Involuntary commitment by country

The usual requirement is that a police officer or a physician determine that a person requires a psychiatric examination, usually through a psychiatric hospital. If the person is detained in the hospital, they usually must be seen by an authorized psychiatrist within a set period of time. In some states, after a further set period or at the request of the person or their representative, a tribunal hearing is held to determine whether the person should continue to be detained. In states where tribunals are not instituted, there is another form of appeal.

Some Australian states require that the person is a danger to the society or themselves; other states only require that the person be suffering from a mental illness that requires treatment. The Victorian Mental Health Act (1986) specifies in part that:

"(1) A person may be admitted to and detained in an approved mental health service as an involuntary patient in accordance with the procedures specified in this Act only if—

(a) the person appears to be mentally ill; and

(b) the person's mental illness requires immediate treatment and that treatment can be obtained by admission to and detention in an approved mental health service; and

(c) because of the person's mental illness, the person should be admitted and detained for treatment as an involuntary patient for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and

(d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and

(e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of that person's freedom of decision and action.

There are additional qualifications and restrictions but the effect of these provisions is that people who are assessed by doctors as being in need of treatment may be admitted involuntarily without the need of demonstrating a risk of danger. This overcomes the pressure described above to exaggerate issues of violence, or to verbal statements, to obtain an admission.[2]

In general, once the person is under involuntary commitment, treatment may be instituted without further requirements. Some treatments, such as electroconvulsive therapy (ECT), often require further procedures to comply with the law before they may be administered involuntarily.

Community treatment orders can be used in the first instance or after a period of admission to hospital as a voluntary/involuntary patient. With the trend towards deinstitutionalization, this situation is becoming increasingly frequent, and hospital admission is restricted to people with severe mental illnesses.

Since the latter half of the 1990s, considerable controversy has grown in Dutch society, about the TBS system. This controversy has two main areas. The first level of controversy resulted from the media increasingly reporting cases of convicts committing crimes while still in, or after, treatment in a TBS clinic.

Some examples of these cases are:

• During 1992, a truck driver was convicted of raping and murdering three young children. Eight years earlier he was released from a TBS clinic after being treated for child molestation.
• A convict, about to be released from a TBS clinic, murdered the owner of a garage in 1996 while under the influence of drugs.
• An ex-convict, treated in a TBS clinic, murdered two women in 1994 and 1997.
• A convict, still being treated by a TBS-clinic, randomly killed a man in the city of Groningen in 1999.
• Between 2000 and 2004, an ex-convict tortured several animals and killed a homeless man. He had been treated in a TBS clinic.
• In 2002 an ex-convict was sentenced for triple murder. He also had been released earlier by TBS.
• In 2005 a convict escaped his escort during leave. He was arrested several days later after killing a man.

Political and social attention increased, and debate started about the effectiveness of the TBS system and whether convicts should be granted leave from TBS clinics. Especially right-wing politicians suggested the TBS system be discarded altogether. Numerous articles in newspapers, magazines, television and radio programs and a revealing book written by an ex-convict (which for the first time openly questioned the effectiveness of the TBS-system) boosted discussion. Prior to that, any problems had been mostly denied by officials of the TBS-clinics themselves.

The center of attention became a highly renowned TBS clinic, Dr. S. Van Mesdagkliniek in the city of Groningen. Events that took place there, by the end of the 1990s and the first years of the 21st century, provoked the second reason for controversy. Concern rose about claims of unprofessional behavior by staff working in TBS clinics, and the Dr. S. Van Mesdagkliniek developed a poor reputation over these problems. This TBS clinic has been plagued with unprofessional and even criminal acts by its staff since 1999.

During that year, the clinic came under investigation by Dutch police after rumors about female staffmembers committing sexual offenses against convicts emerged.[4] Five such cases were discovered during the investigation, and also numerous cases of drug-abuse, smuggling and trading of contraband such as alcohol, mobile phones, pornographic material, and hard drugs.[3] It became apparent that staff members did not have the required education, had not been informed about rules and regulations, disregarded legal procedures, gave false testimonies, tampered with evidence, uttered false accusations against convicts, and intimidated colleagues.[4] At least one psychiatrist, employed as such by the clinic, proved to be not qualified,[5] and treatment of convicts was in many cases simply non-existent.[6]

These problems had been known for long by the management but were kept hidden. After public outcry about this situation, management was replaced[7] and all of the nine (at the time) TBS clinics in the Netherlands were subjected to investigation. Six of them proved to be below the required legal standards.[8] However, problems did not end there. In spite of many measures taken by the government, convicts still were released without proper treatment. As a consequence, numerous crimes were committed by convicts that were regarded as treated by TBS clinics. Also, sexual offenses against convicts by staff members and smuggling of contraband did not cease in several TBS clinics.[9] In 2006, the Dutch government formed a committee to investigate the TBS system. Some problems, however not the worst, were recognized and countermeasures were implemented. One of the known actual results is that fewer convicts escape during temporary release.

Controversy regarding the, often praised, Dutch TBS system continued. In 2005, a staff member working in the Dr. S. Van Mesdagkliniek was caught smuggling liquor to convicts suffering from alcohol-related problems.[10] In 2007, a female staff member committed sexual offenses against a convict, and had smuggled contraband.[11] She was sentenced to three months in prison in 2009. That same year, investigation proved convicts still had ample access to illicit drugs[12] and four inmates from the Dr. S. Van Mesdagkliniek were arrested for possession of child pornography.[13] Many crimes committed by released convicts treated in TBS clinics escape statistics because the crimes were committed in other countries, or because they differ from the crime the convict was originally convicted for (many convicts released from TBS clinics find their way in illegal drug trade and related crimes). Because there seems to be no acceptable alternative available, political support for the much troubled TBS system remains, in spite of the controversy.

In Arizona, the government can mandate inpatient treatment for anyone determined to be "persistently or acutely disabled." Virtually anyone who suspects that someone has mental problems and needs help could file an application to a state-licensed healthcare agency for a court-ordered evaluation.

In Connecticut, someone can be committed only if he or she has "psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled". "Gravely disabled" has usually been interpreted to mean that the person is unable on their own to obtain adequate food, shelter and clothing.

In Iowa, any "interested person" may begin commitment proceedings by submitting a written statement to the court. If the court finds that the respondent is "seriously mentally impaired," he or she will be placed in a psychiatric hospital for further evaluation and possibly treatment. Further hearings are required at specific intervals for as long as the person is being involuntarily held.

The Michigan Mental Health Code provides that a person "whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others" may be subjected to involuntary commitment, a provision paralleled in the laws of many other jurisdictions. The Michigan Mental Health Code allows for one to petition a court to order assisted outpatient treatment for patients with such impaired judgment, which compels them to comply with treatment to avoid relapses. One can petition for assisted outpatient treatment along with, or instead of, hospitalization.

In Nevada, prior to confining someone, the state must demonstrate that the person "is mentally ill and, because of that illness, is likely to harm himself or others if allowed his liberty."

In Oregon, the standard that the allegedly mentally ill person "Peter [h]as been committed and hospitalized twice in the last three years, is showing symptoms or behavior similar to those that preceded and led to a prior hospitalization and, unless treated, will continue, to a reasonable medical probability, to deteriorate to become a danger to self or others or unable to provide for basic needs" may be substituted for the danger to self or others standard.

In Texas, the standard is that, in the judgment of the person seeking involuntary commitment, 1) the person is mentally ill, and 2) because of that mental illness "there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained".[27]

The Utah standard is that the proposed patient has a mental illness that poses a substantial danger.[28] "Substantial danger" means the person, by his or her behavior, due to mental illness: (a) is at serious risk to: (i) commit suicide, (ii) inflict serious bodily injury on himself or herself; or (iii) because of his or her actions or inaction, suffer serious bodily injury because he or she is incapable of providing the basic necessities of life, such as food, clothing, and shelter; (b) is at serious risk to cause or attempt to cause serious bodily injury; or (c) has inflicted or attempted to inflict serious bodily injury on another.[29]

In Wisconsin, the District II Wisconsin Court of Appeals ruled in 2011 that patients with Alzheimer's disease cannot be involuntary committed under Chapter 51 and can only be involuntarily committed for residential care and custody under Chapter 55. The court left open whether this applies also to persons with a dual diagnosis.[30]

The impact of involuntary commitment on the right of self-determination has been a cause of concern.[31] Critics of involuntary commitment have advocated that "the due process protections... provided to criminal defendants" be extended to them.[32] The Libertarian Party opposes the practice in its platform. Thomas Szasz and the anti-psychiatry movement have also been prominent in challenging involuntary commitment. The American Association for the Abolition of Involuntary Mental Hospitalization (AAAIMH) was an organization founded in 1970 by Thomas Szasz, George Alexander, and Erving Goffman for the purpose of abolishing involuntary psychiatric intervention, particularly involuntary commitment, against individuals.[33] The founding of the AAAIMH was announced by Szasz in 1971 in the American Journal of Public Health[34] and American Journal of Psychiatry.[35] The association provided legal help to psychiatric patients and published a journal, The Abolitionist.[36] The organization was dissolved in 1980.[36][37]

A small number of individuals in the U.S. have opposed involuntary commitment in those cases in which the diagnosis forming the justification for the involuntary commitment rests, or the individuals say it rests, on the speech or writings of the person committed, saying that to deprive the person of liberty based in whole or part on such speech and writings violates the First Amendment. Other individuals have opposed involuntary commitment on the basis that they claim (despite the amendment generally being held to apply only to criminal cases) it violates the Fifth Amendment in a number of ways, particularly its privilege against self-incrimination, as the psychiatrically examined individual may not be free to remain silent, and such silence may actually be used as "proof" of his "mental illness".[38]

Although patients involuntarily committed theoretically have a legal right to refuse treatment, refusal to take medications or participate in other treatments is noted by hospital staff. Court reviews usually are heavily weighted toward the hospital staff, with the patient input during such hearings minimal. In Kansas v. Hendricks, the U.S. Supreme Court found that civil commitment is constitutional regardless of whether any treatment is provided.[39]

Accompanying deinstitutionalization was the development of laws expanding the power of courts to order people to take psychiatric medication on an outpatient basis. Though the practice had occasionally occurred earlier, outpatient commitment was used for many people who would otherwise have been involuntarily committed. The court orders often specified that a person who violated the court order and refused to take the medication would be subject to involuntary commitment.

Involuntary commitment is distinguished from conservatorship and guardianship. The intent of conservatorship or guardianship is to protect those not mentally able to handle their affairs from the effects of their bad decisions, particularly with respect to financial dealings.[40] For example, a conservatorship might be used to take control of the finances of a person with dementia, so that the person's assets and income are used to meet their basic needs, e.g., by paying rent and utility bills.

Advance psychiatric directives may have a bearing on involuntary commitment.[41][42]

The service member can be held under the so-called Boxer law (DoD Directive 6490.04).[43]

In the District of Columbia, any police officer, physician, or mental health professional can request to have an individual evaluated at St. Elizabeths Hospital, where they may be detained for up to 48 hours at the direction of the physician on duty. A family member or concerned citizen can also petition the Department of Mental Health, but the claim will be evaluated prior to the police acting upon it. To be held further requires that a request be filed with the Department of Mental Health. However, this only can keep the patient involuntary admitted for up to seven days. For further commitment, the patient is evaluated by a mental health court, part of family court, for which the public defender assists the patient. This can result in the patient being held up to one year at which point the patient returns to mental health court.

This is different for someone first admitted to St. Elizabeths Hospital due to criminal charges. If found to not ever become competent for trial, they will be evaluated via a Jackson hearing for possible continued commitment to protect the public. If they have been found not guilty by reason of insanity, their dangerousness is evaluated at a Bolton Hearing.[44]

In Maryland, any person may request, via an Emergency Evaluation form, that another individual be evaluated against their will by an emergency room physician for involuntary admission. If the judge concurs, he will direct the police to escort the individual to the hospital. A licensed physician, psychologist, social worker, or nurse practitioner who has examined the patient or a police officer may bring a potential patient to the emergency room for forced evaluation without approval from a judge. The patient may be kept in the hospital for up to thirty hours. If by then two physicians, or one physician and one psychologist then decide that the patient meets the Maryland criteria for an involuntary psychiatric admission, then he or she may be kept inpatient involuntarily for up to ten days. During this time, an administrative law judge determines if the following criteria for longer civil commitment are met:

• a person has a mental illness;
• a person needs inpatient care or treatment;
• a person presents a danger to themselves or to others;
• a person is unable or unwilling to be admitted voluntarily;
• there is no available, less restrictive form of care or treatment to meet the person's needs.

In Texas a person may be subject to involuntary commitment by:

• A peace officer, without a warrant, if A) the officer believes that 1) the person is mentally ill, 2) because of that mental illness "there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained", and B) the officer also believes that there is insufficient time to obtain a warrant.[45]
• A guardian of the person of a ward under the age of 18, if the guardian believes that 1) the ward is mentally ill, 2) because of that mental illness "there is a substantial risk of serious harm to the ward or to others unless the ward is immediately restrained".[46]
• An adult may file an application for emergency detention of another person; the application must meet seven outlined items which indicate that, in the applicant's belief, that the person to be detained is mentally ill and poses a threat to the person or to others, why the person considers this to be the case, and the relationship of the applicant to the person.[47]

A person cannot be held for more than 48 hours, and must be released by 4 PM on the day the 48-hour period ends, unless:

• a written order for protective custody is obtained,
• the 48-hour period ends on a Saturday, Sunday, or legal holiday, or before 4 PM on the first succeeding business day (in which case the person may only be held until 4 PM on the first succeeding business day), or
• if extremely hazardous weather events exist or a disaster occurs (in which case, the period may be extended in 24-hour increments by written order specifically stating the weather event or disaster).[48]

Upon release, unless the person was arrested or objects, the person (at the expense of the county where s/he was apprehended) must be transported to either 1) the place where s/he was apprehended, 2) the person's residence in the state, or 3) another suitable location.[49]

As of 2008, Virginia was one of only five states requiring imminent danger to involuntarily commit someone. But after the Virginia Tech Massacre, there was significant political consensus to strengthen the protections for society and allow more leniency in determining that an individual needed to be committed against their will.

• the person has a mental illness and there is a substantial likelihood that, as a result of mental illness, the person will, in the near future, (1) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any
• the person has a mental illness and there is a substantial likelihood that, as a result of mental illness, the person will, in the near future, (2) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs

"Imminent danger" was found to have too much variability throughout Virginia due to vagueness. The new standard is more specific in that substantial likelihood is more clear. However, to not limit potential detainee's freedoms too much it is characterized by the time limit of near future. "Recent acts" is legally established to require more than a mere recitation of past events.