Civil Commitment Changes Only as Good as Funding

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.

The More Things Change...

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 services.

Increasing Role for Psychiatrists

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 laws.

“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 provide.”

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. ▪