Civil Commitment Chapter 9

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

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

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)

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

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

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

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

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

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%

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

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

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

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

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

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