Civil Commitment: Criteria, Processes, and Impacts

1. Civil Commitment Chapter 9

2. What is Civil Commitment? • involuntary hospitalization of mentally ill individuals who are thought to need treatment, care or incapacitation because of self-harming or antisocial tendencies • Parens Patriae • state is the guardian for citizen unable to care for themselves • Police Power • state has obligation to protect the public

3. Criteria for Civil Commitment • Mental illness • Problems with mental illness as a criterion • use legal or medical definition • seriousness of mental illness • hindsight bias

4. Dangerous (to self or others) • O’Connor v. Donaldson (1975) • Danger to self • gravely disabled • Problems with dangerousness as a criterion • Predicting dangerousness among civil patients • Actuarial v. Clinical predictions • Grave Disability • Most frequent reason for commitment behind dangerousness • More typical of young persons (21-35)

5. Need for treatment • a third requirement in some jurisdictions • originally the sole basis for civil commitment • frequently incorporated into the mental illness criterion

6. Process of Civil Commitment • Extended Commitment • Numerous protections are in place • Many attorneys became less adversarial and therefore some protections may be diminished • Emergency Commitment • Allows for short hospitalization • Process tends to be less formal

7. Outpatient Commitment • Form of commitment in which the person involuntarily participates in some form of treatment but does not reside at a facility 24 hours per day • Traditional outpatient commitment • Preventative commitment • Conditional release • Outpatient commitment does not result in a reduction in hospital use but extended outpatient commitment did result in fewer readmissions and fewer days in the hospital

8. Coercion of Civil Commitments • Over 30% of psychiatric patients are committed involuntarily • Most of the remaining 70% not truly voluntary • Coercion may be • Persuasion • Inducement • Threat or show of force • Legal force • Asking for a dispositional preference • Giving an order • Deception

9. The Impact of Coercion on Civil Commitment • May be barrier to patients seeking treatment • May cause poor therapeutic relationships • Clinicians may minimize the effects of coercion • Most patients who originally deny they need to be hospitalized change their mind

10. Sources and Frequency of Coercion • Mental health professionals are the most important source of coercion • Clinicians and patients disagree on level of coercion that occurs • Patients’ perceptions are tied to procedural justice • Frequency of coercions • Persuasion – 61.6% • Asking about preferences – 56.8% • Legal force – 33.1% • Giving orders – 28.8% • Show of force – 22.8% • Threats – 18.6%

11. Right to Make Treatment Decisions and Refuse Treatment • Right to Make Treatment Decision • Wyatt v. Stickney (1971) • Right to Refuse Treatment • Sell v. United States (2002) • Riggins v. Nevada (1992) • Harper v. Washington (1990)

12. Competency to Make Treatment Decisions • Involuntarily committed individuals can make treatment decisions • Zinermon v. Burch (1990) • Majority of mentally ill are competent to make treatment decisions • 50% of patients with schizophrenia and 76% with depression

13. Mental Health Advanced Directives • Also called psychiatric advanced directives • Allow the person to make any treatment decisions before they become incapacitated • Hospital staff are largely unaware of their existence and are hesitant to encourage use

14. Practice of Civil Commitment • Assessment and Treatment of Psychiatric Patients • Any assessment should be comprehensive and look for converging evidence • Most jurisdictions only consider severe mental illness sufficient • Few studies assessing effectiveness of treatment of those committed

15. Assessment of Danger to Self • Clinicians rate the most significant risk factors for suicide • History of suicide • Suicidal thoughts • Severe hopelessness • Attraction to death • Family history of suicide • Acute abuse of alcohol • Loss or separation of relationships • Instruments are available assessing grave disability

16. Assessment of Danger to Others • Identification of mental illness as a risk factor is controversial • May encourages stereotypes of the mentally ill • Vast majority of mentally ill are not violent and are more likely to be victims of violence than perpetrators • The relationship is a complex one and depends on the mental illness itself, presence of certain symptoms, and substance abuse