Civil commitment is one of the most controversial topics of our contemporary time. Advocacy groups work hard to prevent the altering of state mental health laws that would make involuntary commitment easier for individuals with severe or untreated mental illness. The prevailing argument has been that a lack of autonomy and independence would result and that individuals would not have any say in the type of treatment they would receive. Sadly, there is widespread lack of knowledge about mental illness, mental health care, and civil commitment. As a result, many are uncomfortable with the idea of relaxing state civil commitment laws.
Involuntary commitment & “dangerousness” criteria
Involuntary civil commitment, the act of obtaining psychiatric services for an individual who is unable to care for themselves, is typically used only when an individual meets what is known as the “dangerousness” criteria. The dangerousness criteria are a set of standards that an individual must meet in order to be hospitalized against their will. For example, in the state of Pennsylvania, an individual cannot be hospitalized unless there is:
- a “clear and present danger” to him/herself or others. “Danger” specifically includes the inability, without assistance, to satisfy need for nourishment, personal or medical care, shelter, and self-protection or safety.
- a reasonable probability that death, serious bodily injury or serious physical debilitation will ensue within 30 days without treatment.
Pennsylvania law requires that “dangerousness” or “a reasonable probability that death, serious bodily injury, or serious physical debilitation would ensue within 30 days” be present before involuntary commitment could be honored.
History of “dangerousness” criteria
As far back as the 1940s, the standards for civil commitment remained largely in the hands of the state. Individuals were being hospitalized against their will, being hospitalized when family did not approve of them, and sometimes even being “disciplined” by law enforcement by being hospitalized. There were no concrete rules for institutionalization. In the late 1940s, a group known as the Group for the Advancement of Psychiatry developed a report that complained about the excessive use of involuntary commitment and other regulations that appeared problematic. Critics complained about the level of control the state had in enforcing unwanted psychiatric admissions.
The National Institute of Mental Health proposed other options by drafting a report. A lot of mental health conglomerates began to question the usefulness of involuntary commitment. As a result, the District of Columbia, in the mid-1960s, decided to implement what we now call the “dangerousness” criteria. California, unfortunately the national trend-setter, began to implement similar policies as well. Instead of creating a middle-ground or balanced treatment option, the dangerousness criteria created a black and white dilemma.
Today, the dangerousness criteria prevent individuals from being hospitalized without a detailed plan for suicidal or homicidal behavior. It is extremely difficult for families to obtain mental health treatment for their loved one. The dangerousness criteria further prevents families from convincing psychiatric staff of the severity of their love one’s condition. Staff ask a series of questions to determine if “imminent” danger can result from denied hospitalization. If it is found that the individual is not “actively” ill or psychotic, homicidal, or suicidal, the individual will not be hospitalized.
This “evaluation system” is very problematic for cases in which an individual is unable to care for themselves by keeping themselves out of trouble, protecting family or themselves, refraining from chronic substance abuse or risky behaviors, or avoiding incarceration or homelessness.
This issue is far from over. Many mental health advocates and advocating organizations are determined to provide protection for individuals unable to care for themselves. Will you join them? It will be a long trail to travel before change occurs. But let’s change what is wrong with our mental health system.
Read a very touching testimony to the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations held May 22, 2013.
Anfang, A.S., & Appelbaum, (2006). Civil Commitment—the American experience. Israel Journal of Psychiatry & Related sciences 43(3), 209-218.