It’s not hard to find stories of people who have been failed by our mental health care system. Those most in need of help often don’t find it and are left on their own with few resources or support. In many places, treatment is scarce, expensive and inaccessible.
Fortunately, that’s changing with the rise of telehealth providers who offer quality mental and behavioral wellness services online and in person, making it easier than ever to connect with a qualified psychiatrist, therapist or other professional. However, some glaring systemic issues still need to be addressed, particularly for those with severe mental health conditions.
One of these problems is the high standards set for civil commitment, which leaves some people in a gray area when they’re experiencing escalating symptoms and in desperate need of help, but aren't considered dangerous enough to get it if they refuse. Their families aren’t sure where to turn next, creating a repeating cycle of temporary psychiatric holds, emergency room visits and discharges with little to no follow-up care or support.
At Sokya, we’re taking a closer look at civil commitment standards, whether they need to change, and what we can do in the meantime to help those with some of the most serious mental health concerns.
Civil commitment is the process of admitting someone into court-ordered treatment. This decision must be ruled on by a judge or another official acting in a judicial capacity. When approved, the person will be confined to a psychiatric hospital or receive another form of supervised care for a predetermined amount of time.
Nearly every state in the U.S. allows for civil commitment when individuals with a mental health concern are unable to meet their own basic needs or have shown that they’re at risk of hurting themselves or others. However, standards and criteria for civil commitment vary. Most judges will not order someone into treatment if there’s a lack of imminent harm, if a less restrictive plan is available, or if they’re willing to get help on their own.
The problem is that this has resulted in a high bar for commitment that only applies to those exhibiting the most dangerous behavior, which is far past the point where they’re in need of assistance. It also fails to help people with severe mental health problems who need treatment for worsening symptoms, but can’t or won’t get it on their own.
When it comes to civil commitment, the question isn’t whether someone needs help or not. Rather, it’s if they can be forced into getting it. In the U.S., fewer people are being civilly committed each year, but that’s as intended. It reflects changing attitudes toward institutionalization and how we treat mental illness.
In the past, people with mental health concerns were often placed in asylums, sanatoriums and psychiatric hospitals. But in 1963, President John F. Kennedy signed into law the Community Mental Health Act, which provided federal grants and funding for states to establish local mental health centers, directing a deliberate shift away from larger institutions.
Over the following decades, states adopted new civil commitment laws and decreased the resources put into institutionalized mental health treatment. Instead, the responsibility to provide for patients was pushed onto individual counties. This led to drastically fewer beds in state-run hospitals, forcing their local counterparts to fill in the gaps.
In a perfect world, community mental health care would be able to keep up with demand, but that hasn’t always been the case. Still, some experts find it encouraging that there have been fewer civil commitments, as people with mental health concerns should ideally be able to choose where and how they live without getting forced into getting treatment. They claim the current threshold is appropriate and working as it should.
Others argue that it’s a broken system failing those who fall through the cracks. Despite the good intentions of advocates who support the idea that mental health patients are better served by their own communities, along with this belief is the expectation that individuals would seek help on their own and that treatment would be available to them.
In a lot of cases, neither of these things turns out to be true. Some people don’t voluntarily comply with treatment, while others don’t have the resources to access the care they need. Additionally, not all communities are equipped to handle serious mental health symptoms. As a result, these individuals become “revolving door patients,” where they end up in and out of emergency rooms and get discharged without any long-term plans in place. Then, they aren’t seen again until they experience another mental health crisis, repeating the cycle.
For some people, the system works well. An individual exhibiting worrisome behavior, for example, might be placed on a psychiatric hold as a last resort by concerned loved ones, law enforcement or a health care provider. Then, they’ll be assessed and receive an accurate diagnosis before being discharged into a voluntary treatment program.
This type of hold facilitates a more thorough examination that allows doctors to determine if a patient should be civilly committed, but it cannot exceed 72 hours. For some, this is sufficient, but for others, it doesn’t provide enough time to establish if more support is needed.
Furthermore, drugs or alcohol can complicate the situation. The effects of some substances like methamphetamine cause symptoms such as paranoia, hallucinations and psychosis, making it hard to determine if a person is intoxicated, experiencing a mental health crisis, or both. If dangerous behavior is caused by drugs, they can’t be held for treatment.
It's generally agreed upon that civil commitment should remain a last resort, but many experts are wondering if too many people are slipping through the cracks and whether the bar needs to be lowered. Because when someone is released without the appropriate support, they end up continuing to experience the same unresolved symptoms.
While this issue is debated, there is more we can do. Some counties have improved mental health training for first responders and increased access to resources like phone and peer support, face-to-face meetings, case management, care coordination and more. These solutions can help crisis workers and other professionals build personal relationships with patients and connect them with long-term mental health options.
Another way we can help those with the serious mental health concerns is by making their day-to-day lives easier. A big issue for many is housing. Without proper care, some people end up on the streets, where they’re more vulnerable to violence, crime or police encounters. And being arrested can result in disability benefits being taken away, making an already difficult situation even worse. Supportive housing that pairs rental assistance with behavioral health services has been proven to reduce homelessness and improve access to quality treatment options.
Instead of changing state standards, we can also do a better job of following up with people who need wraparound care, medication management and placement in other mental health services. By helping earlier in the treatment process, we can hopefully stop symptoms before they reach a point where someone might be considered for civil commitment in the first place. The goal would be to stop the futile cycle that keeps people going in and out of mental health units without much improvement, instead giving them a sense of hope and balance in their lives.
At Sokya, our goal is to increase access to quality mental wellness services that can help people find relief from their symptoms and connect with professionals who support their emotional and behavioral health. Our treatment options include therapy, groups, medication management, coaching and more, all available either online, in person or through our mobile app. To learn more, click here to connect with a Care Coordinator today or call us at (866) 65-SOKYA.