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
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