Tag: Voluntary Commitment

What is Outpatient Commitment?

Published on by Andrew Marshall1 Comment

Introduction

Outpatient commitment – also termed 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.

This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, and the person’s mental health deteriorates. This generally means taking psychiatric medication as directed and may also include attending appointments with a mental health professional, and sometimes even not to take non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual.

The criteria and process for outpatient commitment are established by law, which vary among nations and, in the US and Canada, among states or provinces. Some jurisdictions require court hearings, where a judge will make a court order, and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted. When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.

Terminology

In the United States the term “assisted outpatient treatment” (AOT) is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well. Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT).

Australia, Canada, England, and New Zealand use the term “community treatment order” (CTO).

Comparison to Inpatient Commitment

The terminology, “outpatient commitment”, and legal construction often equate outpatient commitment with inpatient commitment but providing the patient more freedom. In practice, outpatient commitment may be used in situations where commitment would not be used because it is cheaper than inpatient commitment; seen as less draconian; and protects mental health professionals from moral, civil or criminal liability.

Preventive Use

Outpatient commitment is used in some countries to prevent relapse of mental disorders, as many mental disorders are episodic in natural (for example bipolar disorder or schizophrenia) and it can be difficult to predict whether a mental disorder with reoccur.

Some countries use outpatient commitment for first episode psychosis (FEP).

Implementation

Discussions of “outpatient commitment” began in the psychiatry community in the 1980s following deinstitutionalisation, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community.

Europe

Denmark

Denmark introduced outpatient commitment in 2010 with the Mental Health Act (Danish: Lov om anvendelse af tvang i psykiatrien).

Germany

In Germany, as of 2014, only former forensic psychiatry patients may be placed under community treatment orders. Legislation to allow for wider use of CTOs was considered in 2003-2004, but it was ultimately rejected by the Bundestag.

The Netherlands

As of 2014, Dutch law provides for community treatment orders, and an individual who does not comply with the terms of their CTO may be subject to immediate involuntary commitment.

Norway

When Norway introduced outpatient commitment in the 1961 Mental Health Act, it could only be mandated for individuals who had previously been admitted for inpatient treatment. Revisions in 1999 and 2006 provided for outpatient commitment without previous inpatient treatment, but this provision is seldom used.

Sweden

In Sweden, the Compulsory Psychiatric Care Act (Swedish: Lag om psykiatrisk tvångsvård) provides for an administrative court to mandate psychiatric treatment to prevent harm to the individual or others. The law was created in 1991 and revised in 2008.

England and Wales

Changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. The Mental Health Act 2007 introduced community treatment orders (CTOs). CTOs are legally defined as a form of outpatient leave for individuals detained under section 3 of the Mental Health Act. As such, only members of the medical community are involved in issuing a CTO, though both the section 3 detention underlying the CTO and the CTO itself can be appealed to the Mental Health Tribunal where a panel consisting of medical doctors and a judge will make a decision.

A review of patient data in London found that the average duration of a CTO in the UK was 3 years. Black people in the UK are more than ten times as likely to be under a CTO as white people. 

The legislation in the UK specifically allows CTOs to be issued after a single admission to hospital for treatment. However, the Royal College of Psychiatrists suggested limiting CTOs to patients with a history of noncompliance and hospitalization, when it reviewed the current mental health legislation.

John Mayer Chamberlain argues that this legislation was triggered by the Killing of Jonathan Zito by an individual who had interactions with mental health services prior this event, which led the then conservative government to argue for CTOs.

In a 2021 paper reviewing the mental health act, the UK government proposed a new form of indefinite outpatient commitment allowing for deprivation of liberties an continuous supervision termed supervised discharge. This discharge would be reviewed yearly, and only apply to individuals who would not benefit from treatment in a hospital setting and would be based on risk.  Further, this legislation would only apply to restricted patients who have been diverted to the mental health care system from courts.

Scotland

Scotland has a different community commitment regime from England and Wales introduced in the 2003 Mental Health Act. There is ongoing debate in the UK on the place of coercion and compulsion in community mental health care.

North America

In the last decade of the 20th century and the first of the 21st, “outpatient commitment” laws were passed in a number of US states and jurisdictions in Canada.

Canada

In the mid-1990s, Saskatchewan became the first Canadian province to implement community treatment orders, and Ontario followed in 2000. As of January 2016, New Brunswick was the only province without legislation that provided for either CTOs or extended leave.

United States

By the end of 2010, 44 US states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicised tragedies, such as the murders of Laura Wilcox and Kendra Webdale.

Oceania

Australia and New Zealand introduced community treatment orders in the 1980s and 1990s.

Australia

In Australia, community treatment orders last for a maximum of twelve months but can be renewed after review by a tribunal.

Evidence

A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomised trials had dramatically varying results and found that no randomised controlled trials showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.

The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.

Cost

Research published in 2013 showed that Kendra’s Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests. About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.

“Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized.”

Arrests, Danger, and Violence

The National Institute of Justice considers assisted outpatient treatment an effective crime prevention programme. Some studies in the US have found that AOT programmes have reduced the chances of arrest. Kendra’s Law has lowered risk of violent behaviours, reduced thoughts about suicide.

Outcomes and hospital admissions

AOT “programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior.”

“The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order…and by over one-third during a subsequent six-month renewal of the order…. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals…. Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.”

74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalisation. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager’s ability. 88% said they and their case manager agreed on what was important to work on.

In Nevada County, CA, AOT (“Laura’s Law“) decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura’s Law implementation saved $1.81-$2.52 for every dollar spent, and receiving services under Laura’s Law caused a “reduction in actual hospital costs of $213,300” and a “reduction in actual incarceration costs of $75,600.”

In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot programme performed “beyond wildest dreams.” AOT reduced hospitalisations, shortened inpatient stays, reduced crime and incarceration, stabilised housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.

Writing in the British Journal of Psychiatry in 2013, Jorun Rugkåsa and John Dawson stated:

“The current evidence from RCTs suggests that CTOs do not reduce readmission rates over 12 months.”

“We find that New York State’s AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients.”

“The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.”

Effect on Mental Illness System

Access to Services

“AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.”

“Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.”

“Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources. There is now an organized process to prioritize and monitor individuals with the greatest need; AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve; There is now increased collaboration between inpatient and community-based providers.”

In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.

“In all three regions, for all three groups, the predicted probability of an MPR ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and ‘neither treatment,’ improving 8–19 points). Some regional differences in MPR trajectories were observed.”

“In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.”

“It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.”

Race

“We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.”

“We found no evidence of racial bias. Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity.”

Service Engagement

“After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.”

Consumers approve. Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.

“When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services.”

In Los Angeles, CA, the AOT pilot programme reduced incarceration 78%, hospitalisation 86%, hospitalisation after discharge from the programme 77%, and cut taxpayer costs 40%.

In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.

In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. “During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment.”

In Arizona, “71% [of AOT patients] … voluntarily maintained treatment contacts six months after their orders expired” compared with “almost no patients” who were not court-ordered to outpatient treatment.

In Iowa, “it appears as though outpatient commitment promotes treatment compliance in about 80% of patients… After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis.”

Controversy

Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, lowers incidence of homelessness, arrest, incarceration and hospitalisation and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, or are applied with racial and socioeconomic biases.

Proponents

While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and “revolving door patients” who experience a cycle of hospitalisation, treatment and stabilisation, release, and decompensation. While the cost of repeated hospitalisations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment. Proponents include: Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Justice, Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices. Crime Solutions: Management Strategies to Reduce Psychiatric Readmissions. The Treatment Advocacy Centre are an advocacy group that campaign for the use of outpatient commitment.

Opponents

Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied.

The opponents claim they are giving medication to the patient, but there are no brain chemical imbalances to correct in “mental illness”. Our ability to control ourselves and reason comes from the mind, and the brain is being reduced in size from the psychiatric medications.

The slippery slope argument of “If government bodies are given power, they will use it in excess.” was proven when 350–450 CTOs were expected to be issued in 2008 and more than five times that number were issued in the first few months. Every year there are increasing numbers of people subject to CTO’s.

The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders. The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.

What is a Psychiatric Advance Directive?

Published on by Andrew Marshall1 Comment

Introduction

A psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.

It can inform others about what treatment they want or do not want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of advance health care directive.

Refer to Voluntary Commitment and Involuntary Commitment.

Legal Foundations

Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental health treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney (HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions.

In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents. In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes – expanding the audience for PADs to all 50 states (refer to National Resource Centre on Psychiatric Advance Directives).

In addition, states are beginning to recognise legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and – with certain caveats – that clinicians are obliged to follow these directives.

Finally, the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO) requires behavioural health facilities to ask patients if they have PADs. The Centres for Medicare and Medicaid Services announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare and Medicaid revenue.

Proponents of these directives believe thy of followed by treatment providers, crisis planning using PADs will help involuntary detainees retain control over their decision making – especially during times when they are labelled incompetent. Additionally, advocates argue that health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.

Clinical Benefits

Recent data from a NIH-funded study conducted by researchers at Duke University has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labelled with severe mental illness.

Moreover, PADs provide a transportable document – increasingly accessible through electronic directories – to convey information about a detainee’s treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labelled as psychiatric patients who present or are coercively presented and labelled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making – appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy.

For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy and social welfare for detainees labelled with mental illness. Since PADs are among the first laws that are specifically intended to promote autonomy among people detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.

Barriers

National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD.

Some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, scepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarised, and filing the documents in a medical record or registry may pose a formidable barrier.

Recent studies of practitioners of coercive psychiatry’s attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.

In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care. Further, the more clinicians knew about PAD laws, the more favourable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labelled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.

However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.

Resources

It thus has become clear that the potential significance of PADs is becoming widely recognized among those targeted for coercive psychiatry, survivors of coercive psychiatry, influential policy makers, clinicians, family members, and patient advocacy groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.

As a result, in the United States, a collaboration between the Bazelon Centre for Mental Health Law and Duke University has led to creation of the MacArthur Foundation-funded National Resource Center on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centred crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.

What is Voluntary Commitment?

Published on by Andrew Marshall2 Comments

Introduction

Voluntary commitment is the act or practice of choosing to admit oneself to a psychiatric hospital, or other mental health facility.

Overview

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.

In the UK, people who are admitted to hospital voluntarily are referred to either as voluntary patients or informal patients. These people are free to discharge against medical advice, unless it is felt that they are at immediate risk, then a doctor can use mental health law to hold people in the hospital for up to 72 hours. People who are detained by mental health law are referred to as formal patients.

In Europe, the treatment of mental illness became a health policy priority under the impetus of the World Health Organisation (WHO) Mental Health Plan for Europe elaborated in 2005. This plan promoted a more effective balance between inpatient hospital care and outpatient care through the development of community mental healthcare services. Since the 1970s, the majority of European countries have shifted away from institutionalised care in large mental hospitals to the integration of patients in their living environment through the provision of home and community care services. Germany, England, France and Italy deinstitutionalised psychiatric care in the second half of the 20th century, but the speed and methods by which it was implemented varied, notably due to differences in social and political contexts. In Italy, the reform movement took place a little later. Until the 1968 Mariotti Law introducing voluntary internment, admission into a psychiatric hospital was only by compulsory commitment and was entered in an individual’s criminal records.

What is Involuntary Commitment?

Published on by Andrew Marshall9 Comments

Introduction

Involuntary commitment, civil commitment, or involuntary hospitalisation (also known informally as sectioning or being sectioned in some jurisdictions, such as the UK) 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. 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.

Refer to Voluntary Commitment.

Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalisation, 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 stabilisation 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.

Historically, until the mid-1960s in most jurisdictions in the US, 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, 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, an indefinite form of commitment is applied to people convicted of some sexual offences.

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 where subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. Other jurisdictions have delegated these power to physicians, though may provide an appeal process that involves the judiciary but may also involve physicians. For example in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative.

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 recognising, and authority in managing, situations where involuntary evaluations of behaviour are applicable under law. The extension of first aid training to cover mental health problems and crises is a quite recent development. 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). 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

Refer to Obligatory Dangerousness Criterion.

Austria, Belgium, Germany, Israel, the Netherlands, Northern 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.

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 who suffer from schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public. 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.

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

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, the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as “gravely disabled”.

Deinstitutionalisation

Refer to Deinstitutionalisation.

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 deinstitutionalisation. Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalisation has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. In some jurisdictions, laws authorising 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 and Kendra’s Law).

Before the 1960s deinstitutionalisation there were earlier efforts to free psychiatric patients. Philippe Pinel (1745-1826) ordered the removal of chains from patients.

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 deinstitutionalisation.

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, and, in 1839, he opened the first school for the intellectually disabled. His method of treatment was based on the idea that the intellectually disabled did not suffer from disease.

United Kingdom

In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a large 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 the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

The Lunacy Act 1845 was an important 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, to focus on lunacy legislation reform. The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; 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. 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.

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

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.

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 (e.g. O’Connor v. Donaldson). Thus a person is rarely committed against their will and it is illegal for a person to be committed for an indefinite period of time.

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. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programmes in some countries to assist in this process.

Criticism

The dangers of institutions were chronicled and criticized by reformers almost since their foundation. 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.

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:

“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.”

Scandal after scandal followed, with many high-profile public inquiries. 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

Mental health professionals have, on occasion, wrongfully deemed individuals to have symptoms of a mental disorder, and thereby commit the individual for treatment in a psychiatric hospital. Claims of wrongful commitment are a common theme in the anti-psychiatry movement.

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. 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. 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. 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 wrongfully committed to psychiatric institutions where they were 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 in order to misappropriate additional subsidies from the federal government. Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. 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.

Patients are able to sue if they believe that they have been wrongfully committed. 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.

In many American states 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. Although the United States Supreme Court determined that this practice does not constitute double jeopardy, organisations such as the American Psychiatric Association (APA) strongly oppose the practice. 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.”