authority without question. The outcome is rarely in doubt.
This is not a legal proceeding in any meaningful sense. It is a ritual of rubber-stamped decisions, where the final ruling was made long before the hearing ever began.
The person on trial for their freedom does not get to write their own story—the state does that for them. And once written, that story is nearly impossible to erase.
The Inescapable Story of Psychiatric Commitment
The consequences of psychiatric storytelling are profound. Once labeled, an individual’s future interactions with the legal and medical systems are forever shaped by that label. Even if they challenge their diagnosis, or present evidence that contradicts the initial assessment, the psychiatric story remains the dominant narrative.
In civil commitment, this means that a person can be detained, forceably drugged against their will, and stripped of their legal rights without ever having committed a crime. The justification for this process is based entirely on the authority of the psychiatric story—a story that may bear little resemblance to the individual’s actual reality.
The power of psychiatric storytelling is that it does not require truth, only authority extended by the State via the mental health laws. This reality is why resistance is often futile within the system. Once labeled, the very act of arguing against the label is used as further evidence of illness and a person’s “lack of insight” into their severe mental illness.
Challenging the Psychiatric Narrative: Reclaiming Truth in a Medicalized Society
To challenge the psychiatric-legal system, we must first recognize its foundation: the power of imposed storytelling. The DSM does not define scientific truth—it defines a socially constructed narrative. Involuntary civil commitment is not always about medical necessity—it is about legal authority disguised as treatment and the desire of the hospitals to “keep the census up” meaning keep the beds full.
Reclaiming autonomy means reclaiming the ability to tell one’s own story. It requires questioning the structures that define mental illness, challenging the unchecked power of psychiatric labels, and demanding accountability for the narratives imposed on individuals. It means recognizing that the right to define reality should belong to the person living it—not the institutions that profit from controlling it.
As we become aware we can choose a path of wellness and healing not one of a story that can hold us hostage in a society diving deeper and deeper into illness.
As long as we accept the psychiatric-legal system’s stories as unquestionable truths, we remain complicit in their power. But when we expose them as narratives rather than facts, we begin the process of reclaiming not only our voices but our fundamental right to define our own reality.