Involuntary commitment

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Involuntary commitment, civil commitment, or involuntary hospitalization/hospitalisation [lower-alpha 1] is a legal process through which an individual who is deemed by a qualified person to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.

Contents

Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalization, during which an individual with acute psychiatric symptoms is confined for a relatively short duration (e.g. 72 hours) in a treatment facility for evaluation and stabilization by mental health professionals who may then determine whether further civil commitment is appropriate or necessary. Civil commitment procedures may take place in a court or only involve physicians. If commitment does not involve a court there is normally an appeal process that does involve the judiciary in some capacity, though potentially through a specialist court. [lower-alpha 2]

Purpose

For most jurisdictions, involuntary commitment is applied to individuals believed to be experiencing a mental illness that impairs their ability to reason to such an extent that the agents of the law, state, or courts determine that decisions will be made for the individual under a legal framework. In some jurisdictions, this is a proceeding distinct from being found incompetent. Involuntary commitment is used in some degree for each of the following although different jurisdictions have different criteria. Some jurisdictions limit involuntary treatment to individuals who meet statutory criteria for presenting a danger to self or others. Other jurisdictions have broader criteria. The legal process by which commitment takes place varies between jurisdictions. Some jurisdictions have a formal court hearing where testimony and other evidence may also be submitted and the subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. [4] Other jurisdictions have delegated these power to physicians, [2] though may provide an appeal process that involves the judiciary but may also involve physicians. [lower-alpha 3] For example, in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative. [lower-alpha 4]

First aid

Training is gradually becoming available in mental health first aid to equip community members such as teachers, school administrators, police officers, and medical workers with training in recognizing, and authority in managing, situations where involuntary evaluations of behavior are applicable under law. [7] The extension of first aid training to cover mental health problems and crises is a quite recent development. [8] [9] A mental health first aid training course was developed in Australia in 2001 and has been found to improve assistance provided to persons with an alleged mental illness or mental health crisis. This form of training has now spread to a number of other countries (Canada, Finland, Hong Kong, Ireland, Singapore, Scotland, England, Wales, and the United States). [10] Mental health triage may be used in an emergency room to make a determination about potential risk and apply treatment protocols.

Observation

Observation is sometimes used to determine whether a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person should be committed.

Containment of danger

Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, the Republic of Ireland, Russia, Taiwan, Ontario (Canada), and the United States have adopted commitment criteria based on the presumed danger of the defendant to self or to others. [11]

People with suicidal thoughts may act on these impulses and harm or kill themselves.

People with psychosis are occasionally driven by their delusions or hallucinations to harm themselves or others. Research has found that those with schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public. [12] However, because other confounding factors such as childhood adversity and poverty are correlated with both schizophrenia and violence it can be difficult to determine whether this effect is due to schizophrenia or other factors. In an attempt to avoid these confounding factors, researchers have tried comparing the rates of violence amongst people diagnosed with schizophrenia to their siblings in a similar manner to twin studies. In these studies people with schizophrenia are found to be between 1.3 and 1.8 times more likely to engage in violent behaviour. [12]

People with certain types of personality disorders can occasionally present a danger to themselves or others. [13]

This concern has found expression in the standards for involuntary commitment in every US state and in other countries as the danger to self or others standard, sometimes supplemented by the requirement that the danger be imminent. In some jurisdictions,[ which? ] the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as "gravely disabled". [14]

Deinstitutionalization

Starting in the 1960s, there has been a worldwide trend toward moving psychiatric patients from hospital settings to less restricting settings in the community, a shift known as "deinstitutionalization". Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalization has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. [15] In some jurisdictions, laws authorizing court-ordered outpatient treatment have been passed in an effort to compel individuals with chronic, untreated severe mental illness to take psychiatric medication while living outside the hospital (e.g. Laura's Law, Kendra's Law). [16] [17]

In a study of 269 patients from Vermont State Hospital done by Courtenay M. Harding and associates, about two-thirds of the ex-patients did well after deinstitutionalization. [18]

Around the world

France

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, [19] and, in 1839, he opened the first school for intellectually disabled people. His method of treatment was based on the idea that intellectually disabled people did not suffer from disease. [20]

United Kingdom

In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many "pauper lunatics". Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital - its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions in which the inmates lived. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

Lord Shaftesbury, a vigorous campaigner for the reform of lunacy law in England, and the Head of the Lunacy Commission for 40 years. Anthony Ashley-Cooper, 7th Earl of Shaftesbury by John Collier.jpg
Lord Shaftesbury, a vigorous campaigner for the reform of lunacy law in England, and the Head of the Lunacy Commission for 40 years.

The Lunacy Act 1845 was a landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, focusing on reform of the legislation concerning lunacy. [21] The commission consisted of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; [22] [ full citation needed ] the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. [22] A national body for asylum superintendents - the Medico-Psychological Association - was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841. [23]

At the turn of the century, England and France combined had only a few hundred individuals in asylums. [24] By the late 1890s and early 1900s, those so detained had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization was soon disappointed. [25] Psychiatrists were pressured by an ever-increasing patient population. [25] The average number of patients in asylums kept increasing. [25] Asylums were quickly becoming almost indistinguishable from custodial institutions, [26] and the reputation of psychiatry in the medical world had was at an extreme low. [27]

Sectioning is now regulated by the Mental Health Act 2007 in England and Wales, the Mental Health (Care and Treatment) (Scotland) Act 2003 in Scotland and other legislation in Northern Ireland.

United States

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. [28]

In the United States and most other developed societies, severe restrictions have been placed on the circumstances under which a person may be committed or treated against their will as such actions have been ruled by the United States Supreme Court and other national legislative bodies as a violation of civil rights and/or human rights. The Supreme Court case O'Connor v. Donaldson established that the mere presence of mental illness and the necessity for treatment are not sufficient by themselves to justify involuntary commitment, if the patient is capable of surviving in freedom and does not present a danger of harm to themselves or others. Criteria for involuntary commitment are generally set by the individual states, and often have both short- and long-term types of commitment. Short-term commitment tends to be a few days or less, requiring an examination by a medical professional, while longer-term commitment typically requires a court hearing, or sentencing as part of a criminal trial. Indefinite commitment is rare and is usually reserved for individuals who are violent or present an ongoing danger to themselves and others.

New York City officials under several administrations have implemented programs involving the involuntary hospitalization of people with mental illnesses in the city. [29] Some of these policies have involved reinterpreting the standard of "harm to themselves or others" to include neglecting their own well-being or posing a harm to themselves or others in the future. In 1987–88, a homeless woman named Joyce Brown worked with the New York Civil Liberties Union to challenge her forced hospitalization under a new Mayor Ed Koch administration program. The trial, which attracted significant media attention, ended in her favor, and while the city won on appeal she was ultimately released after a subsequent case determined she could not be forcibly medicated. [30] [31] In 2022, Mayor Eric Adams announced a similar compulsory hospitalization program, relying on similar legal interpretations. [32] [33]

Historically, until the mid-1960s in most jurisdictions in the United States, all committals to public psychiatric facilities and most committals to private ones were involuntary. Since then, there have been alternating trends towards the abolition or substantial reduction of involuntary commitment, [34] a trend known as deinstitutionalisation . In many currents, individuals can voluntarily admit themselves to a mental health hospital and may have more rights than those who are involuntarily committed. This practice is referred to as voluntary commitment.

In the United States, Kansas v. Hendricks established the procedures for a long-term or indefinite form of commitment applicable to people convicted of some sexual offences. [35]

United Nations

United Nations General Assembly Resolution 46/119, "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. [36] These principles have been used in many countries[ which? ] where local laws have been revised or new ones implemented. The UN runs programs in some countries to assist in this process. [37]

Criticism

The potential dangers of institutions have been noted and criticized by reformers/activists almost since their foundation. [ citation needed ] Charles Dickens was an outspoken and high-profile early critic, and several of his novels, in particular Oliver Twist and Hard Times demonstrate his insight into the damage that institutions can do to human beings.[ citation needed ]

Enoch Powell, when Minister for Health in the early 1960s, was a later opponent who was appalled by what he witnessed on his visits to the asylums, and his famous "water tower" speech in 1961 called for the closure of all NHS asylums and their replacement by wards in general hospitals:[ citation needed ]

"There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside - the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defenses which we have to storm." [38]

Scandal after scandal followed, with many high-profile public inquiries. [39] These involved the exposure of abuses such as unscientific surgical techniques such as lobotomy and the widespread neglect and abuse of vulnerable patients in the US and Europe. The growing anti-psychiatry movement in the 1960s and 1970s led in Italy to the first successful legislative challenge to the authority of the mental institutions, culminating in their closure.

During the 1970s and 1990s the hospital population started to fall rapidly, mainly because of the deaths of long-term inmates. Significant efforts were made to re-house large numbers of former residents in a variety of suitable or otherwise alternative accommodation. The first 1,000+ bed hospital to close was Darenth Park Hospital in Kent, swiftly followed by many more across the UK. The haste of these closures, driven by the Conservative governments led by Margaret Thatcher and John Major, led to considerable criticism in the press, as some individuals slipped through the net into homelessness or were discharged to poor quality private sector mini-institutions.

Wrongful involuntary commitment

There are instances in which mental health professionals have wrongfully deemed individuals to have been displaying the symptoms of a mental disorder, and committed the individual for treatment in a psychiatric hospital upon such grounds. Involuntary commitment is undertaken when the information provided to the doctor during the period of evaluation appears to show that the patient is a danger to themselves or others. This can be challenging in some scenarios, when there isn't enough collateral information to disprove the claims erratic or dangerous behaviors. Therefore, claims of wrongful commitment are a common theme in the anti-psychiatry movement. [40] [41] [42]

In 1860, the case of Elizabeth Packard, who was wrongfully committed that year and filed a lawsuit and won thereafter, highlighted the issue of wrongful involuntary commitment. [43] In 1887, investigative journalist Nellie Bly went undercover at an asylum in New York City to expose the terrible conditions that mental patients at the time had to deal with. She published her findings and experiences as articles in New York World , and later made the articles into one book called Ten Days in a Mad-House .

In the first half of the twentieth century there were a few high-profile cases of wrongful commitment based on racism or punishment for political dissenters. In the former Soviet Union, psychiatric hospitals were used as prisons to isolate political prisoners from the rest of society. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals. Stoppard was inspired by a meeting with a Russian exile. [44] In 1927, after the execution of Sacco and Vanzetti in the United States, demonstrator Aurora D'Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists. [45] [ pages needed ] Throughout the 1940s and 1950s in Canada, 20,000 Canadian children, called the Duplessis orphans, were wrongfully certified as being mentally ill and as a result were committed to psychiatric institutions where they were allegedly forced to take psychiatric medication that they did not need and were abused. They were named after Maurice Duplessis, the premier of Quebec at the time, who deliberately committed these children to misappropriate additional subsidies from the federal government. [46] Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. [47] In 1958, black pastor and activist Clennon Washington King Jr. tried enrolling at the University of Mississippi, which at the time was white, for summer classes; the local police secretly arrested and involuntarily committed him to a mental hospital for 12 days. [48] [49]

Patients are able to sue if they believe that they have been wrongfully committed. [50] [51] [52] In one instance, Junius Wilson, an African American man, was committed to Cherry Hospital in Goldsboro, North Carolina in 1925 for an alleged crime without a trial or conviction. He was castrated. He continued to be held at Cherry Hospital for the next 67 years of his life. It turned out he was deaf rather than mentally ill. [53] [54] [55]

In many U.S. states, [56] sex offenders who have completed a period of incarceration can be civilly committed to a mental institution based on a finding of dangerousness due to a mental disorder. [57] Although the United States Supreme Court determined that this practice does not constitute double jeopardy, [58] organizations such as the American Psychiatric Association (APA) strongly oppose the practice. [59] The Task Force on Sexually Dangerous Offenders, a component of APA's Council on Psychiatry and Law, reported that "in the opinion of the task force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry, particularly with regard to defining mental illness and the clinical conditions for compulsory treatment. Moreover, by bending civil commitment to serve essentially non-medical purposes, statutes threaten to undermine the legitimacy of the medical model of commitment." [60] [61]

See also

In the creative arts

Notes

  1. Also known informally as sectioning, being sectioned, commitment, or being committed. [1]
  2. See table 2, many countries such as Australia, Denmark, England and Spain do not require the involvement of the judiciary for commitment. [2] See [3] for a discussion of mental-health tribunals.
  3. For a discussion of the role of physicians in mental health tribunals and its effects see [5]
  4. "The chair of each Mental Health Tribunal is a legal member who is known as a tribunal judge. There are usually three tribunal members at a hearing, one legal member, one medical member, and one other member, as defined above. Any three or more such members, constituted in this manner, may exercise the jurisdiction of a Mental Health Tribunal" [6] :99

Related Research Articles

Outpatient commitment—also called assisted outpatient treatment (AOT) or community treatment orders (CTO)—refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to an outpatient treatment plan designed to prevent further deterioration or recurrence that is harmful to themselves or others.

<span class="mw-page-title-main">Psychiatric hospital</span> Hospital specializing in the treatment of serious mental disorders

Psychiatric hospitals, also known as mental health hospitals, or behavioral health hospitals are hospitals or wards specializing in the treatment of severe mental disorders, including schizophrenia, bipolar disorder, eating disorders, dissociative identity disorder, major depressive disorder, and others.

Anti-psychiatry, sometimes spelled antipsychiatry without the hyphen, is a movement based on the view that psychiatric treatment is often more damaging than helpful to patients, highlighting controversies about psychiatry. Objections include the reliability of psychiatric diagnosis, the questionable effectiveness and harm associated with psychiatric medications, the failure of psychiatry to demonstrate any disease treatment mechanism for psychiatric medication effects, and legal concerns about equal human rights and civil freedom being nullified by the presence of diagnosis. Historical critiques of psychiatry came to light after focus on the extreme harms associated with electroconvulsive therapy or insulin shock therapy. The term "anti-psychiatry" is in dispute and often used to dismiss all critics of psychiatry, many of whom agree that a specialized role of helper for people in emotional distress may at times be appropriate, and allow for individual choice around treatment decisions.

<span class="mw-page-title-main">Forensic psychiatry</span> Subspeciality of psychiatry, related to criminology

Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. According to the American Academy of Psychiatry and the Law, it is defined as "a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment." A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.

<span class="mw-page-title-main">Voluntary commitment</span> Choosing to admit oneself to a psychiatric hospital

Voluntary commitment is the act or practice of choosing to admit oneself to a psychiatric hospital, or other mental health facility. Unlike in involuntary commitment, the person is free to leave the hospital against medical advice, though there may be a requirement of a period of notice or that the leaving take place during daylight hours. In some jurisdictions, a distinction is drawn between formal and informal voluntary commitment, and this may have an effect on how much notice the individual must give before leaving the hospital. This period may be used for the hospital to use involuntary commitment procedures against the patient. People with mental illness can write psychiatric advance directives in which they can, in advance, consent to voluntary admission to a hospital and thus avoid involuntary commitment.

The Lanterman–Petris–Short (LPS) Act regulates involuntary civil commitment to a mental health institution in the state of California. The act set the precedent for modern mental health commitment procedures in the United States. The bipartisan bill was co-authored by California State Assemblyman Frank D. Lanterman (R) and California State Senators Nicholas C. Petris (D) and Alan Short (D), and signed into law in 1967 by Governor Ronald Reagan. The Act went into full effect on July 1, 1972. It cited seven articles of intent:

Laura's Law is a California state law that allows for court-ordered assisted outpatient treatment. To qualify for the program, the person must have a serious mental illness plus a recent history of psychiatric hospitalizations, jailings or acts, threats or attempts of serious violent behavior towards self or others. A complete functional outline of the legal procedures and safeguards within Laura's Law has been prepared by NAMI San Mateo.

<span class="mw-page-title-main">Emergency psychiatry</span> Clinical application of psychiatry in emergency settings

Emergency psychiatry is the clinical application of psychiatry in emergency settings. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behavior.

Involuntary treatment refers to medical treatment undertaken without the consent of the person being treated. Involuntary treatment is permitted by law in some countries when overseen by the judiciary through court orders; other countries defer directly to the medical opinions of doctors.

Kendra's Law, effective since November 1999, is a New York State law concerning involuntary outpatient commitment also known as assisted outpatient treatment. It grants judges the authority to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours. Kendra's Law does not mandate that patients be forced to take medication.

<span class="mw-page-title-main">Deinstitutionalisation</span> Replacement of psychiatric hospitals

Deinstitutionalisation is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all.

The psychiatric survivors movement is a diverse association of individuals who either currently access mental health services, or who have experienced interventions by psychiatry they consider unhelpful, harmful, abusive or illegal.

<span class="mw-page-title-main">Psychiatry</span> Branch of medicine devoted to mental disorders

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, and perceptions.

The obligatory dangerousness criterion is a principle present in the mental health law of many developed countries. It mandates evidence of dangerousness to oneself or to others before involuntary treatment for mental illness. The term "dangerousness" refers to one's ability to hurt oneself or others physically or mentally within an imminent time frame, and the harm caused must have a long-term effect on the person(s).

<span class="mw-page-title-main">Lunatic asylum</span> Place for housing the insane, an aspect of history

The lunatic asylum, insane asylum or mental asylum was an early precursor of the modern psychiatric hospital.

Political abuse of psychiatry, also commonly referred to as punitive psychiatry, is the misuse of psychiatry, including diagnosis, detention, and treatment, for the purposes of obstructing the human rights of individuals and/or groups in a society. In other words, abuse of psychiatry is the deliberate action of having citizens psychiatrically diagnosed who need neither psychiatric restraint nor psychiatric treatment. Psychiatrists have been involved in human rights abuses in states across the world when the definitions of mental disease were expanded to include political disobedience. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances. Nowadays, in many countries, political prisoners are sometimes confined and abused in psychiatric hospitals.

The following outline is provided as an overview of and topical guide to psychiatry:

<span class="mw-page-title-main">Mental health in Russia</span>

Mental health in Russia is covered by a law, known under its official name—the Law of the Russian Federation "On Psychiatric Care and Guarantees of Citizens' Rights during Its Provision", which is the basic legal act that regulates psychiatric care in the Russian Federation and applies not only to persons with mental disorders but all citizens. A notable exception of this rule is those vested with parliamentary or judicial immunity. Providing psychiatric care is regulated by a special law regarding guarantees of citizens' rights.

<span class="mw-page-title-main">Mental health tribunal</span> Tribunal hearing for mental health treatment disputes

A mental health tribunal is a specialist tribunal (hearing) empowered by law to adjudicate disputes about mental health treatment and detention, primarily by conducting independent reviews of patients diagnosed with mental disorders who are detained in psychiatric hospitals, or under outpatient commitment, and who may be subject to involuntary treatment.

Involuntary commitment or civil commitment is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily.

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Further reading