Written by: Abbey Riendeau, LMHC
Civil commitment is the legal process by which individuals with serious mental illnesses are hospitalized or mandated to receive treatment without their consent. It may also be viewed as the intersection of incarceration and therapy. To some, this may sound harsh and abusable. To others, like individuals who have been in the position of having to involuntarily hospitalize a loved one, it may seem reasonable in certain cases. This blog post will briefly review the history of civil commitment. The remainder of this post will then focus on civil commitment for sexual offending and will discuss requirements specific to the state of Massachusetts.
Unfortunately, many individuals in the United States suffer from severe mental illness, which can impact a person’s functioning to a degree that intervention and treatment is critical for the safety of the affected person and others. Often the same disorders that impair a person’s functioning also impair their insight and judgment into the severity of their illness and the care they need. Because of this impaired judgment, affected individuals may refuse necessary hospitalization and treatment. For this reason, involuntary hospitalization, or civil commitment, has been a piece of psychiatric care since the beginning of the field.
When considering involuntary hospitalization or civil commitment, the medical professionals have the challenge of weighing their duty to do no harm, respecting patient autonomy, while also providing the patient with services to benefit them. When an individual is suffering from severe mental illness that distorts their perception of reality, it often becomes clear that the individual does not have the capacity to make decisions in their best interest. This is often when a doctor, psychiatrist, or other professional will step in to make medical decisions for the patient.
State governments have created laws to define the standards to involuntary treatment based on two major legal principles: Parens patriae, which is a Latin term meaning “parent of the country,” and assigns responsibility to the government to intervene on behalf of citizens who cannot act in their own best interest. The second principle, police power, requires a state to protect the interests of all citizens within the state’s boundaries. Due to the obligation to all citizens, the state can create statues that benefit society as a whole, even at the expense of restricting liberties of individual citizens.
History
Between 1817 and 1824, four privately funded asylums were established in the states of Connecticut, New York, Massachusetts, and Pennsylvania. In the following years, more asylums were opened in the southern United States. Asylums became the long-term homes for persons suffering from chronic conditions. Care for these individuals consisted of restraint, sedation, and experimental treatment. During the 1800s, requirements for involuntary hospitalization were minimal, making it possible for families to purchase the confinement of unwanted relatives. The legal standard only required the presence of a mental illness and a recommendation for treatment to prove that admission to a psychiatric hospital was necessary. Beginning in the 1900s, states began to change their civil commitment laws to put protections in place for the rights of the person being considered for involuntary hospitalization. These rights included the right to a trial with an attorney representation prior to admission. This took the decision-making power from medical professionals and gave it to judges, which had its own set of benefits and challenges. For instance, individuals often served short terms of imprisonment while awaiting the completion of legal procedures. Despite these legal procedures, populations in the asylums grew to more than 500,000 during the 1950s.
Then, in 1950, antipsychotic medications became available and institutionalization’s necessity was challenged. These medications helped make possible the idea that previously longlife hospitalization patients could receive community-based outpatient treatment. By the 1960s, the effectiveness of state hospitals and asylums were heavily criticized. Medicare and Medicaid were created in 1960 and U.S. citizens took on a shared responsibility to pay for the care of people struggling with mental illness. The cost of institutionalization versus the effectiveness paired with the civil rights movement led to the push for abandoning mental institutions. In 1963, President John F. Kennedy signed the Community Mental Health Centers Act which called for the transition of patients from inpatient psychiatric hospitals into the community. The populations within remaining state hospitals decreased dramatically to 30,000 by the 1990s.
In addition to the civil rights movement and deinstitutionalization came a change in the legal standard for civil commitment. In 1964, the dangerousness model was instituted in Washington, D.C., which established that a person must be determined to have a mental illness and must pose an imminent threat to the safety of themself or of others before being involuntarily hospitalized. Shortly after, other individual states began establishing similar statutes, until the prevailing standard required the presence of dangerousness as a result of mental abnormality or illness. At present, only a handful of states do not follow this standard.
Despite states governing their individual civil commitment standards, each state’s criteria must reflect standards set forth in Supreme Court decisions. The 1975 case of O’Connor v. Donaldson established the acceptable criteria for holding patients against their will. This criteria establishes that a mentally ill individual must either present a known risk of harm to themselves or others, be in such a state that they would be “hopeless to avoid the hazards of freedom,” or be in need of psychiatric treatment. As with most changes in legal procedures, this shift to a dangerousness model brought about intended benefits and unintended consequences. The requirement of dangerousness compromised access to psychiatric care for non-dangerous individuals who need but are refusing care. Standards based on dangerousness make it so the medical system cannot intervene until the person becomes suicidal, violent, or is unable to perform activities of daily living. This sometimes makes it so families have to watch loved ones decompensate greatly before they can be forced to receive care.
Another shift in the standards for commitment occurred. Patients continued to be admitted to facilities against their will in various states, but it was determined that this could only be done for a short, predetermined time frame. This time frame varies from state to state and is anywhere from two days to two weeks. After that time, the patient is entitled to a hearing to determine if involuntary commitment should continue or cease.
Since deinstitutionalization, the United States has seen a significant increase in the population of mentally ill individuals living on the streets or ending up within correctional facilities. 25% of the homeless population in the U.S. have mental disorders, while only 6% of the general population suffer from mental illness. Among U.S. inmates, 10 to 25% are diagnosed with a mental disorder. Individuals with mental illness are more likely to be arrested than those without mental illness for the same encounter. One reason police cite as a motivating factor for taking mentally ill individuals into criminal custody versus the emergency room is the argument that the justice system is a more likely route to long-term care. This unfortunate result is due to the decrease in the average length of stay for involuntary psychiatric stays. Involuntary hospitalization has become a quick and limited fix for acute and severe mental distress rather than a step towards long-term and effective mental health care.
Sex Offenders and Civil Commitment
There are several special populations that fall into the intersection of psychiatry and law that pose unique challenges. These populations include those found not guilty by reason of insanity, individuals suffering from eating disorders, sex offenders, and individuals suffering from substance abuse. Each of these special populations creates challenges within civil commitment statutes, however, the remainder of this blog post will focus on sexual offenders.
Those found guilty of committing sexual crimes pose challenges to the legal and psychiatric systems. Due to the intense fear and moral reactions from the American public, an extraordinary amount of social and legal means have been put in place in attempts to control those with histories of committing sexual crimes. These restrictions include mandated public registry, restrictions on housing and employment, and the possibility of civil commitment as a Sexually Dangerous Person (SDP). Sexually Dangerous Persons or Sexually Violent Predator (SVP) statutes exist in 20 states and in federal law. These statutes allow those who have been convicted of a sexually violent crime, diagnosed with a mental illness, and judged to present a risk to the public to be involuntarily civilly committed. In these instances, civil commitment is viewed as a psychiatric intervention rather than a punishment, which gives states the right to involuntarily hospitalize those who have already served time for sexual crimes. Additionally, the court opined that if sexual disorders leading to commitment were untreatable, individuals could be held indefinitely.
Forensic Insight Group is located in Massachusetts and has psychologists and clinicians familiar with commitment laws and experienced in working with civilly committed sexual offenders. Massachusetts is one of the 20 states in the U.S. that have civil commitment laws for sexual offenders. Although the Supreme Court has ruled that the standard for burden of proof only needs to meet the level of ‘clear and convincing evidence,’ the state of Massachusetts requires a person to be found to meet the criteria for sexual dangerousness ‘beyond a reasonable doubt’ to be civilly committed. This is an increased level of burden of proof compared to the federal standard.
In the state of Massachusetts, the process of civil commitment begins when the district attorney decides to petition to have an individual indefinitely confined as sexually dangerous upon completion of the individual's incarceration sentence. The district attorney can file a petition against any person who is currently serving a sentence, regardless of the reason for current incarceration, as long as the individual has a qualifying sex offense conviction in his background. This deprivation of liberty after an individual serves their sentence is found to be constitutional as a remedial measure where the state can prove that the individual suffers from a mental illness or abnormality that renders the individual incapable of controlling his sexually dangerous impulses.
Once a petition is filed, the court must determine whether probable cause exists to believe the individual is sexually dangerous. If probable cause is found, the individual will be held as a temporary civil commit for a 60-day period for a more in-depth evaluation by qualified examiners. If a qualified examiner finds that the individual is sexually dangerous and the district attorney petitions for a trial, the individual is held until the trial takes place. This is usually a jury trial and requires a standard of proof that is ‘beyond a reasonable doubt,’ despite this being a civil trial. If a jury finds the individual to be sexually dangerous, they will be housed at the Massachusetts Treatment Center for a day to life, until they can prove they are no longer sexually dangerous.
Sexually Dangerous Person civil commitment requires the government to prove the following beyond a reasonable doubt:
The person has been convicted as an adult, juvenile or youthful offender for a sex offense.
The person is presently a prisoner.
The person suffers from a mental abnormality or personality disorder.
That the abnormality or disorder makes the person likely to engage in sexual offenses if not confined to a secure facility.
Criteria and the process for civil commitment of sexually dangerous persons may vary from state to state. Civil commitment is a controversial subject, with many people citing valid concerns related to individual liberty and autonomy and appropriate and effective treatment of those who are involuntarily committed. On the other side of the argument, many cite concerns for public safety against sexual predators. Stay tuned for a future blog post that will go more in-depth on the controversies of the topic of civil commitment!
Forensic populations, including sexual offenders, are often under-served, despite being one of the most important populations to receive psychological services in order to reduce and prevent recidivism. At FIG, we provide forensic specialists and trained clinicians who can bridge the gap between the criminal justice system and the mental health system. We aim to serve the forensic and legal populations in order to make our communities safer and more productive.
Being involved in the legal system can be confusing, frustrating, and embarrassing, and finding the right support can make a big difference. If you or a loved one are involved in the legal system and are in need of psychological services, please contact our office at 508-296-0229 or email us at info@forensicinsightgroup.com to inquire about services we can provide. If you work in the forensic or legal fields, such as attorneys, law enforcement officers, or correctional officers, we can also provide you or your clients with support and services.
Citation:
Hawthorne, S., & Ihlan, A. (n.d.). “Rethinking Civil Commitment” on PubHub. PubHub by MSU Libraries. https://pubhub.lib.msu.edu/read/rethinking-civil-commitment/section/1e67ef7e-de70-4e7c-8922-a533333a0dc8
Initiative, P. P. (n.d.). What is civil commitment? Recent report raises visibility of this shadowy form of incarceration. https://www.prisonpolicy.org/blog/2023/05/18/civil-commitment/
Overview of SDP Process – CPCS Website. (n.d.). Committee for Public Counsel Services. Retrieved September 12, 2023, from https://www.publiccounsel.net/pc/overview-of-sdp-process/
Testa, M., & West, S. G. (2010). Civil commitment in the United States. Psychiatry (Edgmont (Pa. : Township)), 7(10), 30–40.