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Involuntary Commitment: When and How to Do It

Involuntary Commitment: When and How to Do It

The most recent wave of mass shootings in America has renewed the debate over what kind of people commit such acts and what can be done to stop them. Unfortunately, the latest discussion has unfairly targeted mental illness as the root cause, reviving an inaccurate stigma that mental health advocates have been speaking up against for decades.

Most mass shooters do not meet any clinical or legal definition of mental illness. Instead, most are driven to violence by personal vendettas or ideologies that sanction violence. In fact, less than 5 percent of violent acts are committed by people with serious mental illness (SMI). People with SMI are not only more likely to be victims of violent crime than they are to be perpetrators, they are also ten times more likely to be victims of violence than people in the general population. One study even found that among crimes committed by people with SMI, less than 8 percent were directly related to the symptoms of their mental health conditions.

This does not mean that people with SMI are never violent or dangerous. Sometimes, a person's condition can deteriorate to the point that they are at risk of harming themselves or others. For example, a person with a psychotic disorder might stop taking medications, develop violent delusions, and start hearing voices telling them to hurt themselves or others. A person with a mood disorder might become so hopeless that they decide to act on a plan to hurt themselves or others. In such cases, what can be done?

Fortunately, there is something you can do if you fear someone is at risk of hurting themselves or someone else because of a mental health condition. All fifty states and the District of Columbia have laws in place that allow police, and in many cases, private citizens, to initiate a process of civil commitment so that these individuals can be placed in a treatment facility, held, and treated until they are no longer dangerous. This article provides an overview of how this process works.

Who Can Be Committed?

The Treatment Advocacy Center writes, "Prior to the 1960s, obtaining involuntary treatment was straightforward. Typically, state laws hinged on a simple determination that the person required care and allowed commitments to be continued indefinitely without ongoing judicial oversight."

This means the only requirement for someone to be institutionalized against their will before the 1960s was for them to be mentally ill. Following the deinstitutionalization movement and several legal cases in the 1960s and 1970s, the standard was changed. Now, state laws require that people receive treatment in the least restrictive setting possible and that they should only be involuntarily hospitalized under very specific conditions.

What are those conditions? While laws vary from state to state, all state laws include two basic criteria for commitment. The first is that a person must have or be suspected of having a mental illness. This means a person who is acting erratically or threatening others can't be committed if their behavior is known or believed to be caused by something other than mental illness. People who pose a threat for reasons other than mental illness must instead be arrested and placed in police custody if there are grounds for arrest. (In most states, people can be arrested for making violent threats even before those threats have escalated to assault.)

The second general condition is that a person must be at risk of harming themselves or others. States vary on how they define this risk. In some states, people can only be committed if they pose an overt and immediate risk of violence to themselves or others. However, most states also allow people to be involuntarily hospitalized if they are at risk of harming themselves or others inadvertently due to "grave disability." For example, in most states, people can be committed if they are at risk because they are unable to care for their basic needs or are at risk of deteriorating to the point of becoming dangerous if they are not treated right away.

How Does the Civil Commitment Process Work?

How the civil commitment process works also varies from state to state. However, the process generally follows the same basic steps:

  • A private citizen, mental health professional, or police officer initiates an emergency psychiatric hold so a person can be evaluated for involuntary hospitalization.
  • A police officer takes a person into custody on an emergency hold and brings them to a secure facility, usually a hospital emergency room, where they can be evaluated.
  • A judge or magistrate issues a court order authorizing the person to be detained for a limited period of time while a mental health evaluation is completed.
  • A qualified mental health professional (QMHP) performs an evaluation to determine whether the person meets civil commitment criteria. The QMHP typically interviews the person and other relevant parties and reviews available reports and records.
  • The QMHP completes a pre-screening report and submits it to a judge or magistrate.
  • If the report recommends commitment, and the judge or magistrate agrees, the court issues an order for a person to involuntarily hospitalized pending a formal commitment hearing.
  • The state seeks placement in an accepting facility. This process can take hours, days, or even weeks. How long a person can be held at the emergency room where they were evaluated while waiting for a bed to become available varies from state to state.
  • A facility accepts the person on an involuntary commitment order and the person is transported to the accepting facility.
  • Within a set period of time that varies from state to state, the person who has been hospitalized involuntarily must have a formal commitment hearing. This often takes place at the facility where they are being treated rather than in a courtroom.
  • If a judge or special justice upholds the commitment at the hearing, the person is then committed to inpatient care for a set period of time, often up to 30 days.
  • Hospital staff can release the person prior to the end of the commitment period if they are psychiatrically stable before that point. They can request a recommitment hearing if the person has not stabilized within the commitment period.

Some of the elements of the commitment process that vary from state to state include:

  • Who can initiate a temporary hold or involuntary detention
  • Whether a judge must approve the temporary detention or hold
  • How long a person can be held pending pre-screening or evaluation
  • The rights of the person being held under an emergency commitment
  • The timing and location of the formal commitment hearing and who can attend
  • How long a commitment order signed by the judge stands before another hearing is necessary to keep a person in the hospital

One of the most important variables to know is who can initiate the process and how. In 21 states, "any interested person" can initiate the civil commitment process. In 24 states, a relative can seek an emergency psychiatric hold. Several other states allow a mental health professional to request emergency detention. Some states reserve this right for psychologists or psychiatrists, while others authorize any qualified mental health professional to petition for a temporary hold.

Most states that allow private citizens to request an emergency psychiatric hold simply require the individual requesting the hold to file a written petition with the court. According to an article by Hedman et al, some states require the individual requesting a hold to "show probable cause before a judge or magistrate that emergency commitment criteria have been met." If you're not sure what your state requires, you can look up state-specific information on the Treatment Advocacy Center's website.

If you're still not sure, the easiest and most universal way to initiate the civil commitment process is to call 911 or otherwise get a police officer to come to the scene and initiate a hold. In all states, police can detain anyone who poses an imminent threat, and 38 states "explicitly authorize police and peace or parole officers to initiate the emergency hold process," according to Hedman et al. Explain to the 911 dispatcher that you are concerned that a person is mentally ill and at risk of harm to self or others and that you would like to have an officer take them in to be evaluated for commitment. Do note that the officer may not follow your recommended course of action.

What Are the Potential Outcomes of the Commitment Process?

No one who initiates the civil commitment process can guarantee that the process will end in commitment. In states that require a court order to proceed, a judge can reject a petition for a hold. If you call 911 to request an officer-initiated hold, the officer who responds may not agree that a hold is appropriate and may arrest the person instead. Alternately, the officer may not agree that there is a legitimate concern and may not take the person into custody at all.

If a hold is approved, the mental health professional who conducts the evaluation may determine that an individual does not meet commitment criteria. Even when an evaluator does recommend commitment, a judge may disagree and refuse to order it, in which case the person will be released. An officer may choose to arrest the person after finding out they do not meet commitment criteria, but in many cases, the person will simply be able to go home. If evaluation by emergency room doctors reveals that the cause of the concerning behavior was medical, the person may be admitted to the hospital for inpatient medical treatment instead.

Sometimes, the evaluator will recommend an alternative course of action, such as having the person agree to follow a safety plan or set up an appointment with a therapist. However, the only thing other than inpatient commitment that can be enforced by the court is mandatory or involuntary outpatient treatment in states whose laws permit it. When commitment is ordered, it is still possible that the person will not be held or treated in the accepting facility for very long. The accepting facility may release a person if they become stable after a few days of treatment.

The commitment process temporarily suspends a person's rights and should not be taken lightly. If it's safe to talk to the person you're concerned about, take the time. You may find that they need help but not the kind you thought. If you find a person is not at immediate risk of harm, and does not have symptoms severe enough to merit inpatient treatment, consider using the search tools on OpenCounseling or BetterHelp (a sponsor) to find affordable local or online therapy and helping them set up an appointment. If you do find that they need immediate help and aren't able or willing to get it, reach out. Commitment can save lives when used wisely and well.

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Stephanie Hairston, MSW
Posted on 08/19/2019 by Stephanie Hairston, MSW

Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a masters-level clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments. She has also worked as a technical writer for a medical software company and as an editor for a company that appeals denials of insurance coverage for behavioral health treatment. As a writer, she is motivated by the same desire to help others that brought her into the field of social work and believes that knowledge is one of the most essential recovery tools. She strongly believes in the mission of OpenCounseling and in making therapy accessible for everyone.