Mental Health Commitment Laws: Making the Case for U.S. Civil Commitment Reform

Earlier this month, I posted a blog titled, Understanding Lack of Access to Mental Healthcare in the US: 3 Lessons from the Gus Deeds StoryIn that post, I highlighted how current mental health commitment laws were one of the barriers to accessing mental health care:

 

“….federal and state laws, surrounding the involuntary hospitalization of individuals with mental illness, whilst designed to protect patient’s rights, often leave loved ones and mental health professionals who understand the patient and their illness with no voice, and minimal sway and influence over decisions that get made in courts.”

 

treatment advocacy centerIn follow up to this point, I am blogging today on a recent report published by the Treatment Advocacy Center (a national nonprofit organization) titled Mental Health Commitment Laws: A Survey of the States.

The results of this report validate the experience of those of us who work in the mental health field.  For many of us, it often seems like an uphill battle to get much needed mental health services for patients living with serious mental illness, because our hands are tied by restrictive laws (or restrictive interpretations of such laws).

 

Background:

The deinstitutionalization movement of the 1960’s brought a national trend to reform civil commitment laws and a shifting of focus to the person’s “dangerousness to self or others” as the sole basis for civil commitment (i.e. involuntary treatment or hospitalization).

depressed womanBy the late 1970’s, the results of deinstitutionalization were becoming more apparent, and many had started to wonder if perhaps the pendulum had swung too far. Though community integration had improved the lives of some, a large number of desperately ill people had been abandoned to the streets or to the prison system.

This is why it is so important to re-evaluate the laws surrounding civil commitment and change the very reductionistic and rigid focus on imminent risk of violence or suicide as the only reasons that warrant hospital commitment. Another approach has been to minimize the need for involuntary hospitalizations via the use of less intrusive modalities, such as court-ordered outpatient treatment (i.e. AOT= assisted outpatient treatment).

 

Results of the TAC report?

state-of-statesThe TAC report analyzed the quality and use of laws that each state had enacted to meet the needs of people with severe mental illness who cannot recognize their own need for treatment. The report graded each state on the quality of the civil commitment laws that determined who received court-ordered treatment for mental illness, under what conditions, and for how long. States also received grades on their use of treatment laws based on a survey of mental health officials.

No state earned a grade of “A” on the use of its civil commitment laws. Seventeen states earned a cumulative grade of “D” or “F” for the quality of their laws, and only 14 states earned a grade of “B” or better for the quality of their civil commitment laws. Twenty-seven states provide court-ordered hospital treatment only to people at risk of violence or suicide, even though most of these states have laws that allow treatment under additional circumstances.

 

The report ended with these recommendations:

 

“The deplorable conditions under which more than one million men and women with the most severe mental illness live in America will not end until states universally recognize and implement involuntary commitment as an indispensable tool in promoting recovery among individuals too ill to seek treatment. To that end, the Treatment Advocacy Center recommends:

· Universal adoption of need-for-treatment standards to provide a legally viable means of intervening in psychiatric deterioration prior to the onset of dangerousness or grave disability

· Enactment of AOT laws by the five states that have not yet passed them – Connecticut, Maryland, Massachusetts, New Mexico and Tennessee

· Universal adoption of emergency hospitalization standards that create no additional barriers to treatment

· Provision of sufficient inpatient psychiatric treatment beds for individuals in need of treatment to meet the standard of 50 beds per 100,000 in population”

 

I could not agree more.

 

To view this report, in its entirety, follow this link.

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4 Responses to Mental Health Commitment Laws: Making the Case for U.S. Civil Commitment Reform

  1. Dinah says:

    Dr. Jain — You’re in California and the California laws allow for much easier civil commitment than we have here in Maryland. You have a “gravely disabled” clause in your “5150″ law which allows for fairly easy 72 hour holds, and you have AOT. And yet, there are many thousands of people who sleep on the streets in California — and I’m guessing a few have psychotic disorders? In San Francisco alone, over 3,000 people sleep on the streets each night, and that’s but one city. Perhaps it’s not about forcing care, but about having care?

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    • Shaili Jain, MD says:

      Hi Dinah, thanks for your comment. My 2/6 blog highlighted the many issues that interfere with access to mental health care including the availability of care. Of course, parity, cuts to public funding, health insurance, lack of psychiatric beds are all major major issues (in fact I cited your grt post on kevin md on the hassles that insurance companies put doctor through in that 2/6 blog). So no argument from me on that front…

      This post I wanted to focus, in light of this TAC report, specifically on the issue surr civil commitment. I wish I could report that things in California are acceptable but I am afraid there are too many stories of 51/50 being dropped prematurely secondary to rigid interpretations of laws and the bureaucratic hoops/mounds of paperwork psychiatrists have to go through to make their case for commitment only to have it come to nothing secondary to a technicality or non clinical justification….as I write I can’t help think it is all related, that the er doc who drops the 51/50 put on by the outpatient psychiatrist has no psych bed for the patient to go to anyway etc etc, but still I think there is much rm for improvement in the actual laws, how they are interpreted and also how, in the case of aot, are enforced.

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  2. Onita says:

    Nice post. I learn something new and challenging on blogs I stumbleupon every day.
    It will always be exciting to read articles from other
    writers and practice something from their web sites.

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  3. Really descriptive article, I liked that a good deal. Will there be a part 2?

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