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Two clinicians who helped develop the National Center for State Courts' 50 guidelines for involuntary civil commitment assess how well the guidelines address some of the common problems clinicians face during the commitment process. The guidelines with potential to help clinicians call for the establishment of screening agencies to reduce unnecessary commitments; encourage the development of models for outpatient commitment; attempt to ensure that information gathered during the evaluation process reaches clinicians; suggest how clinicians can more validly predict whether a patient is dangerous; and advocate more research and evaluation of civil commitment processes. The guidelines that would hamper good clinical care advocate using lawyers as brokers of services and requiring the courts to approve treatment plans. Clinicians are urged to become familiar with the guidelines.
A multidisciplinary task force convened by the National Center for State Courts has developed 50 guidelines that contain practical solutions to problems associated with involuntary civil commitment processes; most can be implemented within existing statutory frameworks. The guidelines call for greater cooperation and communication among the mental health, social service, public safety, and justice systems at each step in the commitment process and recommend that these systems form interdisciplinary community coordinating councils to seek expedient remedies to problems in the commitment process. Other guidelines outline the roles of law enforcement officers, lawyers, mental health professionals, and judges in maintaining the continuity of the commitment process and propose measures for improving screening of individuals as they enter the mental health system. Efforts to facilitate implementation of the guidelines are described.
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Some assumptions that guided the national task force in developing the Guidelines for Involuntary Civil Commitment are identified and discussed. The task force's multidisciplinary membership is seen as enhancing the credibility of the suggested reforms. The task force developed guidelines instead of a model law, avoiding disputes about the philosophical basis of commitment laws and providing local jurisdictions the liberty to adapt the task force's recommendations to suit local conditions. Both the problems identified and the suggestions offered by the guidelines were based on the empirical experience of local commitment systems. Communication among the components of civil commitment systems was seen as crucial to reform and as achievable through a recommended structural change.
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Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.
OBJECTIVE: This study was undertaken to improve understanding of the admission decision process by distinguishing between the clinically indicated level of care and actual level-of-care decisions in emergency psychiatry. METHODS: Clinicians in emergency psychiatric services in Rotterdam, The Netherlands, prospectively rated 720 patients by using the Severity of Psychiatric Illness Scale and collected information on demographic, clinical, and contextual parameters. The clinically indicated level of care and actual level-of-care decisions were studied independently, by using multivariate logistic regression analyses. The decision-making process was divided into three consecutive steps: evaluation of clinically indicated inpatient or outpatient level of care (step 1), voluntary or involuntary admission (step 2), and actual admission of patients for whom voluntary admission was indicated (step 3). RESULTS: Each step was determined by separate factors. Specifically, clinically indicated admission (step 1) was associated with family or friends' desire for admission (odds ratio [OR]=3.7), previous admissions (OR=2.9), symptom severity (OR=2.7), and personality disorder (OR=.4). Involuntary admission (step 2) was associated with lack of motivation (OR=5.7), symptom severity (OR=3.7), time of referral (OR=3.5) and danger to self or others (OR=2.7). Actual voluntary admission (step 3) was associated mainly with bed availability (OR=8.7). The overall percentage of correctly predicted cases was 82 percent for all steps in the decision process. CONCLUSIONS: This study showed that each step in the admission decision process is determined by a unique set of variables and provided evidence that contextual factors influence decision making. Guidelines for voluntary admission and civil commitment need to be based on the results of studies that distinguish between the clinical needs of patients and contextual factors.