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Shift to Dangerousness Criteria as the Standard for Civil Commitment

[Following is an excerpt from "Civil Commitment in the United States", by Megan Testa, MD and Sara G. West, MD]

Along with the civil rights movement and deinstitutionalization came a shift in the legal standard for civil commitment away from a need-for-treatment model to a dangerousness model. In 1964, Washington, DC, instituted a standard for civil commitment that established that a person must be determined to have a mental illness before he or she could be hospitalized against his or her will. Second, the person had to pose an imminent threat to the safety of him- or herself or others or be shown to be “gravely disabled,” meaning that he or she could not provide for the necessities for basic survival. The district did not define the terms of the statute concretely, leaving some room for interpretation. However, it is commonly interpreted that dangerousness refers to physical harm to self (suicide) or physical harm to others (homicide), and that the requirement for imminence means that the threat must be likely to occur in the close future. California adopted a similar statute five years later. One by one, other states followed suit until the prevailing standard for civil commitment in the United States required the presence of dangerousness as a result of mental disease.,,, Currently, there are only a few states that do not follow the trend. Delaware requires only proof that a person is not able to make “responsible choices” about hospitalization or treatment for that person to be committed. Iowa's statute mandates only proof that a person is likely to cause “severe emotional injury” to people who are unable to avoid contact with him (e.g., family members).

Each state's civil commitment criteria also still reflect standards set forth in an important Supreme Court case—O'Connor v. Donaldson—in 1975. This case involved a man named Kenneth Donaldson who was diagnosed with paranoid schizophrenia and was held in a psychiatric hospital against his will for 15 years. When his release was repeatedly denied by the psychiatrist in charge of his care, despite the fact that he had not shown any evidence of suicidality or intentions to harm others, Mr. Donaldson argued to the court for restoration of his freedom. The case was eventually heard by the Supreme Court, who determined that Mr. Donaldson should be released. The Supreme Court laid out acceptable criteria for holding patients against their will. Justices stated that a mentally ill individual must either present a known risk of harm to him- or herself or others, be in such a state that he or she would be “hopeless to avoid the hazards of freedom,” or in need of psychiatric treatment. The court seemed to embrace the dangerousness model for civil commitment; however, they did also find that individuals with mental disorders could not be kept in institutions “without more.”,, The word “more” is generally believed to refer to treatment.

In addition to the redefinition of criteria for involuntary hospitalization, there was also a shift in procedural standards for civil commitment that granted potential psychiatric inpatients greater procedural safeguards.,, States continued to allow patients to be admitted directly to hospitals against their wishes; however, they determined that this could only be done for a short, pre-determined period of time that varied by state from two days to approximately two weeks. After that time, patients were entitled to a hearing before the court to determine whether their involuntary commitment should continue. Patients were also guaranteed that they would have legal representation at their commitment hearings.

Another aspect of civil commitment proceedings that was defined at this time was the issue of burden of proof, or the degree to which the evidence presented convinces the trier of fact that his decision is correct. There are three standards of proof that can apply when decisions are made in court. The highest standard of proof is “beyond a reasonable doubt.” This standard requires that the trier of fact be convinced of his decision without any reservations that would be expected of a reasonable person. It applies in criminal cases. The lowest standard of proof is by a “preponderance of the evidence,” and it requires only that the trier of fact be certain that her decision is more likely to be correct than incorrect. It applies in civil suits. The third standard of proof allows decisions to be made based on “clear and convincing evidence,” which is defined as being greater than a preponderance of evidence, but less than beyond a reasonable doubt. An important Supreme Court case in 1978, Addington v. Texas, considered the following question: “Which standard of proof does the person requesting involuntary hospitalization of a psychiatric patient have to meet to satisfy the court that the patient meets criteria for commitment?”,,,

Frank Addington was a man with a long history of psychotic illness who had been hospitalized numerous times in the past. His mother filed a case requesting that he be committed indefinitely because he assaulted her in the past. Her request was granted and Mr. Addington appealed this decision because the court committed him based on a standard of clear and convincing evidence, the mid-level standard of proof. He argued that the evidence against him should have been required to reach the highest standard of proof, beyond a reasonable doubt., The Supreme Court disagreed with Mr. Addington and supported the ruling of the lower court. The justices opined that because psychiatry was a field dealing with the inexact science of predicting future risk, the standard of beyond a reasonable doubt was so burdensome that it would serve as a barrier to the hospitalization of many patients who were in clear need of care.

In 1966, another important legal case occurred that underscored dangerousness as the key criteria for involuntary hospitalization of psychiatric patients by establishing a right to less confining treatment for nondangerous patients. This was the case of Lake v. Cameron, which was presented before a Washington, DC, appeals court in 1966. Catherine Lake was a woman with mental illness who had been hospitalized against her will and kept involuntarily at St. Elizabeth's psychiatric hospital for many years, despite not showing any evidence of dangerousness to herself or anyone else. She desired freedom and petitioned the district for her release.,, The court determined that all patients who were not dangerous “should not be confined if a less restrictive alternative is available.” To this day, because of this ruling, psychiatrists who complete emergency evaluations are required by law to recommend the least restrictive level of treatment that will meet the needs of nondangerous psychiatric patients.