Unintended Consequences Of Civil Commitment Criteria. Writer Blasts Reliance On Danger.


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(12-21-21) I’ve always argued that using “dangerousness” alone or as the primary legal standard for involuntary civil commitment is foolish. I do not believe anyone can accurately predict dangerousness. This doesn’t mean I oppose all criteria intended to protect individuals from being abused and unnecessarily hospitalized. I have written before about how other countries lean more on “need for treatment standards” rather than solely sticking with dangerousness. (click here to read about Australia and here about Europe.)

In 2010, Drs. Megan Testa and Sara G. West published a well-researched paper that chronicles the abuses that led to the dangerousness criteria and the unintended consequences that criteria has created.

“Although the shift toward strict dangerousness criteria for civil commitment was based on the honorable intentions of protecting the rights of individuals with mental illnesses and ensuring that they received effective treatment delivered in the least socially disruptive settings, serious unintended negative consequences have occurred…Current civil commitment criteria force relatives to watch their loved ones go through progressive stages of psychiatric decompensation before they can get them any help at all.”

Strict adherence to dangerousness has increased homelessness and incarceration of individuals with serious mental illnesses, they conclude.

Sadly, most major mental health organizations shy away from discussing civil commitment, except for the Treatment Advocacy Center. One of its board members, Evelyn Burton, published an editorial this month in The Baltimore Sun arguing that Maryland’s civil commitment laws need to be reformed. I suspect she is speaking for many others who are watching a loved one grow sicker and sicker without any way to intervene.

Treatment Before Tragedy; Reform Maryland Involuntary Commitment Law

Guest commentary for The Baltimore Sun written by Evelyn Burton

Involuntary psychiatric hospital treatment can help prevent homelessness and incarceration and is a potential lifesaver for those in the midst of a psychiatric crisis and people around them — people like Sara Alacote, Ismael Quintanilla and Sagar Ghimire, who were killed in Baltimore County in May by a neighbor with severe, untreated paranoid delusions. It is a safety net for those whose mental illness makes them unable to recognize their need for hospital treatment and can lead to successful community living.

Yet, Gov. Larry Hogan’s Commission to Study Mental and Behavioral Health in Maryland, chaired by Lt. Gov. Boyd Rutherford, has received testimony this year from, doctors, community and jail mental health providers, individuals with mental illness and many families, detailing how the current danger standard in Maryland’s involuntary treatment law often presents a barrier to such treatment, leading to homelessness, incarceration and violence with potentially fatal results.

In Maryland, involuntary hospital commitment requires that a person with mental illness present a danger to themselves or others. But Maryland is one of only five states whose involuntary commitment law fails to define “danger,” a contributing factor in Maryland earning an “F” grade in last year’s national ranking of civil commitment laws by the Treatment Advocacy Center.

This lack of a clear definition for danger results in inconsistent interpretations across the state, with imminent suicidal or homicidal behavior often being required by physicians and judges charged with making these commitment decisions.

Some people in crisis get treatment, but many others get the door slammed in their face.

Star Gomez recently told the commission of repeated denial of involuntary hospital treatment for her family member because he “only” exhibited psychiatric deterioration with severe delusions. He continually cycles between emergency rooms, homelessness and jail, always due to behaviors caused by untreated psychosis.

Robert Buchanan, director of the Maryland Psychiatric Research Center, testified last month to the commission that considerable evidence indicates that prolonged duration of untreated psychosis is associated with worse outcomes, including increased risk of suicide and violence. His conclusion: “Early intervention is critical.”

To promote such early intervention, it is vital that Maryland’s definition of “danger” include “psychiatric deterioration” as a form of danger to self, recognizing the deteriorating judgment and self-control in one’s daily affairs and brain damage caused by untreated psychosis. Without the addition of a psychiatric deterioration standard, treatment will still be denied, and Maryland’s streets and jails will continue to fill up with people with mental illness. According to Randall Nero, former mental health director for Maryland prisons, by 2019 the population of inmates with mental illness had exploded to 25%. The 2020 Maryland homeless survey reported 24% with serious mental illness.

Since 2001, scores of families have testified before the state legislature, commissions and work groups, that the danger standard barrier to care, forces them to fear a tragedy while helplessly watching their loved ones suffer from depression, delusions or hallucinations and lose the ability to reason. For 20 years, legislators and administrators have ignored families’ cries for help.

This month, they have an opportunity to prevent the nightmare scenarios like that of Sara Alacote, Ismael Quintanilla, Sagar Ghimire and the Gomez family. However, a deadline looms. The commission is scheduled to make recommendations to the governor by Dec. 31.

To remove the barrier to hospital treatment, the danger standard must make explicit that:

(1) The consequence of non-treatment the person is in danger of is reasonably expected to occur in the foreseeable future and need not be imminent;

(2) A danger of psychiatric deterioration is a form of “danger to self”; and

(3) Any available personal, medical and psychiatric history, must be considered — not just the person’s behavior in the present moment.

Will the commission have the political willpower and courage to stand up to groups opposing a psychiatric deterioration standard because of their unsubstantiated fears of inappropriate hospitalizations and increased hospital bed demand?

Fear of change is understandable, but the 25 states with a current psychiatric deterioration standard have not reported any adverse consequences. Our loved ones with severe mental illness, their families and the public need this protection and deserve no less.

Families are counting on the commission and Governor Hogan to recognize that treatment delayed is treatment denied. Tear down this legal barrier and enable treatment before tragedy.

Evelyn Burton (evelyn.burton@SCZaction.org) is the Maryland advocacy chair of the Schizophrenia & Psychosis Action Alliance and a board member of the Treatment Advocacy Center.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.