Virginia recently became the latest state to add muscle to its
civil-commitment law when the legislature approved changes to it in March. But
the impact of the changes, which were spurred by the April 2007 killing spree
at Virginia Tech by a mentally ill student, will likely be limited by the
amount of funding added to the state's mental health system.
The crucial link between funding and plans to enhance treatment and access
has been demonstrated repeatedly as states have moved in recent decades to
strengthen or adopt civil-commitment laws, according to forensic psychiatry
experts who spoke at a symposium on changes to such laws at APA's 2008 annual
meeting in Washington, D.C., in May.
They noted, however, that despite good intentions, changes in
civil-commitment laws to get needed treatment to more seriously ill people
usually have little effect on the number who receive treatment unless
legislators enact funding increases to pay for the changes.
"Having a wonderful law is meaningless if you don't have adequate
resources available," said Lawrence Real, M.D., medical director of
Philadelphia's Belmont Center for Comprehensive Treatment.
Speakers at an annual meeting forum on civil commitment noted that the
number of people treated under such laws is largely dependent on the amount of
public funds available for psychiatric care. From left are Claire Pouncey,
M.D., Fayez El Gabalawi, M.D., Karoline Adler, J.D., Lawrence Real, M.D., and
Paul Appelbaum, M.D.
Credit: David Hathcox
Long-term research on civil-commitment laws has shown that regardless of
whether legislators liberalize or tighten their statutes, the number of people
treated decreases or increases for a short period before returning to the
level it was before the change, he said. The reason for the limited impact of
the change is because available funds limit whether the personnel or
facilities are able to provide the treatment mandated by judges, said Paul
Appelbaum, M.D., past chair of APA's Council on Psychiatry and Law. He is the
Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and director
of the Division of Psychiatry, Law, and Ethics at Columbia University.
The number of people who are civilly committed is more a function of the
knowledge of local judges about what treatment resources are available than
the standards delineated in state law, he said. This goes a long way toward
explaining the wide variation in commitment rates attributed to judges within
the same state.
"I think [inpatient civil commitment] is actually driven by the
availability of psychiatric beds," Appelbaum said.
Real noted that major changes in out-patient civil-commitment laws in some
states—despite concerns about their cost—have not driven any
states to economic collapse, nor, however, have they resulted in a substantial
influx of funding for community mental health
Some states have increased funding to support expanded treatment for those
with serious mental disorders under laws that allow for commitment of a wider
range of people, which spotlights the importance of a stepped-up role for
psychiatrists, Real said. Studies of state commitment laws show that
psychiatrists' involvement in the civil-commitment process has often been
minimized. Most state laws lack detailed definitions of mental illness,
although commitment regulations sometimes refer to the DSM.
In many states a psychiatrist provides evidence that a mental illness
caused the behavior that brought the person into the civil-commitment process.
However, the psychiatrist's opinion in deciding whether to place that person
in treatment "has been excised from the process and is no longer
relevant," Real said.
Definitions of mental illness should be relegated to psychiatrists, Real
said. And to ensure that, psychiatric clinicians need to become more involved
in advocating for an increased role in the formulation of civil-commitment
"We shouldn't wait for case law to clarify this, because we don't
know where and when that case law will come from," he said.
Appelbaum pointed out that it is unlikely that legislators will be able to
identify a definition of mental illness that is "encompassing but not
impossibly vague." Instead he urged a pragmatic effort by mental health
advocates in each state to ensure that help is available for "each
category of person when [his or her] condition requires the kind of
containment and attentive care or support that a hospital setting can
Research and legislative efforts in each state, he added, should aim to
identify and then address the need for civil commitment to respond to mental
illness, substance abuse, and mental retardation in the U.S. population. This
will allow physicians and state officials to identify treatment gaps and how
the state can address them through the civil-commitment process.
"When we know that there is actually enough of a problem here to
warrant a legislative fix we can then decide what specific remedy is most
likely to be effective," Appelbaum said. ▪