By Dr. Greg Brown
During early historical periods, individuals who were regarded as being mentally ill or who acted strangely were often taken care of in the communities where they lived, sometimes performing an important social role. By the beginning of the Renaissance, communities had begun the process of building facilities to keep the mentally ill separate from the general population. These were asylums where patients were held often indefinitely. Since no effective treatment was available for mental illness during that time period, this was more akin to a form of imprisonment than actual treatment, even though no crime had been committed.
By the 19th century in the United States, most jurisdictions began to develop a series of state-run psychiatric facilities under the influence of a reform movement led by Dorothea Dix. The legal criteria for admission to psychiatric facilities during that time was one which was justified under the Parens Patriae Principle, that is the state acting in the role of a parent. Under this general ideology, patients could be held in psychiatric facilities essentially indefinitely because it was thought they could not take care of themselves and they needed a substitute parent to make decisions for what was in their best interests. As the populations within these facilities ballooned, often the ability to care humanely for the patients waned and many individuals would see their entire lives spent locked away from society.
Major reform occurred in the late 1960s and 1970s after a series of egregious cases that went to the level of the United Stated Supreme Court. In the wake of those decision, the basis for involuntary commitment to an inpatient psychiatric facility changed to that of the police powers authority of the state. Under this new revision of mental health law, in order to be involuntarily held in a psychiatric hospital, a patient would need to be both mentally ill and dangerous to either self or others or, in some jurisdictions, so severely impaired that they would be incapable of taking care of basic needs of survival. This transition of legal structure for involuntary commitment allowed for the release over the de-institutionalization period of hundreds of thousands of people previously treated at an inpatient level of care.
It is certainly known that the average dangerousness risk for a mentally ill person is statistically no higher than the risk non-mentally ill persons. However, in those periods of acute psychosis or acute suicidality in which dangerousness levels are temporarily elevated, involuntary commitment is now seen as a brief means of stabilizing individuals so that they can return to life in their community soon thereafter.
When someone needs psychiatric help acutely due to the combination of illness and dangerousness, and they are refusing to go to a psychiatric facility of their own free will, this is the situation in which an involuntary admission may be considered. This is called an involuntary hold which may later turn into an involuntary commitment if the person does not stabilize rapidly. Each state has slightly different wordings for how this process works, and each has slightly different timeframes. The general principle, however, is that an individual is placed on a brief hold because of concern that they are both mentally ill and dangerous. If someone is only mentally ill but not dangerous they are allowed to be free in the community as mental illness, in and of itself, does not warrant the loss of liberty that is part of a hospitalization. Conversely, if someone is dangerous but not mentally ill, they need to be sent to a jail or correctional facility, not a psychiatric facility, because psychiatric facilities exist ethically only for the purpose of treating mental illness. It is only in the presence of both mental illness and dangerousness toward self or others that an involuntary hold can be presented. Some states allow for involuntary holds on the basis of substance use in addition to other defined mental illness, and other states do not. After a brief involuntary hold, which also requires that the mental condition not be the result of a medical condition, the hospital may then petition the court for a longer involuntary hold, which is then termed an involuntary commitment for the treatment and stabilization of the patient now found judicially to be both mentally ill and dangerous. The hospital is allowed, and required, to release anyone from an involuntary hold at the point when they are no longer acutely dangerous and their mental illness is reasonably stabilized. Dangerousness under civil commitment statutes is temporary by definition.
This evolution in the involuntary commitment process has allowed for substantially more liberty rights on the behalf of patients who do not wish to be held in psychiatric hospitals. However, unfortunately, the degree of intensive outpatient services promised in the de-institutionalization process in the 1970s never materialized, which often leaves a subset of these individuals with less than ideal outpatient support after they have been discharged from an inpatient facility.
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Dr. Greg Brown
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