The aged and the dangerousness criterion in involuntary civil commitment

Using data from official court records and observations in court hearings throughout one state with a typical reform statute, this study investigates the elderly against whom petitions are brought for involuntary civil commitment. In relation to their proportion in the population, the aged are only slightly more likely than younger persons to become respondents in commitment proceedings; but they are over three times more likely to remain involuntarily hospitalized and to be subjected to recommitment proceedings. Once brought into the process, they are more likely than younger respondents to be committed and are more likely to be successively recommitted. In analyzing court testimony, focus is on evidence of dangerousness since involuntary commitment is limited to the mentally ill who are dangerous. Almost half of the young old initial respondents with formal hearings have no testimony alleging dangerous behavior and more than half of the old old have no such testimony. The alleged dangerous acts of the aged tend to be unintentional harm rather than assault.     

REPRESENTING RESPONDENTS UNDER NEW CIVIL COMMITMENT STATUTES: An Analysis of Counsel's Role In and Out of the Courtroom

Using quantifiable attorney behavior measures, instead of outcome measures, both before and during court hearings, this study attempts to evaluate legal representation under reform civil commitment procedures. Counsel representing involuntary commitment respondents full time were well prepared. Court appointed counsel, though better prepared than reported in studies done prior to reform, did not fully investigate their cases. Lack of adequate preparation was associated with a passive role and a non adversary position in court.     

Dangerousness of civil commitment candidates

This study followed a large, statewide sample of civil commitment candidates both in and out of the hospital for 6 months following their postcourt hearings to determine their postcourt dangerousness. It objectively measures dangerousness by dividing it into five legal components of behavior: (1) type, (2) object, (3) frequency, (4) weapon/means, and (5) severity of outcome. Using data from ward charts, readmission evaluations, recommitment affidavits, and arrest and community mental health center records, it describes candidates' dangerousness in terms of those, five components and compares that dangerousness with the alleged dangerous behavior that brought them into the civil commitment process. It finds that candidates do not tend to be dangerous in the 6 months following their court hearings.     

Investigators' and judges' opinions about civil commitment

As part of our work with the Oregon Task Force on Civil Commitment, we surveyed the judges and commitment investigators involved in the state's involuntary treatment program. In Oregon the investigators recommend whether or not a commitment hearing should be held. These mental health professionals indicated that current confidentiality laws restrict their access to important information. The investigators also expressed concern about the lack of resources with which to divert clients out of the commitment system. Judges too felt that relaxing the rules of evidence would improve the quality of commitment hearings. Regarding changes in the system, investigators and judges indicated that outpatient treatment (including compliance with medications) should be required of committed patients. These professionals noted that involuntary outpatient treatment could only be enforced if the system included a mechanism for hospitalizing patients who were noncompliant. Although the investigators believed commitment criteria should be broadened so that their clients could receive treatment before becoming dangerous, judges did not generally endorse this view. We discuss the implications of these findings for new civil commitment legislation.     

Involuntary administration of medication in the community: the judicial opportunity

In a state in which patient refusal of antipsychotic medication in all nonemergency situations must be respected, lawyers and psychiatrists in western Massachusetts have employed probate court decisions as involuntary outpatient treatment orders. The legal, administrative, and clinical issues in sustaining court-ordered outpatient treatment are discussed by focusing on case examples demonstrating some successes, some challenges, and some failures. Judicially sanctioned involuntary outpatient treatment presents an alternative model to statutorily based outpatient commitment.     

“治疗可能性”要件:遵从抑或摒弃?

精神病人的强制医疗一般以患有精神疾病且对本人或他人具有危险性为条件,"治疗可能性"是否应作为强制医疗的条件,理论和实践均存在较大的分歧。出于公共秩序之维护,摈弃"治疗可能性"要件呼声的日渐高涨,但基于精神病人权利之保护仍有必要将"治疗可能性"作为强制医疗的要件,而对于无治疗可能、具有危险性的精神病人应通过其他社会控制机制予以解决,而不应纳入强制医疗的范围。     

Does involuntary outpatient commitment lead to more intensive treatment?

Studies of involuntary outpatient commitment (OPC) among persons with severe mental illness have concluded that OPC is only effective in improving treatment outcomes when it is sustained for 6 months or longer and is combined with frequent outpatient services. This article explores factors that influence the delivery of outpatient services to subjects in a randomized trial of OPC and finds 2 general patterns. Outpatient visits were more frequent among all subjects with apparent clinical need, regardless of study assignment, and among subjects whose OPC was sustained beyond an initial court order. These results suggest that, in practice, sustained OPC represents a consensual agreement between clinicians and the court to more intensively address the complex needs of persons with severe and persistent mental illness.     

A population at risk: civil commitment of substance abusers after Kansas v. Hendricks

In its 1997 decision, Kansas v. Hendricks, the U.S. Supreme Court radically changed the face of civil commitment. In finding the Kansas Sexually Violent Predators Act constitutional, the Court liberalized the first constitutional requirement for involuntary commitment from "mental illness" to a much broader "mental abnormality" standard, without correspondingly restricting the second requirement of dangerousness. The decision essentially authorizes states to civilly commit a broad range of individuals without sufficient due process protections. This Comment explores the possibilities for expansion of civil commitment in the wake of Hendricks. It argues that the holding was unjustifiably broad, focusing in particular on the potential danger facing substance abusers. In conclusion, it offers several suggestions for mitigating the potential misuse of this dangerous precedent.     

Civil commitment and the criminal insanity plea in Israeli law

In Israeli jurisprudence there is a substantial difference towards mentally ill patients between the civil and penal law systems that goes well beyond differences required by their separate objectives. Mentally ill people dangerous to others due to their illness belong in the hospital, not in the community or in jail. The data gathered especially for this paper make it hard to escape the conclusion that contemporary practice in Israel does not accord with this objective. On the civil front, inaccuracy in predicting who is dangerous may lead to involuntary commitment of people who are not dangerous. On the criminal side, too few people are sent to the hospital in Israel and correspondingly too many to jail. Comparison with US data and practice shows that on the civil side prediction has been improved by using actuarial methods, while on the penal side more up to date definitions of mental illness have been adopted. Whatever the appropriate solution for Israel, surely the first requirement is recognition of the problem.     

Suicide and civil commitment

The contemporary approach to suicide prevention relies primarily on involuntary commitment of the suicidal individual. While there is generally widespread acceptance of the principle of society's right, even its moral obligation, to intervene to prevent a suicide, there is much less agreement concerning the conditions under which such an action should proceed. Most of the debate centers on the widely applied commitment criteria of mental illness and dangerousness to self and others. Questions have also been raised regarding the efficacy of commitment as a preventive measure. In this paper, these controversies are placed in a broader historical context. We examine empirical evidence concerning prevailing commitment criteria and the prophylactic value of involuntary hospitalization, and discuss the appropriateness of our current approach to civil commitment in light of existing data.     

Severe mental disorder as a basic commitment criterion for minors

Since 1991, commitment to involuntary psychiatric care has been allowed in Finland for minors in broader terms than for adults. While in adults mental illness has to be diagnosable before involuntary treatment can be imposed, minors can be committed to and detained in involuntary psychiatric treatment if they suffer from "severe mental disorders", and fulfil the further commitment criteria defined in the Mental Health Act. The first years of the new mental health legislation showed an increase in involuntary treatment of minors in Finland. Concerns were raised about the imprecise nature of the commitment criterion "severe mental illness". This study set out to find out whether Finnish child and adolescent psychiatrists are in agreement on how to define severe mental illness and whether their interpretations are sufficiently similar to ensure the equality of minors in commitment to psychiatric care as prescribed by the Mental Health Act. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative content analysis. There was general agreement about what constitutes a "severe mental disorder" justifying the involuntary psychiatric treatment of minors. The child and adolescent psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories. Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment.     

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. AIM: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. METHOD: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. RESULTS: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. DISCUSSION: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.     

From Helping Court to Community‐Based Services: The 30‐Year Evolution of Australia's Family Relationship Centres

As a centrepiece of Australia's 2006 family law reforms, the community‐based Family Relationship Centres (FRCs) represented a major development in the Government's commitment to incorporate family relationship services into its family law system. This paper sees FRCs as a logical development of the original conceptualising the Family Court of Australia as a “helping court”. The paper suggests that the aspiration to create a helping court was partially achieved in 1976 via the creation of an in‐house family court counselling service, which was primarily focused not on law and legal principles, but on supporting the ways in which family members were managing the task of redefining relationships. While generally valued by judges and others, this service nonetheless found itself in tension with the Family Court's continued primary commitment to legally informed and adversarially driven negotiation and decision‐making processes. Since 2006, the creation of FRCs has spearheaded a family law system that provides relationship‐focused interventions away from the courts as the default option for most parenting disputes. Consistent with this aim, there is evidence of a diminished percentage of cases now requiring judicial intervention. The 2006 legislation also provides for courts to conduct “less adversarial trials.” Paradoxically, this has occurred alongside unequivocal evidence from the Australian Institute of Family Studies’ evaluation data that judicial officers are dealing mainly with families displaying seriously dysfunctional attitudes and behaviours. The legal challenge in dealing with these cases is for courts to provide child focused, fair and non‐destructive internal processes. In addition, however, it is increasingly clear that to support and help facilitate their decisions, courts also need good working relationships with FRCs and other community based services. FRCs and the 2006 reforms offer the possibility of moving beyond the ideal of a “helping court” to the broader concept of helping family law system.     

The impact of public policy and publicity on admissions to state mental health hospitals

This paper examines the impact of broadened Washington state civil commitment standards on utilization of the state's mental hospitals. Included in the analysis is an assessment of the impact of a public event (a well-publicized murder case) which was in all likelihood a precursor to the law's revision. We also examine the different ways Washington's two state hospitals managed the dramatic increase in civilly committed patients that occurred after the revision took effect. The findings indicate that the murder case, in which the defendant had been denied voluntary admission to a state hospital prior to the killing, resulted in an increase in involuntary admissions in the county where it occurred a full year before the standards were revised. The law itself had the effect of increasing commitments throughout the state, reducing the levels of voluntary admissions, and increasing the likelihood of involuntary admission for individuals previously admitted voluntarily, thus transforming a principally voluntary system into one which was primarily involuntary. Finally, it was found that the increased demand for services mandated by the broadened commitment standards was managed differently in the two state hospitals: one imposed a cap on admissions; the other phased out voluntary admissions at a rate roughly equal to the increase in commitments. These findings illustrate both the substantive impact of broadened civil commitment law and the importance, when assessing the impact of laws, of examining public events and administrative interventions which may have significant causal links with legal interventions.     

PARENS PA TRIAE: Poltergeist of Mental Health Law

This article examines the uncanny resiliency of an ancient doctrine called parens patriae despite legislative and judicial attempts to restrict its use in involuntary commitment proceedings of the mentally ill. Attempts by the legislature and courts to reduce parens patriae rationales, which are heavily promoted by the medical profession, have emphasized police power rationales and have followed two general strategies. One strategy sets up a number of procedural steps that provide monitoring of individual rights at critical junctures during the commitment process. The second strategy attempts to establish multiple criteria that must be met before any commitment decision can by made. It is pointed out that legislatures, and to some extent the courts, have focused on the procedural strategy, while neglecting the more substantive issue of behavioral criteria. It is argued that the lack of attention to the second strategy, specifically in relation to clear definitions and rigorous criteria, have created the impetus for the medical-psychiatric profession to continue its dominance in involuntary commitment proceedings under the guise of parens patriae.     

The "untreatability" of psychopathy and hospital commitment in the USA

One argument in support of a public policy of not subjecting persons with psychopathic disorders to civil or criminal commitment is that these disorders do not improve with treatment. This article examines the relationship between the assumption of untreatability of psychopathic disorders and outpatient civil commitment, inpatient civil commitment, and insanity acquittee commitment. Research on the treatability of psychopathy is reviewed and the treatment of conditions co-morbid with psychopathy is considered. Research evidence is insufficient to support the conclusion that psychopathy is improved, worsened or not affected by treatment. Evidence does support effective treatments for conditions that can be co-morbid with psychopathic disorders including impulsive aggression which can be interpreted as a manifestation of psychopathic disorder.The absence of evidence based treatment efficacy for psychopathic disorders is a logical reason for not subjecting individuals with only a psychopathic disorder to involuntary hospitalization. This assumption should not becloud the possibility of treatable co-morbid conditions which may or may not qualify for involuntary hospitalization. Where the primary mental disorder, for which an individual is involuntarily hospitalized, results in behavioral improvement, the continued presence of a psychopathic disorder itself, should not be sufficient reason to continue coerced confinement. Even so, where the primary disorder is incompletely treated, psychopathy can be considered a risk factor when deciding upon the appropriate time for discharge and when formulating a safe and effective after care plan.     

The impact of a change in commitment procedures on the character of involuntary psychiatric patients

The statutory requirements for involuntary civil psychiatric confinement have become increasingly restrictive. In the jurisdiction under investigation, patients were originally admitted under an Order to Apprehend (OTA) procedure simply on the petition of two affiants who indicated the patient was in need of care. A newly elected judge instituted changes requiring affiants to claim the subject was "dangerous" to self or others and asking for a clinical assessment and recommendation before signing the petitioned request for involuntary confinement. It might be expected that the more restrictive procedures would have produced a population of more assaultive patients. A study of petitions signed under in the earlier (N = 133) and later, more restrictive (N = 218) procedures indicated that the proportion of assaultive or dangerous patients was virtually identical. Further investigation, using hospital data an OTA patients from this area in both time periods, suggested that while patients were not more assaultive, they appeared to be more seriously ill or psychiatrically impaired. Apparently, movement to a dangerousness standard that allows clinical discretion in interpreting its presence may result in involuntary commitments for more seriously ill, although not necessarily more assaultive, patients.     

Interpreters of the Koran: The Legacy of a Theologian Is Held to Be Extremism

A court proceeding that gave rise to an ambiguous reaction in society came to a close yesterday. The Koptev district court in the capital held fourteen books of the collected works Rusale-i-Noor, of Turkish theologian Baduzzaman Said Nursi to be extremist literature. His work was considered by the court to be dangerous for society upon the basis of a petition of the procurator of Tatarstan. And the proceeding itself took place in a closed manner and was delayed several times due to the appointment of another expert review, for which time was naturally required.     

Chapter 2: The Legal Position and Organizational Forms of Forensic Psychiatric Expert Examination

The practical task of forensic psychiatry, which is one of the subdivisions of psychiatry, is to give an expert evaluation, on assignment from investigatory agencies and courts, and to devise and recommend measures for the prevention of socially dangerous acts by the mentally ill. Forensic psychiatric expert examination, like forensic medical, criminal, or any other type of expert examination, aids agencies of justice in establishing the facts in a case. Forensic psychiatric expert examination is called upon to assist the investigator and the court in determining whether an individual is a criminal or a legally irresponsible, mentally ill person; whether a person sentenced to a prison term should, because of mental illness, be released before his time is served; whether the investigator and the court may pursue the interrogation of a witness or victim with mental disorders, and whether the testimony of such persons may be used as court evidence. Such an expert examination is necessary in a civil suit in deciding the question of an individual's competence.