Research Paper on Mental Illness

The commitment process involves subjecting a mentally ill person to treatment, either voluntary or involuntary. Involuntary commitment, also referred to as the civil commitment process, is designed ‘[t]o treat persons with mental illnesses when they are unable or unwilling to seek treatment voluntarily...[and]...to protect the person with mental illness and others from harm due to the illness’ (National Alliance on Mental Health 2006: 2).

A patient cannot be committed for treatment against his or her will unless several legal standards are met and certain procedures are followed. As a general rule, minors cannot be subjected to involuntary commitment as well (although there might be variations in local provisions with regard to commitment of teenagers aged 16 and 17); there are other options for helping children and teenagers with mental illnesses. 

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As the National Alliance on Mental Health (2006) informs, commitment process generally consists of six stages, namely initiation of the process and the pre-petition process; beginning of the petition process; conducting the examination; the preliminary hearing; the commitment hearing; and determination of the outcome of the commitment process. The first step includes an optional emergency hold and a mandatory pre-petition screening. Emergency holds are necessary in cases when there is an imminent threat to a person with mental illness or others. In this case, the mentally ill person can be placed in custody before a petition for commitment is submitted. Emergency holds last for 72 hours excluding weekends and holidays. Furthermore, it is important to keep in mind that emergency holds do not automatically result in commitment:

‘An emergency hold does not necessarily result in starting the commitment process. It only serves as a way to assess the individual to determine if commitment is necessary’ (National Alliance on Mental Health 2006: 7).

Emergency hold can be initiated by a physician or doctoral level psychologist, a peace or health officer, or a court. Emergency hold initiated by a physician, also referred to as a physician’s hold, implies placing a mentally ill person in a secure treatment facility, e.g. a hospital, if family, friends, or community members believe the person might cause harm to him/herself. A physician’s hold also gives medical personnel of a hospital the right to treat the person against his or her will. The procedural requirement for initiating this kind of emergency hold is ‘a statement from the examiner that is no more than 15 days old that says the person has a mental illness and must be detained to prevent injury to himself or to others’ (National Alliance on Mental Health 2006: 8).

Additionally, the head of the hospital should agree to the mentally ill person being confined in the facility. The second type of emergency hold, the one initiated by a peace or health officer, implies filling out an application for admission of the mentally ill person to a secure treatment facility if this person poses danger to the community. In the application, the peace or health officer must substantiate why he or she believes the person poses danger to the community. The hold is effective for maximum 12 hours and is necessary to bring the mentally ill person to an emergency room (National Alliance on Mental Health 2006).

The third type of emergency hold, referred to as a ‘court hold’ or a ‘judicial hold,’ occurs when a judge decides that a mentally ill person is likely to cause danger to him/herself or other if confinement does not take place immediately; if a mentally ill person fails to appear for a court hearing or examination; or if a mentally ill person has been under emergency hold for more than 72 hours and the commitment petition has been filed but not examined yet (National Alliance on Mental Health 2006).

If an emergency hold is not an immediate necessity, the commitment process starts with pre-petition screening. It involves screening team gathering information about the condition of the mentally ill person and includes interviewing the person with mental illness; investigating the alleged behavior that justifies commitment; exploring alternatives to commitment; contacting the person’s insurance company to clarify the issue of paying for treatment; informing the mentally ill person about his or her rights, the commitment process, and the legal effects of commitment; and gathering relevant information from family members, hospital staff, insurers and psychiatrists about past treatments and other aspects of mental illness (National Alliance on Mental Health 2006).

The next step in the commitment process is filing the petition. This can be done by anyone familiar with the mentally ill person:

‘The petitioner is often the head of a treatment facility where the person with mental illness is being treated, but the petitioner can also be a family member, friend or someone in the community’ (National Alliance on Mental Health 2006: 14).

This step is followed by an examination by a professional psychologist or psychiatrist, referred to as a court appointed examiner, with a view to determining whether commitment is necessary. The following step, the preliminary trial, is meant for the judge and lawyers, so that they could discuss important issues before the trial and possibly reach a settlement. The final step of the process, the commitment hearing, is a civil trial before the judge, and ‘[t]he burden of proof is on the county attorney, who must prove that the person has a mental illness and meets all the requirements for commitment’ (National Alliance on Mental Health 2006: 15).

The ongoing trend in psychiatry is to decrease the number of involuntary commitments, either by persuading patients to commit voluntary, or by offering alternatives to hospital-based treatment, such as community-based outpatient facilities. There have been concerns that ‘physicians may overprescribe commitment in an effort to insure treatment in a desperate, but not ‘dangerous,’ mental health crisis’ (Shore 1978: 209).

Even involuntary outpatient commitment has come in for much criticism, since the widely held believe suggests that ‘outpatient commitment may not improve public safety and may not be more effective than voluntary services...[and]...may undermine the delivery of voluntary services and may drive consumers away from the mental health system’ (Allen & Smith 2001: 342).

According to the American Psychiatric Association (Shore 1978: 207), ‘[i]nvoluntary treatment is necessary for the few patients who will endanger themselves or others because of a mental illness, and who are unable to make a free and informed decision’

With regard to methods of assessing ‘dangerousness,’ it is important to keep in mind that mental illness itself can not serve as a basis for involuntary commitment: the U.S. Supreme Court case of O’Connor v. Donaldson of 1975 has established that ‘A finding of ’mental illness’ alone cannot justify a state’s locking up a person against his [or her] will and keeping him [or her] indefinitely in custodial confinement’ (Werth, 2001: 352).

‘Dangerousness for self’ should be construed as a life-threatening condition: if a patient is ruining his or her own personal life and career, there would be no sound grounds for involuntary admission. At the same time, ‘dangerousness for others’ is defined by evaluating patients’ actions or clear intentions. As Petris (Shore 1978: 207) informs, ‘[i]f danger to the community is the issue and custody of the dangerous person is the objective, then medical considerations are secondary.’

Signs of a possibility that a person is likely to be a danger to him/herself or society include ‘a failure to obtain food, clothing, shelter, or medical care as a result of the illness, taking into account the possibility of anasognosia, or the individual’s unawareness of her own symptoms’ (National Alliance on Mental Health 2006: 6).

Except for the criteria of ‘dangerousness,’ legal requirements for involuntary commitment across the U.S. include ‘that the person be in need of treatment, that hospitalization would be a benefit to the person, and that there were no less restrictive alternatives’ (Werth, 2001: 349).

As concerns the question of evidence that must be shown in order to use the NGRI plea (‘not guilty by reason of insanity’) in a court case, it is first necessary to note that in reality ‘the NGRI plea is infrequently raised and even more infrequently successful as an affirmative defense’ (McPherson 1998: 443).

In order to raise the NGRI plea, it is necessary to prove that a mentally ill person was unable to differentiate between right and wrong at the moment of committing the crime, and such inability was the direct consequence of a mental illness, most commonly a psychotic disorders, mood disorders or organic conditions such as mental retardation. The Supreme Court ruling USC Title 18, Chap 1, Sec 17, has established the following:

‘It is an affirmative defense to a prosecution under any Federal statute that, at the time of the commission of the acts constituting the offense, the defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality or the wrongfulness of his acts’ (Hooper and McLearen 2002: 2).

The NGRI plea should be distinguished from the GBMI plea. GMBI is ‘both a plea and a verdict in which a mentally ill defendant can be found criminally responsible for an act despite mental impairment; in other words, impairment is recognized but judged not severe enough to make the defendant legally insane’ (Steadman et al. 1993: 35).

With regard to the provision of quality mental health care under HMO plans, a common problem at the insurance market – adverse selection – makes such provision problematic. People with mental health problems or other chronic conditions are more likely to be excluded from managed care plans paid by capitation. Discrimination against such persons may take a form of a limited mental health provider network or particularly detailed conditions for referral to mental health specialty care. Additionally, ‘HMOs control the cost of medical and mental health care services by selective enrollment of healthier people, by impeding access to mental health services or by using less intensive services per user’ (American Family Physician 1991: 532).

As concerns the possible ways to alleviate this problem, ‘service-level risk adjustment should be adopted in the Medicare payment policy to offset the HMOs’ incentive to select against people with higher MH risk’ (Cao and McGuire 2006: Abstract).

Another viable option that is being explored by many employers is to ‘‘carve-out’’ mental health benefits from other medical insurance benefit packages, and contract with a mental health managed care firm to provide or administer the mental health benefit’ (Reidy 1993: 34).

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