Appropriate Involuntary Psychiatric Hospitalzation and Treatment Is Not Considered Persecution or Torture Under U.S. Asylum Law
The case of Joshi v. Garland, 112 F.4th 181 (4th Cir. 2024), addresses the question of whether involuntary psychiatric hospitalization and treatment are considered persecution or torture in the context of applications for protection from removal from the United States. Hanumant Joshi, an Indian national with a history of severe mental illness, asserted that he should be granted asylum, withholding of removal, and protection under the United Nations’ Convention Against Torture (CAT) because of involuntary psychiatric hospitalization and treatment, including electroconvulsive therapy (ECT) administered in India. The U.S. Court of Appeals for the Fourth Circuit upheld the rulings of the lower courts in denying Mr. Joshi’s applications for protection from removal.
Facts of the Case
Mr. Joshi came to the United States from India in 2015 to attend graduate school on a student visa. He had a history of mental illness beginning in 2011 and had received various diagnoses, including depression, bipolar disorder, schizoaffective disorder, and antisocial personality disorder. Between 2016 and 2019, he had several episodes of acute psychiatric illness for which he was hospitalized and treated involuntarily in the United States and in India. The concerns in this case are most closely related to his hospitalization in 2019 while in India. During this admission, he was involuntarily committed. He also received involuntary treatment with both medication and electroconvulsive therapy (ECT). He returned to the United States in 2020. Later that year, he did not return to his graduate program because of his mental illness. His student visa was terminated in October 2020 because of his withdrawal from school. He remained in the United States and continued to experience psychiatric symptoms requiring hospitalization. In November 2021, he was apprehended by U.S. Immigrations and Customs Enforcement (ICE) because of his terminated student visa.
Mr. Joshi eventually filed for three forms of relief from removal: asylum, withholding of removal, and protection under CAT. He argued his involuntary psychiatric treatment was a form of persecution and torture; that this harm was because of a protected characteristic, in his case, essentially his identity as an Indian man with mental illness and related characteristics; and that he had a well-founded fear that he may experience such harm if he returned to India. Mr. Joshi provided information regarding his prolonged psychiatric admissions. He reported family members had contacted social services regarding his deterioration on three occasions. He opined that they did so once because of a desire to obtain his inheritance.
The immigration judge (IJ) rejected all three forms of relief from removal for which Mr. Joshi was applying. He found that Mr. Joshi did not experience persecution, a threat to life or freedom on account of a characteristic via psychiatric treatment. The IJ also found that he was not targeted because of a protected characteristic, as Mr. Joshi himself explained that his family arranged for involuntary treatment for motives such as financial gain and genuine concern, not because of a desire to target him as an Indian man with mental illness. The IJ determined that he did not qualify for withholding of removal as this required a higher evidentiary standard than that of asylum. The IJ also determined that Mr. Joshi was ineligible for CAT protection, as he did not show evidence of having experienced torture as defined by CAT, given that ECT was not administered for the purpose of inflicting pain or torture. Because this was the treatment he claimed to fear if returned to India, Mr. Joshi was found to not be at risk of future torture.
Mr. Joshi appealed the IJ’s initial decision to the Board of Immigration Appeals (BIA). The BIA rejected his appeal and affirmed the IJ’s findings. The case was then brought to the U.S. Court of Appeals for the Fourth Circuit.
Ruling and Reasoning
The Fourth Circuit Court of Appeals rejected Mr. Joshi’s argument and upheld the IJ and BIA decisions, affirming that Mr. Joshi did not meet criteria for relief from removal under asylum, withholding, or CAT. The court reasoned that Mr. Joshi failed to demonstrate that his hospitalization and treatment with ECT amounted to persecution. The court concluded that the sovereign state of India enacted its authority to provide care against Mr. Joshi’s wishes. Further, the court found that, although he did not want the prior involuntary treatment and did not wish to receive such treatment again, it does not qualify as persecution. The court explained that, just as conscription or incarceration may restrict freedom and introduce risk of harm, involuntary treatment for individuals is an expression of sovereign authority and not persecution if performed fairly under a state’s legal system.
The court specifically addressed Mr. Joshi’s claims that treatment with ECT, involuntary hospitalization, and medication constituted persecution and thereby qualified for asylum protections. The court found that ECT was utilized based on broad standards of care and without the intent to cause him harm. The court reasoned that Mr. Joshi’s hospitalization and treatment were not persecution, as they were pursued because of legitimate medical indications. The court added that, although standards of care may differ between the United States and India, he received broadly similar treatment while in the United States. The court rejected his claim that he had a well-founded fear of future persecution, as the feared future events are similar to what he experienced in the past.
Mr. Joshi also argued that he suffered persecution because of his family members’ actions leading to his institutionalization. The court rejected this claim, holding family disputes over wealth were unrelated to his identified protected characteristic. The court rejected Mr. Joshi’s application for withholding of removal, as this too requires evidence of persecution, which he did not adequately demonstrate.
Finally, the court upheld the lower courts’ finding that Mr. Joshi did not qualify for CAT protection because he did not prove he was likely to experience torture committed or allowed by the government if he returned to India. Mr. Joshi failed to demonstrate his past institutionalization or treatment with ECT were administered inappropriately or with the intent to cause him harm. Thus, the court agreed that his previous involuntary treatment did not constitute torture. The court said that, for actions to be considered torture, they must be committed with the intent to cause physical or mental suffering. The court reasoned the treatment was genuinely intended to help him and not intended to harm him. Given the “torture” he fears upon return to India is involuntary hospitalization, medication, and ECT, the court found no grounds to determine that he would experience torture if returned to India.
Discussion
The Fourth Circuit’s ruling in Joshi is of particular importance to psychiatrists serving as experts in the asylum process. An asylum seeker must show that the seeker has a reasonable fear of persecution, or has experienced and would continue to experience persecution because of a protected characteristic if returned to the country from which the seeker came. The court rejected Mr. Joshi’s argument that involuntary treatment with ECT and involuntary psychiatric hospitalization constitute persecution in the context of his asylum application. The court compared institutionalization with other state powers, noting it is within a sovereign nation’s authority to commit mentally ill individuals for treatment on the bases of parens patriae and police powers.
The court reasoned that, although ECT for schizoaffective disorder may be falling out of favor in the United States, it is a widely accepted treatment for refractory mental illness. The court clarified it was not ruling on the standard of care in India. The court held substandard care is not in and of itself persecution, that sovereign states cannot be held to U.S. standards of care, and U.S. courts lack authority to determine the standard of care in foreign jurisdictions. This point is relevant for forensic psychiatrists reviewing care provided in other countries for the purpose of asylum applications. Forensic psychiatrists must be able to clarify for the court whether the interventions provided constitute treatment in a broad sense, but not whether treatment matches standards of care in the United States. For example, the court cited Temu v. Holder, 740 F.3d 887 (4th Cir. 2014), as an example of an instance in which an individual experienced physical and emotional abuse under the guise of psychiatric treatment. The court explained that, in this case, the purported “treatment” fell outside of any reasonable standard of care and therefore constituted persecution and torture.
The court clarified that, under asylum law, a nexus between persecution and a protected characteristic must be demonstrated. Mental illness may constitute a protected characteristic. Involuntary treatment is not inherently persecution or torture. Whether such care constitutes persecution or torture depends on the specific interventions used and the motivations behind them. Forensic psychiatrists can provide critical assistance to the court making these determinations. The forensic psychiatrist needs to be aware of the definitions of torture and persecution to be prepared to help the court differentiate legitimate care from persecution masquerading as treatment. The forensic psychiatrist can further assist the court in identifying whether the asylum seeker has a protected characteristic, and must be prepared to explain the nexus between an identified protected characteristic and any interventions potentially constituting persecution or torture. The holdings in Joshi do not provide guidelines for determining when involuntary care crosses from a legitimate exercise of a state’s sovereign authority to persecution or torture. Future case law will be needed to provide clarity about this boundary.
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