Commitment (psychiatric)

Involuntary commitment is the practice of using legal means or forms as part of a mental health law to commit a person to a mental hospital, insane asylum or psychiatric ward against their will or over their protests. Many but not all countries have mental health laws governing involuntary commitment. Some, such as the United States, require a court hearing if the subject of the more or less brief initial commitment (approved by a doctor, psychologist or psychiatrist) protests, though in some cases this initial hearing must be immediate; while others allow involuntary commitment at the request of physicians who must follow set legal procedures. In the latter case there are then additional checks and sometimes hearings to ensure compliance with the law. It may also sometimes be possible to challenge the commitment through habeas corpus.

Though involuntary commitment has long been a practice of most societies, some individuals and groups have challenged it from a civil libertarian perspective, particularly in countries that are part of the Anglo-American judicial tradition. There have also been allegations, many widely accepted, that at certain places and at certain times the practice of involuntary commitment has been used for the suppression of dissent, or in a punitive way.

Purposes of involuntary commitment
Involuntary commitment has been used for a variety of purposes over the years and in different jurisdictions. There has been considerable debate about these purposes and this has been a factor in leading to the various laws. A number of individuals and groups remain strongly opposed to either all these laws, some of these laws, or some aspects of their application.

In most jurisdictions involuntary commitment is specifically directed at people claimed or found to be suffering from a mental illness which impairs their reasoning ability to such an extent that the laws state or courts find that decisions must or should be made for them under a legal framework. (However, it should be noted that in some jurisdictions this is a distinct proceeding from being "found incompetent.") This decision requires a subjective opinion and is therefore open to error or abuse, both of which have been documented as occurring at different times in various places. There have been numerous official enquiries into such matters around the world and these have often led to legal and system reforms, but there have also been allegations that the requirements for involuntary commitment are "too lenient," with a consequential strengthening of such laws.

Involuntary commitment is used to some degree for each of the following headings although different jurisdictions have different criteria. Some allow involuntary commitment only if the person both appears to be suffering from a mental illness and that the effects of this produce a risk to themselves or others. Other jurisdictions have criteria that are broader.

Observation
Observation is sometimes used to determine if a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person is psychotic or otherwise warrants commitment and so sometimes people are admitted for a period to observe their behavior. This period of observation can be helpful in determining the actual diagnosis but can tend to produce an expectation of disease which can alter the perceptions and behavior of the staff. Rosenhan's classic paper, "On being sane in insane places",1 demonstrated a variety of problems. In this study a number of volunteers mimicked illnesses to obtain admission to hospital and then subsequently behaved normally. The staff continued to perceive that they were exhibiting signs of the illness diagnosed on admission and treated them as such. This paper has since been criticised by Spitzer2 who argued that given the initial "symptoms" presented that the mindset of the staff was not only understandable but that it did not invalidate an ability to diagnose conditions as Rosenhan had claimed. Rosenhan's experiment remains a cautionary tale that informs the teaching of trainee psychiatrists.

Containment of danger
A common reason given for involuntary commitment is to prevent danger to the individual or society. People with suicidal thoughts may act on these thoughts and harm or kill themselves. People with psychoses are occasionally driven by their delusions or hallucinations to harm themselves or others. People with personality disorders are occasionally violent.

This concern has found expression in the standards for involuntary commitment of a number of jurisdictions in the U.S. and other countries as the "danger to self or others" standard if someone has a "mental illness" or "mental disorder" (though sometimes explicit exceptions are made, as in Arizona law, in which "drug abuse, alcoholism or mental retardation" and "[t]he declining mental abilities that directly accompany impending death" are specifically excepted), sometimes supplemented by the requirement that the danger be "imminent". However, it has come under criticism from two directions. Those who are concerned that the "danger to self or others" standard is too narrow and will not permit the commitment of those for whom it is necessary have occasionally advocated that it be replaced by the "gravely disabled" standard. There are others who are concerned that the "danger to self or others" standard is vague and not precisely defined, which could lead to abuse of involuntary commitment. However, some people find that the increasingly narrow definition of "danger to self or others" provided by statute and court rulings have to some degree mitigated these concerns.

Some of the same people who are concerned about the overbreadth of the "danger to self or others" standard are more concerned about the "gravely disabled" standard, as they find it broader still. The First District Court of Appeal in California, however, held in Conservatorship of Chambers (1977) 71 Cal.App.3d 277, 139 Cal.Rptr. 357, that the standard was not unconstitutional due to overbreadth or vagueness, and excluded commitment of people whose lifestyles were simply eccentric or unusual. In In re Maricopa County, 840 P.2d 1042, (Ariz. Ct. App. 1992), the court held that "persistently or acutely disabled" was not an unconstitutionally vague standard.

The Michigan Mental Health Code provides that a person


 * whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others

may be subjected to involuntary commitment, a provision paralleled in the laws of many other jurisdictions. These types of provisions have been criticised as a sort of "heads I win, tails you lose;" understanding one's "need for treatment" would cause one to agree to voluntary commitment, but the Bazelon Center has said that this "lack of insight" is "often no more than disagreement with the treating professional," and this disagreement might form part of the evidence to support one's involuntary commitment.

In Oregon the standard that the allegedly mentally ill person


 * [h]as been committed and hospitalized twice in the last three years, is showing symptoms or behavior similar to those that preceded and led to a prior hospitalization and, unless treated, will continue, to a reasonable medical probability, to deteriorate to become a danger to self or others or unable to provide for basic needs

may be substituted for the danger to self or others standard.

Treatment of illness
Many psychiatric disorders are treated with therapies such as antipsychotics, antidepressants or, more rarely, electroconvulsive therapy also known as electroshock. Many studies have shown the effectiveness of these treatments in their ability to produce a reduction in symptoms and signs of psychiatric disorders. These studies have been used in some jurisdictions as reasons to allow involuntary commitment solely on the basis of the person having a treatable psychiatric disorder. In those jurisdictions where danger is required for commitment, involuntary treatment is still usually allowed. Other studies have shown that psychiatric treatment is less effective than no treatment at all.

Community treatment as an alternative
There have been some criticisms of the efficacy or appropriateness of inpatient treatment. For example, the "Pan American Health Organization (PAHO) Caracas Declaration of 1990... identified inpatient psychiatric treatment as isolating individuals from the community and thus as an obstacle to recovery." The isolation produced in the past with big asylums is now generally regarded as unhelpful. Integration into mainstream services and the community is supported by most in the treating professions and in the community.

Deinstitutionalization
Starting in the 1960s, there has been a worldwide movement toward deinstitutionalization of mental patients from mental hospitals into community care centers, and this has been matched with efforts at reform of involuntary commitment laws. (In the US from the 1970s onwards a relatively small number of ex-mental patients and former "consumers of psychiatric services" have promoted what they call "mad liberation," often calling for the abolition of involuntary commitment.) In many countries deinstitutionalization was put into practice without adequate provision or funding for community care facilities; those who described themselves as "advocates for the mentally ill" complained that deinstitutionalized former inmates of mental hospitals often ended up homeless, and others have complained that they found their way into jails and prisons. In the US in the 1980s, there was a return back to institutionalization and less strict commitment laws. However, Michael L. Perlin3 has claimed that throughout this entire period psychiatrists have frequently and as a practice committed perjury during commitment hearings in order to make it more likely that a patient they believe would benefit from commitment will be committed. E. Fuller Torrey, a prominent proponent of involuntary commitment, has stated:


 * It would probably be difficult to find any American Psychiatrist working with the mentally ill who has not, at a minimum, exaggerated the dangerousness of a mentally ill person's behavior to obtain a judicial order for commitment . . . Thus, ignoring the law, exaggerating symptoms, and outright lying by families to get care for those who need it are important reasons the mental illness system is not even worse than it is.

Dr. Torrey also quotes Psychiatrist Paul Applebaum as saying when "confronted with psychotic persons who might well benefit from treatment, and who would certainly suffer without it, mental health professionals and judges alike were reluctant to comply with the law," noting that in "'the dominance of the commonsense model,' the laws are sometimes simply disregarded."4

The general trend worldwide remains one of closing large mental hospitals, increasing the integration of psychiatric treatment into general hospitals and of increasing community care at times using involuntary community treatment where in the past involuntary admission would have been used. Despite this trend, and given the limitations of current treatment regimes, some involuntary admissions will continue for more severe conditions.

United Nations
United Nations General Assembly resolution 46/119 of 1991, "Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care" is a non-binding resolution advocating certain broadly-drawn procedures for the carrying-out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programs in some countries to assist in this process.

United States
Involuntary commitment is governed by state law and procedures vary from state to state, under laws often called mental hygiene laws. Involuntary commitment is typically used against people diagnosed with, or alleged to have, a mental illness, particularly schizophrenia. It should be noted that, at least in some jurisdictions, laws regarding the commitment of juveniles may vary, with what is the de facto involuntary commitment of a juvenile perhaps de jure defined as "voluntary" if his parents agree (though he may still have a right to protest and attempt to get released).

An example of involuntary commitment procedures is the Baker Act used by the state of Florida. Under this law, a person may be committed only if he or she presents a danger to himself or others. A police officer may issue an emergency commitment order which lasts for up to 72 hours. Within this time, a person must appear before a judge who can extend the commitment. The Baker Act also requires that all commitment orders be reviewed every six months in addition to insuring certain rights to the committed including the right to contact outsiders. Also, a person under an involuntary commitment order has a right to counsel and a right to have the state provide a public defender if they cannot afford a private lawyer. This procedure is considered to be necessary in the United States, as police (today in isolated incidents, previously in widespread treatment of minorities) would use the involuntary commitment procedures as a way of holding and/or punishing a person they wished to punish, when that person had committed no crime.

Controversy
(Of particular concern to some civil libertarians is the acknowledged role of the United States Secret Service in obtaining involuntary psychiatric hospitalizations of those it believes to be a danger to protectees, without any claim that these "dangerous" individuals are "mentally ill.") Though few would argue that under no circumstances should a psychiatric patient be held against his will, exceptions to this have included Lawrence Stevens, an attorney who has argued that involuntary commitment is a violation of substantive due process under the United States Constitution (see link at end of article). (Fred Foldvary has proposed that since judges will not follow the Constitution and continue to subject individuals to involuntary commitment -- this is based on the theory that involuntary commitment is unconstitutional -- Constitutional amendments should be made depriving judges of the ability to involuntarily commit.) Most believers in the theory of reality enforcement also oppose it, and the Libertarian Party opposes the practice in its platform. Surrealism has also categorically opposed involuntary commitment, and many Western Marxists have also opposed the practice. Dr. Thomas Szasz has also been prominent in challenging involuntary commitment (see anti-psychiatry).

A small number of individuals in the United States have opposed involuntary commitment in those cases in which the diagnosis forming the justification for the involuntary commitment rests, or the individuals say it rests, on the speech or writings of the person committed, saying that to deprive him of liberty based in whole or part on such speech and writings violates the First Amendment. Other individuals have opposed involuntary commitment on the bases that they claim (despite the amendment generally being held to apply only to criminal cases) it violates the Fifth Amendment in a number of ways, particularly its privilege against self-incrimination, as the psychiatrically-examined individual may not be free to remain silent, and such silence may actually be used as "proof" of his "mental illness". (This criticism has motivated the creation, in some jurisdictions, of a similar statutory privilege in this context.) There have also been claims that conditions in, or "treatments" commonly performed in, mental hospitals to which individuals are involuntarily committed constitute torture, or are prohibited by the Convention Against Torture. While the overwhelming majority of this opposition has been nonviolent or even self-consciously based on the principles of nonviolence, there have been isolated examples of violence, including sabotage arguably directed against involuntary commitment.

The mainstream debate has for the most part, however, regarded only the procedures of involuntary commitment. Until the 1960s, legal safeguards against involuntary commitment were lax and this led to a number of horror stories of people with no mental illness being trapped in an institution.

Use with criminals
In the 1990s, a novel and extremely controversial use of involuntary commitment laws known as "Mentally Abnormal Sexually Violent Predator" laws were enacted in order to hold sex offenders after their terms have expired. (This is generally referred to as "civil commitment," not "involuntary commitment," although, perhaps confusingly, involuntary commitment in general is sometimes referred to as "civil commitment".) Supporters claim that this is a valid use of involuntary commitment laws, while opponents claim that this is a potentially extremely dangerous way of bypassing the safeguards in the criminal justice system. This matter has been the subject of a number of cases before the Supreme Court of the United States, most notably Kansas v. Hendricks and Kansas v. Crane.

Community based treatment
Accompanying deinstitutionalization was the development of laws expanding the power of courts to order people to take psychiatric medication on an outpatient basis. Though the practice had occasionally occurred earlier, outpatient commitment was used for many people who would otherwise have been involuntarily committed. The court orders often specified that a person who violated the court order and refused to take the medication would be subject to involuntary commitment.

Conservatorship
Involuntary commitment is distinguished from conservatorship, which was used by deprogrammers as a legal means to hold alleged cult victims against their will while talking them out of their faith. In hundreds of cases documented by attorney Jeremiah Gutman, deprogrammers were able to obtain conservatorship orders without having to bring the subject of the order before a judge.

Advance psychiatric directives
Advance psychiatric directives may have a bearing on involuntary commitment.

Australia
Australia is used as an example of a country where court hearings are not required for involuntary commitment. Mental health law is constitutionally under the state powers. Each state thus has different laws, many of which have been updated in recent years.

Mechanisms
The usual requirement is that a police officer or a doctor may determine that a person requires a psychiatric examination and may convey them, or have them conveyed to a psychiatric hospital for that purpose. Once at the hospital a doctor, usually a trainee psychiatrist, will either endorse this or order their release. If the person is detained in the hospital then they usually must be seen by an authorised psychiatist within a set period of time. In some states, after a further set period or at the request of the person or their representative, a tribunal hearing is held to determine whether the person should continue to be detained. In states where tribunals are not instituted, there is another form of appeal.

Allowed reasons
Some states require that the person is a danger to the society or themselves, other states only require that the person be suffering from a mental illness that requires treatment. The Victorian act specifies in part that:
 * "(1) A person may be admitted to and detained in an approved mental health service as an involuntary patient in accordance with the procedures specified in this Act only if&#8212;
 * (a) the person appears to be mentally ill; and
 * (b) the person's mental illness requires immediate treatment and that treatment can be obtained by admission to and detention in an approved mental health service; and
 * (c) because of the person's mental illness, the person should be admitted and detained for treatment as an involuntary patient for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and
 * (d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and
 * (e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of that person's freedom of decision and action.
 * (1A) Subject to sub-section (2), a person is mentally ill if he or she has a mental illness, being a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory."

There are additional qualifications and restrictions but the effect of these provisions is that people who are assessed by doctors as being in need of treatment may be admitted involuntarily without the need of demonstrating a risk of danger. This then overcomes the pressure described above to exaggerate issues of violence to obtain an admission.

Treatment
In general, once the person is under involuntary commitment, treatment may be instituted without further requirements. Some treatments such as electroconvulsive therapy (ECT) often require further procedures to comply with the law before they may be administered involuntarily.

Community treatment orders
These can be used in the first instance or after a period of admission to hospital as a voluntary or involuntary patient. With the trend towards deinstitutionalization this is becoming increasingly frequent and hospital admission is restricted to people with severe mental illnesses.

United Kingdom
In the United Kingdom, the process known in the United States as involuntary commitment is unofficially known as sectioning, after the various sections of the Mental Health Act 1983 (covering England and Wales), the Mental Health (Northern Ireland) Order 1986 and the Mental Health (Care and Treatment) (Scotland) Act 2003 that provide its legal basis.

Involuntary commitment in popular culture
The television series Conviction has shown hearings related to involuntary commitment.

Reference
1 Rosenhan, D.L. (1973). On being sane in insane places. Science, 179, 250-258.

2 Spitzer, R.L. (1975). On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan's "On being sane in insane places." Journal of Abnormal Psychology, 84, 442-452.

3 Perlin, M.L. (1993/1994). The ADA and Persons with Mental Disabilities: Can Sanist Attitudes Be Undone? Journal of Law and Health,, 8 JLHEALTH 15, 33-34.

4 Torrey, E. Fuller. (1997). Out of the Shadows: Confronting America's Mental Illness Crisis. New York: John Wiley and Sons.