In this piece we take a look at civil commitment generally. The topic is a broad one and we use it to refer to the hospitalization or treatment of an individual done in apparent opposition to his or her request.
Many physicians are exposed to civil commitment early in their training. The practice is not limited to psychiatrists, although much of the time psychiatrists are involved in civil commitment. The civil commitment process first crops up for most physicians when they are confronted by a patient who has a life-threatening illness that he or she does not want treated, or when he or she is psychiatrically unstable.
Why can we lock people up?
Before delving too deep into the kinds of civil commitment, it seems appropriate to explain exactly from where the physician's power comes. In the United States, forcing someone to enter a facility to undergo treatment is considered a relatively significant curtailment of his or her rights, and the power needs to be granted to us.
It may not be an obvious question to ask, but you may have wondered why it is that we, as physicians, can lock people in a hospital or force them to be in treatment against their will. In doing so, we are essentially working as extensions of the state where we practice. The State is really the entity with the power, and that power is extended to physicians. This power is really derived from two traditional sources: parens patriae and police powers.
Parens patriae
If you entered medical school in a previous era, latin may have been a requirement. That is no longer the case and so it makes sense to explain the literal meaning of the phrase parens patriae which is “father of the country.” This literal translation makes more sense in the setting from which it derives, where the ruler was to use his power to protect the best interests of his citizens. In the United States the sovereign is a government and the phrase has come to mean “the state as parent.” This power is put into action when the State acts for those who are unable to due to age, illness, or other infirmity. The key principle is that it protects the individual.
Police power
Police power derives from the interest of the government to protect its citizens from others and to maintain order in the interest of public safety. This power is, therefore, invoked in psychiatry if someone's actions threaten the safety or welfare of others.
Traditional commitment statutes generally attempt to capture the essence of these two powers and are used for those with a mental illness who are a danger to themselves or others or both.
Deinstitutionalization and Commitment
Taking a historical perspective on the use of civil commitment and the growth and then contraction of the inpatient mental health institutions in this country paints a picture of the power that such commitment statutes have and through these statutes physicians have.
The significant numbers of patient outflows from such institutions in the 1960s, commonly referred to as ‘deinstitutionalization.' are a reflection of changes in the laws that govern these powers. Commitment statutes went from those with low hurdles for criteria to being committed to more rigorous standards in parallel with the civil rights movement.
A major case which assisted in the tightening of commitment standards is a case named Lake v. Cameron. This case is considered the pioneer of the phrase 'least restrictive alternative' when considering commitment of an individual.
At first, glance one might think that mental health clinicians and family members of the mentally ill would champion efforts to curb overuse of commitment statutes through such changes to the legal landscape. As with many things there was mixed reception. Some family members and clinicians grew concerned about the difficulty that arose in treating those who were in need, but might not qualify for new, more rigorous standards.
The mixed feelings about the statutes has led to mixed results in terms of the final text that States use. It is important to check the law in the State where one is practicing and make sure they are using the right standard which may be different from the place that they trained.
Outpatient commitment vs inpatient
One power that was utilized infrequently until recently was outpatient commitment. While the power to commit someone to treatment on an outpatient basis existed in many states for long periods of time there was little or no effort at the level of state government to fund such programs or organize them.
Outpatient commitment grew increasingly popular after the introduction of ‘least restrictive alternative' language into the law. State and local agencies were forced to provide mechanisms to enable outpatient commitment to occur. Additionally, these efforts were galvanized by media reports of actions by patients who were not taking their medication. An example of this is the death of Kendra Webdale in New York City. In 1999, a man (Andrew Goldstein) with a lengthy mental illness as well as history of non-adherence with medication as an outpatient, pushed Ms. Webdale onto a subway track leading to her death. This event led to swift efforts to enact programs for outpatient commitment in New York which were signed into law in mid 1999.
Civil Commitment Continues to Evolve
Civil commitment continues to evolve as an area that responds to changes in the law and public policy. Perhaps the most vibrant area of change today involves civil commitment of sexual offenders, utilizing the state powers described earlier to keep sexual offenders in treatment after their criminal sentences end. This will be further examined in a piece later in the series.