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Encouraging signs for commitment laws.

Encouraging Signs for Commitment Laws

In the past 20 years, legislators have altered most state laws governing the involuntary commitment of people diagnosed as mentally ill, stressing "dangerousness" rather than a "need for treatment." Many psychiatrists say these laws encourage the hospitalization of people who are dangerous but not mentally ill, while the truly ill, in one critic's words, "die with their rights on." But three studies of commitment decisions in public psychiatric emergency rooms in California, reported in the August ARCHIVES OF GENERAL PSYCHIATRY, suggest the commitment process is working better than critics have assumed.

Steven P. Segal of the University of California, Berkeley, and his colleagues came up with three findings in their three studies. First, they report, emergency room clinicians -- who initially decide who should be referred for commitment--apply a consistent set of rules to determine someone's "dangerousness." Second, patients deemed most dangerous are also seen as the most severely mentally ill. Finally, patients who are actually committed are more dangerous, more mentally ill and more impulsive than those who are released.

The studies provide important reassurance that violent people with no mental disorders are not being dumped in mental hospitals, says psychiatrist and lawyer Mark J. Mills of the University of California, Los Angeles. "The issue of who should be committed, and by what standards, continues unresolved," writes Mills in an accompanying editorial.

Most state commitment laws specify that patients may be involuntarily admitted to a hospital only on grounds of danger to self, danger to others or grave disability. The latter term refers to the inability, due to mental disorder, to provide for basic personal needs of food, clothing or shelter.

Segal and his co-workers measured these concepts with three specially designed checklists filled out by 70 clinicians (including psychiatrists, nurses and social workers) for 251 emergency room cases. An independent social worker also completed the checklist for each case. The five psychiatric facilities in the studies are located in both rural and urban settings.

Clinicians and independent observers showed substantial agreement on the types of behavior indicating dangerousness, say the researchers. Mills notes, however, that it is not known if people dubbed "dangerous" in an emergency room are the most likely to engage in violence in the community.

The psychiatric symptom most closely tied to ratings of severe dangerousness was impulsivity, marked by the pursuit of immediate gratification and an inability to choose and work toward long-term goals. Among the 71 patients with no previous hospitalizations, impulsivity was more influential than dangerousness in clinicians' decisions for commitment, explain the investigators. Overall, they conclude, those patients selected for involuntary commitment are both the most dangerous and the most severely mentally ill.

"These findings should serve as a calming influence for those who think involuntary commitment is being misused," says psychiatrist Robert Miller of the University of Wisconsin in Madison. But these are tremendous differences from state to state, and even from court to court, in how virtually identical commitment laws are implemented, adds Miller. In addition, social influences, such as widely publicized murders, have sparked sudden jumps in involuntary admissions under the same commitment statutes.

Miller supports a "model commitment law" endorsed by the American Psychiatric Association. This alternative approach focuses on the presence of a severe, treatable mental disorder and a patient's incompetence to make treatment decisions as key criteria for involuntary commitment. There is evidence, he says, that fewer patients would qualify for commitment under these standards than under "dangerousness" standards.
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Title Annotation:involuntary commitment of those diagnosed mentally ill
Author:Bower, Bruce
Publication:Science News
Date:Aug 27, 1988
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