Involuntary Commitment Background- the Healthcare

Involuntary Commitment

Background- The healthcare profession is based on the paradigm of "do no harm." This paradigm has been in place since the days of Ancient Greece and is a focal portion of most modern medical ethic theories. However, there are times when individuals with severe mental symptoms need treatment but are unable or unwilling to seek such. In this case, involuntary treatment, involuntary commitment, or civil commitments are legal tools to allow for court-ordered hospital (inpatient) or community (outpatient) treatment. Treatment, of course, is varied, as is the criteria, which varies between nations and from state to state in the United States. Commitment proceedings often follow a specialized period of emergency hospitalization undergone by a patient with acute psychological symptoms (usually 48-72 hours). During this time, the patient is observed by healthcare professions and a recommendation given whether further commitment is necessary. The point of the initial period is to stabilize the external symptoms so that an accurate assessment may be made. If further commitment is necessary, healthcare professionals must follow a formal civil and legal procedure in which evidence is presented, other testimony if necessary, and any relevant medical or personal information. The individual is entitled to legal counsel and may actually challenge the commitment through habeas corpus. Typically, however, at least in the last 3-4 decades, there is a more consistent and balanced approach to commitment that sets certain limitations for review upon the institution or parties requesting the actual commitment. This is in contrast to the first third of the 20th century in which most commitments to public psychiatric facilities and most committals to private institutions remained involuntary. Since then, however, there has been a trend toward the abolition and/or substantial reduction of any involuntary commitment procedures -- also called deinstitutionalization (Atkinson).

Purpose of Involuntary Commitment -- Society realizes that, at times, a patient is in such a state that they may pose a danger to themselves or to society and be unable to make rational decisions. In fact, in most jurisdictions in the modern world, involuntary commitment procedures are specifically applied to individuals who have manifested some form of serious mental illness that acts to impair their reasoning to such extent that they are unable to make cogent and logical decisions. Therefore, at these times the state (the Court system) must intercede to find ways to make the appropriate decisions under a legal template. Involuntary commitment may have, in the past, been used in certain situations, inappropriately, but the statutory criteria that indicates one is a danger to self or others usually acts as a legal axiom (Korba). Other criteria exist when making a recommendation regarding involuntary comittment:

First Aid -- Societal changes in both substantive and qualitative approaches to mental illness now provide means for community members (teachers, administrators, police officers, medical workers, etc.) to understand that mental first aid is just as viable as physical first aid. First developed as a fird course in Australia in 2001, mental health triage and first aid are now used and training disseminated throughout many communities (Kitchener and Jorm).

Observation -- Often, a psychiatric or mental breakdown is the result of a single event; overdose of substance, unexpected tragedy, disaster (natural or otherwise). In this case, sometimes individuals are simply unable to cope with the immediacy of the situation. The period of observation once mental first aid is given is designed to: a) stabalize the situation to the point where a cogent observation may be made, b) see if once the crisis or substance issue is over the patient is able to return to a reasonable decision-making and cognizant state, c) use whatever mental health provisions that are available to mitigate the situation to the fullest extent. Typically, in most states, this is anywhere from 48-72 hours, with the occasional addition of 24-hour periods as deemed necessary by healthcare professionals. The key concept for observation is that it requires a basis in probable cause to determine if a hearing is needed, or if further treatment is required (Parry and Drogin, 296-7).

Containment of Danger -- The most common reason given in the legal literature for involuntary treatment or commitment is that the individual manifests symptoms that appear to cause imminent danger to themselves or society. Individuals with suicidal thoughts may act upon these thoughts and do harm to themselves, or even kill themselves. Individuals that manifest psychoses might be driven by delusional thoughts or hallucinations that might cause them to harm themselves or others; and people with certain types of personality disorders (schizophrenia, etc.) are sometimes in a position to present a clear and present danger to themselves or others. These concerns are listed in every U.S. state as the "danger to self and others" standard. The standard is often supplemented by the requirement that the danger actually be imminent, and not a hypothetical future issue. In recent years, many states have included criteria that includes need for treatment because the patient is "gravely disabled" (Corey, 194-5).

Deinstitutionalization -- Beginning in the 1960s, the liberalization of legal proceedings regarding involutary commitment is used only after less restrictive alternatives have failed. There has been a worldwide trend toward moving mental health patients from insititutional settings to less restrivtive settings in the community (1/2 way houses, etc.). Due to the fact that this shift was unfortunately not accompanied by a similar development of community-based services, many critics use this process as evidence that a large number of people who might have once been institutionalized are now in the correction system or part of the vast homeless population. This is a direct result of outpatient services not being available, or those individuals who are unable to maintain treatment outside of a clinical setting. As this problem became chronic in many larger urban areas, laws authorizing court-ordered outpatient treatment have been passed to help compel these individuals (chronic or untreated mental illness) to accept treatment while living outside a clinical environment. As might be expected, however, legalizing outpatient treatment is extremely difficult to enforce in a system in which there are too few healthcare workers per needed population (Palermo).