Friday, June 1, 2018

We must come together to establish a mental health system that includes robust services at all levels and that provides a full continuum of care for those with the most severe mental illness.

The Real Civil Commitment Crisis and How To Solve It


A recent column highlighted the longstanding debate around the role of civil commitment laws, occasioned by the inartful response of President Donald Trump to the tragic school shooting in Parkland, Florida. The need to strike a proper balance between guarding one’s civil liberties while ensuring the public welfare is an important discussion, especially in light of what appears to be an increasing number of high-profile tragedies that might call for commitment law reform. Yet, the authors conflated this important discussion with a second argument against providing inpatient psychiatric care. This conflation is too frequently exploited by decision makers as a cynical means of reducing desperately needed mental health resources. Given the dire state of our inpatient treatment system, the issue is deserving of careful interrogation and consideration.

Civil Commitment Trends Are Clear

It is important to first define what is meant by “expanding” civil commitment laws. By “expanding,” the authors most likely meant moving from a standard requiring overt or immediate danger to self or others to one that considers other factors such as the person’s need for treatment as a basis for civil commitment.
Civil commitment is by tradition a state purview, with little role for the president or federal government. In state legislatures, the debate over dangerousness standards has largely ended.
Over the past 20 years, my organization, the Treatment Advocacy Center, has worked with more than 30 states to modernize their civil commitment standards to include factors beyond overt dangerousness. This reform effort gained vital advocacy support from families who had faced the nightmare of seeing an obviously ill loved one denied care simply because they had not yet become violent. As evidenced by these families’ experiences, demanding immediate evidence of danger delays the provision of care, often leading to unjustifiable deterioration and unnecessary criminalization.

Dangerousness Standard Stigmatizes

Moreover, an overreliance on dangerousness may actually reinforce the damaging stigmatization of mental illness. A study in the journal Social Psychiatry and Psychiatric Epidemiology noted that “widespread public knowledge of the dangerousness criterion … might indeed have fueled the stereotype that people with mental illnesses are dangerous.” For the general public, it stands to reason that if mental illness is the only condition in which an individual’s care is predicated on evidencing dangerousness, those with mental illness must logically be more dangerous.
In “expanding” their commitment laws, states have moved from determinations of danger and violence to what could now be termed a medically informed model. For example, Arkansas expanded its interpretation of “clear and present danger” to include a person whose illness causes them to be unable to understand their need for treatment and who needs care to prevent a relapse or harmful deterioration. Washington State’s “gravely disabled” standard has been repeatedly “expanded” to address various types of harm and deterioration that have little to do with overt violence. And, after recently clarifying its treatment standards to make clear that its treatment standard explicitly considers more than a person’s current level of danger, California is now debating additional updates to help serve its chronically homeless population.

The Bed-Shortage Crisis

Despite the importance of reforming civil commitment standards, debating these laws in isolation obscures a vital point: Facilities that provide needed inpatient care have been under assault from policy makers, with devastating consequences for the most severely ill and for society at large.
A 2017 analysis of psychiatric inpatient capacity by the National Association of State Mental Health Program Directors (NASMHPD) detailed a 77.4 percent decline in psychiatric beds since 1970. Similarly, my organization found that state psychiatric hospital beds are now at their lowest level since the 1850s, with less than 12 such beds per 100,000 population nationally.
With fewer beds available for those in need, patients stay lengths have shortened and readmission rates have climbed. In 1980, the median length-of-stay for an acute episode of schizophrenia was 42 days. In 2013, it was less than one week.
Schizophrenia and mood disorders account for more readmissions of Medicaid patients than any other medical conditions. Schizophrenia hospitalizations alone cost $11.5 billion in 2013, of which $646.0 million resulted from readmission within just 30 days of discharge.

Consequences Of Nontreatment

The weakening of the inpatient care system has placed an increasingly heavy burden on systems of care that are not designed to address psychiatric crisis. A survey of emergency department physicians by the American College of Emergency Physicians found that nearly 9 of 10 doctors reported psychiatric patients being held in their emergency departments while waiting for an inpatient bed.
Nearly 95 percent of jails report housing inmates with serious mental illness. In fact, at least 45 states now house more people with serious mental illness in jails or prisons than in the largest remaining state psychiatric hospital in each of these states. A majority surveyed reported maintaining wait lists for mentally ill inmates in jail who needed care in a psychiatric inpatient facility, but for whom no bed was available. In numerous states, mental health officials have even been threatened with contempt of court owing to their lack of available beds.

A False Choice

Unfortunately, deep budget cuts have pitted well-meaning advocates against each other, allowing the debate about how to solve this crisis to become focused on providing either community-based services or more inpatient facilities—a false distinction that serves no one.
For example, organizations such as the Bazelon Center for Mental Health Law have regularly opposed the Centers for Medicare and Medicaid Services regulatory changes that would free up state resources to rebuild inpatient crisis care, because “it would be particularly damaging to a state’s ability to rebuild community capacity … for the state to invest in increasing institutional services.” By contrast, groups such as the National Alliance on Mental Illness have supported such changes specifically because they would “create an incentive to create additional options for psychiatric care.
Both inpatient and outpatient services are necessary for a functioning system. A solution thus lies in the middle, with a system that provides a continuum of needed psychiatric services, including community, crisis, and inpatient care.

A Continuum Of Care

In a joint report released by the Substance Abuse and Mental Health Services Administration, my organization joined with the NASMHPD in recommending that we prioritize and fund the development of a comprehensive continuum of mental health care that incorporates a full spectrum of services, including both robust community services and inpatient psychiatric beds.
These sentiments were echoed by the recently formed federal Interdepartmental Serious Mental Illness Coordinating Committee, whose first report to Congress noted that “most states report insufficient crisis response capacity as well as insufficient numbers of inpatient psychiatric beds.”


Communities across the country are facing a mental health crisis of unimaginable proportions. Our safety nets—jails, emergency departments, and homeless shelters—are stretched beyond their breaking point. In the face of such urgency, our task should be clear: We must come together to establish a mental health system that includes robust services at all levels and that provides a full continuum of care for those with the most severe mental illness. That this position could be seen as controversial is a testament to the severity of the problems we face. We can and must do better.