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NAACPBlack MuslimsBlack PanthersBlack Congressional CaucusBETAfrican American Chamber of Commerce of Western PennsylvaniaLet me go on… Just substitute “Old White Guys” for African American in the following examples. Of they seem racist with that change in name then they are….100 Black Men of AmericaWorking to improve the quality of life within the African American community.Based in Atlanta, Georgiawww.100blackmen.orgAfrican American Planning Commission (AAPC)Addresses issues of homelessness (domestic violence, HIV/AIDS, housing shortage, and unemployment) within the communities in which we live and serve.Based in Brooklyn, New Yorkwww.aapci.orgAfrican American Speaker Bureau (AASB)This organization is dedicated to the representation of people and projects that address the issues, concerns and celebrations of the African American community.Based in San Francisco, Californiawww.aasb.netBe Someone, Inc.Uses numerous tools, including the game of chess, to promote self-esteem, responsibility, and analytical thinking amoung at-risk kids.Based in Atlanta, Georgiawww.besomeone.orgBlack Culinarians Alliance (BCA)A nationwide non-profit, educational and networking organization of hospitality and food service professionals.Based in New York, New Yorkwww.blackculinarians.comBlacks In Government (BIG)Promotes equity in all aspects of life, and excellence in public service.Based in Washington, DCwww.bignet.orgBlack Wall Street Merchants AssociationServes as an advocate for commerce in the African American community.Based in Oakland, Californiawww.blackwallstreet.orgBlack Women In Sisterhood For Action (BISA)Develops and promotes alternative strategies for educational and career development of black women.Based in Washington, DCwww.bisa-hq.orgJack and Jill of AmericaA family organization that provides cultural, social, civic and recreational activities that stimulate and expand the mind to enhance life.Based in Washington, DCwww.jack-and-jill.orgMiss Black USAProvides educational opportunities to outstanding young women of color and to develop the whole woman mind, body, and spirit.Based in Upper Marlboro, Marylandwww.missblackusa.orgNational Action Council For Minorities in Engineering (NACME)Offers support to African Americans and other minorities who want to pursue careers in engineering, technology, math and science.Based in White Plains, New Yorkwww.nacme.orgNational Action NetworkThis organization, led by Al Sharpton ,promotes a modern civil rights agenda that includes just and decency for all people regardless of race, social justice for communities, and the improvement of race relations.Based in New York, New Yorkwww.nationalactionanetwork.netNational Association of the Advancement of Colored People (NAACP)A champion of social justice, that has fought long and hard to ensure that the voices of African Americans would be heard.Based in Baltimore, Marylandwww.naacp.orgNational Association of Black Hotel Owners, Operators and Developers (NABHOOD)Works to increase the number of African-Americans owning, developing, managing and operating hotels; increase vendor opportunities & executive level jobs for minorities.Based in Fort Lauderdale, Floriawww.nabhood.comNational Association of Black Accountants (NABA)The leader in expanding the influence of minority professionals in the fields of accounting and finance.Based in Greenbelt, Marylandwww.nabainc.orgNational Association of Black Storytellers (NABSPromotes and perpetuates the art of Black Storytelling, which embodies the history, heritage, and culture of African Americans.Based in Baltimore, Marylandwww.nabsinc.orgNational Association of Blacks In Criminal Justice (NABCJ)Provides leaders dedicated to improving the administration of criminal justice, with a goal of achieving equal justice for blacks and other minorities.Based in Durham, North Carolinawww.nabcj.orgNational Association of Market Developers (NAMD)Cultivates the aspects of the Black experience that can produce results for both the African-American community and institutions, private and public.Based In Plainfield, New Jerseywww.namdntl.orgNational Black Child Development Institute (NBCDI)Improves and protects the lives of African American children.Based in Washington, DCwww.nbcdi.orgNational Registry of Black Baby NamesLargest online collection of names that African American and African parents can choose for their unborn child.Based in Columbus, Ohio.www.blackbabynames.orgNational Society of Black Engineers (NSBE)One of the largest student-managed organizations in the country that focuses on increasing the number of Black engineers who excel academically and in the workplace.Based in Fairfax, Virginiawww.nsbe.orgNational Urban League (NUL)The nation's oldest and largest community- based movement devoted to empowering African Americans to enter the economic and social mainstream.Based in New York, New Yorkwww.nul.orgRainbow Push CoalitionThis organization, led by Jesse Jackson, is a progressive organization fighting for social change as a mighty coalition of workers, women and people of color.Based in Chicago, Illinoiswww.rainbowpush.orgNeed I say more? Now show me an equivalent number of “White” organizations. Should I go on about the Hispanic organizations or the Asian organizations or others. The only people deemed racists are White folks. That’s simply not the case.

This is copied out of a BSA newsletter that I received todayAugust 14, 2019This article was contributed by Michael Johnson, National Youth Protection Director for the Boy Scouts of America.Recent media reports have highlighted claims of abuse against the Boy Scouts of America (BSA). As Director of Youth Protection here at the BSA, I share the same concerns as anyone seeing these stories, and I have the utmost respect for the courage demonstrated by these men coming forward. These claims understandably raise questions about what we do to keep kids safe in Scouting today, and I’d like to take the time to address those questions.Sadly, there have been times when individuals targeted youth in our organization and took advantage of our programs in order to harm children. This infuriates me and our entire organization. We are heartbroken for victims and apologize to anyone who was harmed during their time in Scouting. We believe victims, we support survivors, and we encourage them to come forward.In my 24 years investigating child abuse cases as a police detective, I spoke with hundreds of victims and spent decades interrogating predators and sending them to prison. I know what we as an organization and as a society are up against.I understand the scars victims carry throughout their lives and have seen firsthand the impact on families. Victims and survivors must be believed and supported unconditionally. Protecting children is a duty we all share.The BSA understood this when it took the step of creating a full-time National Director of Youth Protection position in 2010, which is dedicated exclusively to working to keep kids safe from predators in Scouting programs. Contrary to many inaccurate reports, our youth protection policies are in line with – and sometimes even ahead of – society’s knowledge of abuse and best practices for preventing abuse. We actively share and continually improve these policies through our mandatory youth protection training, our ongoing collaborations with groups such as the Centers for Disease Control[1] and youth-serving organizations, and continuous engagement with survivors of abuse and top experts in this area. We also make our training and policies available free to the public.Our efforts began in the 1920s with what we now call the Volunteer Screening Database (VSD), formerly known as the Ineligible Volunteer Files. This system has been the subject of much misinformation, but it was established at a time when there were virtually no resources or tools for protecting youth. It was intended as a screening mechanism to prevent individuals accused of abuse or inappropriate conduct from joining or rejoining our programs. Today, experts[2] agree that maintaining such a database is one of the most effective ways to prevent predators from having access to children.While local chartered organizations and parents are responsible for selecting their unit leaders, the national organization mandates criminal background checks as part of that selection process. It is worth noting, however, that background checks alone are not sufficient, as experts have found a significant amount of abuse goes unreported.[3] This is why we will continue to push for the creation of a national database to serve as a clearing house for all youth-serving organizations and go beyond existing criminal databases. We believe all organizations such as ours should identify, document and report adults who have harmed children or have been suspected of harming children and report this information into a national registry so that these individuals cannot move from one organization to another, regardless of whether authorities pursue criminal charges.In addition to mandating that volunteers complete comprehensive, research-based and expert-informed youth protection training, we also require adherence to youth protection policies including “two-deep leadership,” which prevents one-on-one interactions between adults and children – both in person and via digital channels. Additionally, even when not required by state or local law, we mandate all volunteers and staff members nationwide immediately report any abuse allegation to law enforcement. We require this in every Scouting program across the country despite the fact some states have exceptions to the mandated reporting of child abuse.[4] The child safety policies and procedures we utilize are among the most advanced and comprehensive of any youth-serving organization today.It is a tragedy and a national epidemic that out of the general U.S. population, one in six boys and one in four girls experience sexual abuse or assault by the time they turn 18.[5] This is an unacceptable public health and safety problem that must be addressed. I’m proud that our organization has long sought to be a part of a collective solution to confront this epidemic and work toward a holistic solution, and we will continue to do so.I can’t say that I, or the BSA, have all the answers; nor will there ever be a simple solution, but I can say we are working with key stakeholders to identify solutions. Our organization has always sought to protect youth, both in and out of Scouting. If there’s one thing that we have learned, it’s that keeping children safe requires a commitment by experts, government officials, organizations, families and survivors across the country to work together to end the national crisis of child abuse and exploitation.If you have been a victim of abuse or have any information about suspected abuse, please reach out to our 24/7 Scouts First Hotline at 1-844-Scouts1 for immediate assistance. For more on what the BSA is doing to keep kids safe, please visit: Youth Protection | Boy Scouts of America.Michael Johnson is the National Youth Protection Director for the Boy Scouts of America. He is an internationally recognized expert on child abuse prevention and investigation, and for 24 years of his 28-year law enforcement career he served as a Detective and the Lead Child Abuse Investigator in the Criminal Investigation division of the Plano Police Department outside of Dallas, Texas. He has conducted more than 350 trainings for child abuse prevention professionals in 47 states and internationally.[1] Child Safety in Youth Serving Organizations: Assuring Safe, Stable, Nurturing Relationships and Environments. The CDC Foundation.[2] Saul J, Audage NC. Preventing Child Sexual Abuse Within Youth-serving Organizations: Getting Started on Policies and Procedures. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2007.[3] Michael L. Bourke, Lance Fragomeli, Paul J. Detar, Michael A. Sullivan, Edward Meyle & Mark O’Riordan (2014): The use of tactical polygraph with sex offenders, Journal of Sexual Aggression: An international, interdisciplinary forum for research, theory and practice, DOI: 10.1080/13552600.2014.886729[4] Child Welfare Information Gateway. (2016). Mandatory reporters of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.[5] Dube, S.R., Anda, R.F., Whitfield, C.L., et al. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28, 430-438.Nathan JohnsonAs a member of the Communications team at Boy Scouts of America, Nathan Johnson enjoys finding and sharing the stories that inform, inspire, and delight the Scouting family.

Civil Commitment in the United StatesGo to:https://www.onlinedollarincome.com/2018/12/500-high-social-bookmarking-sites-list.htmlAbstractThis article reviews the academic literature on the psychiatric practice of civil commitment. It provides an overview of the history of involuntary psychiatric hospitalization in the United States—from the creation of the first asylum and the era of institutionalization to the movement of deinstitutionalization. The ethical conflict that the practice of involuntary hospitalization presents for providers, namely the conflict between the ethical duties of beneficence and respect for patient autonomy, is presented. The evolution of the United States commitment standards, from being based on a right to treatment for patients with mental illness to being based on dangerousness, as well as the implications that the changes in commitment criteria has had on patients and society, are discussed. Involuntary hospitalization of patient populations that present unique challenges for psychiatry (e.g., not guilty by reason of insanity acquittees, sex offenders, and individuals with eating disorders, substance use disorders, and personality disorders) is discussed. Finally, an overview of outpatient commitment is provided. By reading this article, one will learn the history of involuntary psychiatric hospitalization in the United States and gain an understanding of the ethical issues that make civil commitment one of the most controversial practices in modern psychiatry.Keywords: Civil commitment, involuntary hospitalization, institutionalization, deinstitutionalizationGo to:https://www.onlinedollarincome.com/2018/12/500-high-social-bookmarking-sites-list.htmlIntroductionMany people with psychiatric illnesses spend much of their lives struggling with disorders that affect the most fundamental aspects of the human experience—their perceptions of themselves and the world in which they live. The perceptual distortions caused by disorders of mood, thought, and cognition can interfere with a person's functioning to such a severe degree that treatment is critical to the safety of the affected individual and of others. For example, a person with depression may see him- or herself as worthless and, in his or her despair, make efforts to end his or her life. A woman in a manic state, acting in accordance with a grandiose belief of indestructibility, may engage in erratic, unsafe driving that puts her life, as well as the lives of other drivers, in jeopardy. Someone with schizophrenia may become overwhelmed by paranoid delusions and hallucinations that command him or her to act violently against others. And an individual suffering from dementia may become so out of touch with his or her basic needs that the individual fails to provide him- or herself a level of nourishment and self care that is necessary for survival.Despite the clear need for psychiatric intervention in cases such as these, providing necessary treatment to persons with mental illnesses is often not an easy task. Unfortunately, the same disorders that impair a person's mood, thoughts, and functioning also impair his or her insight and judgment, making refusal of care common in psychiatry. Hospitalization is often a critical first step in initiation of psychiatric care. For this reason, involuntary hospitalization, or civil commitment, has been a mainstay of psychiatric care since the inception of our field. It continues to be a mainstay of treatment even today, although provisions for outpatient involuntary treatment have been created in an effort to avoid hospitalization when possible yet ensure that individuals get the care that they need.Go to:https://www.onlinedollarincome.com/2018/12/500-high-social-bookmarking-sites-list.htmlEthical Issues in Involuntary HospitalizationOur society defines the role of the physician in terms of our professional responsibilities to patients. Physicians' professional responsibilities are derived from the ethical principles of medical practice dating back to the time of Hippocrates.1https://www.onlinedollarincome.com/2018/12/500-high-social-bookmarking-sites-list.htmlThe first and foremost principle of medical ethics is the principle of nonmaleficence—the physician's duty to “do no harm.”1,2One way that physicians can avoid harming patients is by showing respect for their autonomy (i.e., by allowing patients to make their own decisions regarding whether to accept or reject recommended medical care). Physicians are also bound by a professional obligation to help patients. This duty is prescribed by the ethical principle of beneficence,1,2which requires that doctors provide to patients services that will benefit them.Psychiatrists often encounter cases in which patients are in grave need of treatment yet adamantly refuse to cooperate with the provision of the necessary treatment. In these cases, psychiatrists face the challenge of weighing their professional obligations of nonmalevolence and beneficence in deciding whether to hospitalize patients against their wishes. When an individual is suffering from a severe mental illness that grossly distorts his perception of reality, it is often clear that he or she has lost the usual capacity for making decisions in his or her best interest. In this case, the individual is not truly autonomous, and the decision to override his or her expressed wishes in favor of hospitalization and treatment to benefit the patient and restore autonomy does not cause much conflict for the psychiatrist. In other cases, involving, for example, patients with eating disorders, substance abuse disorders, and personality disorders, which do not necessarily grossly impact individuals' reality testing, the weighing of ethical obligations can be a very difficult task.Go to:The State's Role in Involuntary HospitalizationFortunately, psychiatrists do not struggle alone or without guidance when making the difficult decision of recommending involuntary hospitalization. State governments—acting on the basis of two major legal principles—have enacted laws defining the standards for involuntary treatment, which serve as guidelines for physicians confronted with patients who are refusing hospital admission.There are two main legal principles that underly the state's interest in the process of civil commitment. The first of these is parens patriae Parens patriae is a Latin term that means “parent of the country.” It refers to a doctrine from English common law that assigns to the government a responsibility to intervene on behalf of citizens who cannot act in their own best interest.3,4,13–16A second legal principle, police power, requires a state to protect the interests of its citizens.4,5,13–16Whereas physicians have a duty to people other than our patients in only very narrow circumstances (those involving a clear and imminent threat to an identifiable person or persons),6the state, on the basis of police powers, has a duty to consider the welfare of all people living within its boundaries. Because of this obligation to all citizens, the state has the right to write statutes for the benefit of society at large, even when providing this benefit may come at the cost of restricting the liberties of certain individuals.5Go to:Institutionalization of the Mentally IllIn 1403, London's Bedlam Hospital, which had been in operation since the mid-1200s, began operating an asylum for the provision of inpatient care to people with mental illnesses.4,7Several centuries later, inpatient psychiatric facilities started to emerge in the United States.4Prior to the inception of American asylums, people with mental illness were relegated to prisons and shelters for the poor. In these settings, the mentally ill were warehoused to ensure the safety of the community and were not offered treatment of any kind.8Between 1817 and 1824, four privately funded asylums were established in the northeastern states of Connecticut, New York, Massachusetts, and Pennsylvania.7,9Subsequently, public asylums were opened in the southern United States,9and the widespread establishment of state-run mental institutions soon followed.8https://www.onlinedollarincome.com/2018/12/500-high-social-bookmarking-sites-list.htmlMost persons who ended up in American asylums were patients suffering from dementia, seizure disorders, diseases involving paralysis, or advanced neurosyphilis. These individuals were incurable by the available treatments of the day. Asylums thus became long-term homes for chronic patients whose care consisted of restraint, sedation with medications, such as bromides and chloral hydrate,7or experimental treatment with opium, camphor, and cathartics.9These treatments were neither effective in curing patients nor did they affect a level of improvement that could render patients able to survive outside the facilities. Populations in America's asylums swelled to more than 500,000 during the 1950s,4with an all time high of 559,000 United States psychiatric inpatients in 1953.9During the era of institutionalization, the societal view in America was that persons with mental illness lacked the capacity to make decisions. There was no distinction between voluntary and involuntary admissions to psychiatric hospitals; all admissions were involuntary. Furthermore, because many institutions operated on private funding, it was quite possible for families to purchase the confinement of unwanted relatives.8When patients were eventually released from asylums, they often found that they had lost many of their civil rights (e.g., their property and custody rights).4The case of Mrs. Elizabeth Packard illustrates how problematic the civil commitment standards of the time were. Mrs. Packard was committed to a Jacksonville, Illinois, asylum in 1860 at the behest of her husband who was a clergyman.10Mr. Packard initiated the hospitalization of his wife to punish her for having an unclean spirit,10a decision that he based on her exploration of spiritual traditions outside the Presbyterian faith.4Mrs. Packard was diagnosed with “moral insanity” and held involuntarily in the hospital for three years before ultimately being declared sane. Once released, Mrs. Packard learned that she had lost custody of her children and ownership of her property. She filed a lawsuit for wrongful confinement and won. She then devoted her life to promoting change in civil commitment laws.4It was the legal standards for civil commitment in 1860 that allowed Mrs. Packard to be hospitalized. The standards of the day required only that the presence of mental illness and a recommendation for treatment be established to prove that admission of a person to a psychiatric hospital against his or her will was necessary.8–13The assumption prevailed that inpatient care was of benefit to patients with mental illness.8The admissions process was easy;4there were no established procedural barriers to stand between a prospective psychiatric inpatient and the doorway of the asylum. Patients were presumed incapable of making decisions, and commitment was based on a need for treatment.8State commitment standards during this time were based on the doctrine of parens patriae—the government's obligation to provide for the incapacitated.4For these reasons, coercing patients to comply with prescribed therapies was considered to be acceptable.In response to abuses of civil commitment, such as the injustice that Mrs. Packard suffered, 20th century America saw a shift in the standards for involuntary hospitalization. States changed civil commitment laws to put legal protections in place to protect the right to liberty of the person being considered for commitment. These legal protections included the potential inpatient's right to a trial, with attorney representation, prior to psychiatric admission.8Stricter commitment standards were imposed,8,13and the decision-making power was taken from the hands of medical professionals and placed in the hands of judges and magistrates.13While these changes were made to better protect the rights of people with mental illnesses, there were problems. Many times, individuals served short terms of imprisonment while awaiting the completion of the required procedural standards. For example, a person may have waited in jail for days because an attorney was not immediately available to represent them in a precommitment trial, and he or she may have waited even longer for the precommitment trial to occur. Psychiatrists and mental health advocates protested the standards, which they saw as extreme and harmful to patients. In 1951, the National Institute of Mental Health (NIMH) published the “Draft Act Governing Hospitalization of the Mentally Ill.” The Act functioned to restore psychiatrists' decision-making power on the issue of civil commitment to its prior state, unburdened by lengthy legal procedures.8Go to:DeinstitutionalizationAnother important event occurred in 1950. During the same time that the NIMH was successful in advocating for a public view of commitment as a necessary step to treatment, new medications were invented that challenged the assumption that institutionalization was necessary for the care of patients with mental illness. In this year, novel medications called antipsychotics arrived on the market.4,8,11Chlorpromazine was invented and sold under the trade name Thorazine. The medication was so effective in treating psychosis that the idea of community-based outpatient treatment of individuals who were previously considered to be lifelong hospital cases seemed plausible.9By 1960, state hospitals were being widely criticized. They were portrayed as places where “little effective treatment” was administered. They were described as run-down archaic establishments that simply housed the mentally ill.8The United States government created Medicare and Medicaid in that year, and as a result society assumed a shared responsibility to pay for the care of people suffering from mental disorders.11Americans started to believe that the cost of caring for the mentally ill in institutions was not worth the limited benefit that could be seen as a result of institutionalization.8Additionally, the civil rights movement, which was gaining momentum in the United States at that time, lent to the public push for the abandonment of mental institutions in favor of more humane psychiatric care.4American President John F. Kennedy signed the Community Mental Health Centers Act in 1963 as a means of facilitating the transitioning of patients from inpatient psychiatric hospitals out into communities.11As a result of all of these factors, deinstitutionalization began. Huge numbers of state hospitals were closed all across the United States.7–12The number of psychiatric inpatients declined precipitously from a high of more than 550,000 in 1950 to 30,000 by the 1990s.4Go to:Shift to Dangerousness Criteria as the Standard for Civil CommitmentAlong with the civil rights movement and deinstitutionalization came a shift in the legal standard for civil commitment away from a need-for-treatment model to a dangerousness model. In 1964, Washington, DC, instituted a standard for civil commitment that established that a person must be determined to have a mental illness before he or she could be hospitalized against his or her will. Second, the person had to pose an imminent threat to the safety of him- or herself or others or be shown to be “gravely disabled,” meaning that he or she could not provide for the necessities for basic survival.8The district did not define the terms of the statute concretely, leaving some room for interpretation. However, it is commonly interpreted that dangerousness refers to physical harm to self (suicide) or physical harm to others (homicide), and that the requirement for imminence means that the threat must be likely to occur in the close future.13California adopted a similar statute five years later.8One by one, other states followed suit until the prevailing standard for civil commitment in the United States required the presence of dangerousness as a result of mental disease.8,13,16,17Currently, there are only a few states that do not follow the trend. Delaware requires only proof that a person is not able to make “responsible choices” about hospitalization or treatment for that person to be committed. Iowa's statute mandates only proof that a person is likely to cause “severe emotional injury” to people who are unable to avoid contact with him (e.g., family members).17Each state's civil commitment criteria also still reflect standards set forth in an important Supreme Court case—O'Connor v. Donaldson—in 1975.13This case involved a man named Kenneth Donaldson who was diagnosed with paranoid schizophrenia and was held in a psychiatric hospital against his will for 15 years. When his release was repeatedly denied by the psychiatrist in charge of his care, despite the fact that he had not shown any evidence of suicidality or intentions to harm others, Mr. Donaldson argued to the court for restoration of his freedom. The case was eventually heard by the Supreme Court, who determined that Mr. Donaldson should be released. The Supreme Court laid out acceptable criteria for holding patients against their will. Justices stated that a mentally ill individual must either present a known risk of harm to him- or herself or others, be in such a state that he or she would be “hopeless to avoid the hazards of freedom,”13or in need of psychiatric treatment. The court seemed to embrace the dangerousness model for civil commitment; however, they did also find that individuals with mental disorders could not be kept in institutions “without more.”8,13,18The word “more” is generally believed to refer to treatment.4In addition to the redefinition of criteria for involuntary hospitalization, there was also a shift in procedural standards for civil commitment that granted potential psychiatric inpatients greater procedural safeguards.4,8,13–15States continued to allow patients to be admitted directly to hospitals against their wishes; however, they determined that this could only be done for a short, pre-determined period of time that varied by state from two days to approximately two weeks. After that time, patients were entitled to a hearing before the court to determine whether their involuntary commitment should continue.4Patients were also guaranteed that they would have legal representation at their commitment hearings.Another aspect of civil commitment proceedings that was defined at this time was the issue of burden of proof, or the degree to which the evidence presented convinces the trier of fact that his decision is correct. There are three standards of proof that can apply when decisions are made in court. The highest standard of proof is “beyond a reasonable doubt.” This standard requires that the trier of fact be convinced of his decision without any reservations that would be expected of a reasonable person. It applies in criminal cases. The lowest standard of proof is by a “preponderance of the evidence,” and it requires only that the trier of fact be certain that her decision is more likely to be correct than incorrect. It applies in civil suits. The third standard of proof allows decisions to be made based on “clear and convincing evidence,” which is defined as being greater than a preponderance of evidence, but less than beyond a reasonable doubt. An important Supreme Court case in 1978, Addington v. Texas, considered the following question: “Which standard of proof does the person requesting involuntary hospitalization of a psychiatric patient have to meet to satisfy the court that the patient meets criteria for commitment?”4,8,13,19Frank Addington was a man with a long history of psychotic illness who had been hospitalized numerous times in the past.13His mother filed a case requesting that he be committed indefinitely because he assaulted her in the past. Her request was granted and Mr. Addington appealed this decision because the court committed him based on a standard of clear and convincing evidence, the mid-level standard of proof. He argued that the evidence against him should have been required to reach the highest standard of proof, beyond a reasonable doubt.8,13The Supreme Court disagreed with Mr. Addington and supported the ruling of the lower court.19The justices opined that because psychiatry was a field dealing with the inexact science of predicting future risk, the standard of beyond a reasonable doubt was so burdensome that it would serve as a barrier to the hospitalization of many patients who were in clear need of care.13In 1966, another important legal case occurred that underscored dangerousness as the key criteria for involuntary hospitalization of psychiatric patients by establishing a right to less confining treatment for nondangerous patients. This was the case of Lake v. Cameron, which was presented before a Washington, DC, appeals court in 1966.4Catherine Lake was a woman with mental illness who had been hospitalized against her will and kept involuntarily at St. Elizabeth's psychiatric hospital for many years, despite not showing any evidence of dangerousness to herself or anyone else. She desired freedom and petitioned the district for her release.4,17,20The court determined that all patients who were not dangerous “should not be confined if a less restrictive alternative is available.”20To this day, because of this ruling, psychiatrists who complete emergency evaluations are required by law to recommend the least restrictive level of treatment that will meet the needs of nondangerous psychiatric patients.16Go to:Unintended Consequences of Basing Civil Commitment on Dangerousness Rather than A Need for TreatmentAlthough the shift toward strict dangerousness criteria for civil commitment was based on the honorable intentions of protecting the rights of individuals with mental illnesses and ensuring that they received effective treatment delivered in the least socially disruptive settings, serious unintended negative consequences have occurred. Because an inpatient stay is often the first step in treatment for people with mental illness, one consequence of the shift toward dangerousness criteria has been compromised access to psychiatric care for nondangerous individuals with mental illness who need but are refusing treatment. Under treatment-driven criteria for commitment, these persons would have gained access to the system through hospitalization on an involuntary basis if necessary. However, under standards based on dangerousness, the medical system will not intervene against a person's wishes until he or she becomes suicidal, physically violent, or grossly unable to perform activities of daily living. Through interviews of mothers of individuals with mental illness, Copeland learned that current civil commitment criteria force relatives to watch their loved ones go through progressive stages of psychiatric decompensation before they can get them any help at all.21Furthermore, since the tightening of criteria for involuntary psychiatric hospitalization, the United States has seen a trend of persons with mental illness being marginalized to unsafe and inappropriate settings. Since deinstitutionalization, there has been a tremendous increase in America's population of people with mental illness who are living on the streets.8,22,23The latest estimates by the United States' Substance Abuse and Mental Health Services Administration reveal that up to 25 percent of our country's homeless population is made up of individuals with mental disorders, despite the fact that only approximately six percent of the general population suffers from mental illness.23Individuals with mental illness are not only overrepresented in our nation's homeless population, but they are overrepresented among the United States' correctional population as well. Since the 1970s, coincident with deinstitutionalization and reform of civil commitment standards toward dangerousness criteria, the trend of “criminalization of the mentally ill” has occurred.24It is currently estimated that, among our country's prison inmates, there is a 10- to 25-percent prevalence of mental illness.22,24Many of these mentally ill inmates are nonviolent offenders,8a fair number of whom were convicted of survival crimes (e.g., theft of food or trespassing for shelter) related to limitations in social functioning and ability to meet basic needs because of chronic mental illness.25It has been shown that people with mental illness are arrested more often than people without mental illness that encounter law enforcement under similar circumstances. Additionally, persons who have been civilly committed in the past have a higher likelihood of arrest than persons with histories of voluntary psychiatric hospital stays. One reason that police cite as a motivating factor for taking people with mental disorders into criminal custody rather than to hospital emergency rooms is that the justice system is a more likely route through which long-term care can be achieved. It is unfortunate, but this is a direct result of the decreased average length of involuntary hospitalization that has occurred because of the shift to dangerousness criteria for civil commitment. Involuntary hospitalization has become a quick and limited fix for acute and severe mental pathology rather than a step toward long-term psychiatric care.25Go to:Special PopulationsThere are several special populations of people with mental illness that fall at the intersection between psychiatry and law. These individuals present unique challenges to psychiatry and are often subject to civil commitment.The first such population consists of persons with mental illness who have histories of breaking laws during episodes of mental illness and are found by the court to be not guilty by reason of insanity (NGRI). The American public may view the insanity defense critically due to a widespread belief that it provides an easy route for criminals to avoid social punishment.26In reality, insanity acquittees are not quickly released to society. Although these persons are technically acquitted by the justice system, they are almost always subsequently remanded to the medical system with the expectation that they will receive psychiatric care. This expectation is met through civil commitment, and insanity acquittees remain hospitalized until they can prove that they have been sufficiently psychiatrically rehabilitated to no longer pose a risk to society.27The process of release from commitment for persons found NGRI can be very lengthy and complicated, and the time acquittees spend in psychiatric facilities may exceed the term of the jail sentence that they would have served if found guilty of the crime that they committed.26,27In fact, the issue of length of commitment after a court finding of NGRI went before the Supreme Court of the United States in 1983. In the case of Jones v. United States, a man who had been arrested for the misdemeanor-level crime of attempted petty larceny entered an insanity plea. He was found NGRI by the court and subsequently civilly committed. After he had been hospitalized for more than 12 months, the maximum possible term of incarceration for misdemeanor offenses, he went back to the court asking to be released. He presented the argument that he should not be involuntarily hospitalized for a longer period than he would have spent in jail. The court rejected Mr. Jones's argument.4,28The justices ruled that, because a finding of NGRI was technically an acquittal, the length of the “hypothetical criminal sentence” was irrelevant to the determination of the length of involuntary hospitalization.28The Supreme Court set a standard with this ruling that persons committed after findings of NGRI could be hospitalized against their will for an indefinite period of time, regardless of the maximum length of time that could be served if they were convicted.4,28,29A second group that presents a challenge at the interface of psychiatry and law is sex offenders. There is a deeply ingrained and intense fear of victimization by sexual predators among the American public. This has led to an extraordinary number of socially and legally sanctioned means of social control of persons with histories of committing sexual crimes. As a society, we label these individuals “sex offenders” and control them with a variety of measures, including mandated public registry participation, restriction of housing and employment opportunities, and civil commitment. Sexually violent predator (SVP) commitment laws exist in the legal statutes of 20 states as well as in federal law.30These laws allow civil commitment of individuals who have been convicted of sexually violent crimes provided that they have been diagnosed with a mental illness and are judged to present a risk to the general public because of their diagnoses.31Several cases that challenged SVP commitment laws were judicated by the United States Supreme Court. The issue of whether post-release civil commitment of sex offenders who have completed prison sentences violated the protection from double jeopardy guaranteed by the Constitution was considered by the Supreme Court in the 1997 case Kansas v. Hendricks. This case involved Mr. Hendricks, a man with pedophilia and a history of child molestation who had been civilly committed in Kansas after serving a jail sentence for his crimes. He requested his release based on his belief that he was then being punished twice for one crime.32The Court determined that civil commitment by definition was a psychiatric intervention rather than a punishment, and therefore, states had the right to involuntarily hospitalize even those individuals who had already served time for crimes arising from sexual disorders. Additionally, the Court determined that if sexual conditions leading to commitment were untreatable, commitment could last indefinitely.4,30,31Five years later, in 2002, another case challenging Kansas's practices of civil commitment of sex offenders was brought to the Supreme Court. The case of Kansas v. Crane again upheld the constitutionality of the commitment of individuals who had committed violent sex crimes.30The justices deciding this case also ruled that an evaluator's judgment that a person has an impaired ability to control his behavior stemming from a “mental abnormality or personality disorder” could suffice for establishing the presence of mental disorder required for civil commitment.30,33SVP commitment laws are very controversial and have strong opponents. The American Psychiatric Association formally opposed SVP commitment laws,30and a large number of psychiatrists over the years have expressed professional concerns that these laws mandate physicians to serve the inappropriate, nonclinical function of incarcerating persons with criminal pasts in facilities that were established for treatment of psychiatric disorders.4Additionally, many individuals classified as sex offenders, (e.g., those who have committed rape) do not clearly meet criteria for any Diagnostic and Statistical Manual of Mental Disorders diagnosis. A common diagnosis among committed sex offenders (second only to pedophilia) is paraphilia, not otherwise specified. Critics of civil commitment of sex offenders argue that providers are using catch-all diagnoses to justify the continued deprivation of liberty, and that the end of public safety does not justify the unethical means used to achieve it.30On the other hand, SVP commitment laws also have strong supporters. Those in favor of the laws believe that disorders of aberrant sexual behavior are largely untreatable and that individuals suffering from them pose a great risk to innocent citizens.4,31Individuals who support civil commitment of sex offenders point out that, even with the best hormonal and behavioral treatments, there is still some degree of recidivism. Grossman et al34published a review of current literature on outcomes after treatment of sex offenders, through which the authors found that existing hormonal and behavioral treatments for sex offenders were effective in decreasing recidivism by 30 percent over a seven-year follow-up period. Given this data, supporters of SVP commitment laws serve an important function in protecting society from individuals who may still be dangerous.With regard to a personality disorder, antisocial personality disorder, which predisposes individuals to dangerousness, there is controversy regarding the issue of civil commitment. Psychiatrists disagree about whether this diagnosis alone should be grounds for commitment, and there have been conflicting legal decisions on the matter. The Supreme Court ruled through Kansas v. Hendricks that a personality disorder could be grounds for keeping a sexual predator civilly committed.31,36However, in the case Foucha v. Louisiana a different ruling was made. In this case, Terry Foucha committed the offenses of aggravated burglary and illegal discharge of a firearm while under the influence of psychosis, which was later determined to have been drug-induced. When he was no longer psychotic, he petitioned for his release on the basis that he was not mentally ill. Psychiatrists evaluated Mr. Foucha and opined that he had antisocial personality disorder and that he would likely present a danger to others if discharged.35The case went to the United States Supreme Court, which determined that antisocial personality disorder did not qualify as a diagnosis of mental illness because of which a person could be involuntarily hospitalized, and that Foucha should be discharged.35,36Individuals with eating disorders are another population that presents special challenges to psychiatrists, especially when the issue of involuntary hospitalization arises. Eating disorders carry high mortality rates. A 1995 study reported that the mortality rate for patients with anorexia was nearly six percent per decade.38A subsequent meta-analysis published in 2009 reported that eating disorders had crude mortality rates between 3.9 and 5.2 percent.38Death occurs not only from medical complications of chronic starvation and purging behaviors (self-induced vomiting and laxative abuse), but also from suicide.37–39Patients with eating disorders also show a large degree of reluctance toward and refusal of treatment.40Despite the potential lethality of the disorders, the fact that an inpatient setting is often the most appropriate setting for weight restoration and intense psychiatric treatment, and the commonality of treatment refusal among those with the disorders, commitment of individuals with eating disorders is uncommon. It is notable that within the extensive literature on eating disorders, there is scant mention of the role of civil commitment in their treatment, and that the Practice Guidelines on Eating Disorders published by the American Psychiatric Association gives no concrete guidelines on commitment of patients with eating disorders.41There are many reasons why civil commitment of patients with eating disorders is a challenge for United States psychiatrists. A primary reason is that many psychiatric providers are not certain about whether an eating disorder qualifies as a “severe mental disease or defect.”41There is a common impression throughout the United States that eating disorders are not serious mental disorders.39Furthermore, patients with eating disorders can often hide the extent to which their thought processes and judgment are impaired by perceptual disturbances regarding body image and weight. The typical patient with anorexia, for example, is not the picture of an obviously certifiable patient, but that of a well-spoken, seemingly put together young woman.40Providers may find it difficult to assert that patients with eating disorders pose an imminent risk of harm to themselves. Chronic starvation is not typically considered to be a suicidal behavior, and even providers who see this behavior as suicidal do not necessarily see it as imminently life threatening. Although many states have statutes that allow for commitment of patients whose behavior renders them gravely disabled, the behavior has to be so disabling as to create an imminent risk of harm to the patient. Currently, even among mental health providers who specialize in eating disorders, there is no clear consensus about what clinical signs indicate that this imminent risk exists.41Patients who abuse substances are another special population in our discussion of civil commitment practices in the United States. Individuals with substance use disorders have illnesses that pose a high mortality risk to them. Substance abusers have a high degree of treatment reluctance and often refuse residential treatment even when critically necessary for their survival. Furthermore, patients with substance dependencies do not demonstrate clear evidence of thought disorder. Just as these factors contribute to a relatively low rate of civil commitment of patients with eating disorders, they contribute to a relatively low rate of civil commitment for patients with addictions. As of the year 2001, 11 of the 50 states had commitment statutes that allowed for involuntary hospitalization of individuals based solely on the presence of drug dependence (without even the presence of dangerousness), and in eight states commitment of individuals based solely on the presence of alcohol dependence was allowed.42Researchers found, however, that in states where these statutes existed only 20 percent of psychiatrists believed that substance dependence as a diagnosis fulfilled criteria for civil commitment.42One area in which compulsory residential treatment of persons with addictions is often employed is in the field of forensic psychiatry. In 1961, California passed legislation allowing for involuntary hospitalization of narcotic-addicted individuals who had been arrested for drug-related crimes. New York passed its own law allowing for civil commitment of persons with opioid dependence in 1962. Subsequently, in 1966, Congress passed the Narcotic Addict Rehabilitation Act (NARA), a federal law that allowed for commitment of persons with addictions to narcotics. Currently, there are many states with systems in place that allow persons convicted of drug offenses to go to treatment as an alternative to going to jail. Research has shown that these individuals, who are coerced into treatment, have just as favorable outcomes as do voluntary patients.43Although NARA does allow for compulsory treatment of drug abusers who have not been convicted or even charged with legal offenses, in practice, most involuntary hospitalization of substance abusers occurs within the forensic psychiatric population. This is an area of controversy. Advocates of drug treatment argue that because involuntary treatment is as effective as voluntary treatment, commitment should be used more often in treating addictions. However, because of limited access to programs and a widely shared belief that resources should be prioritized for people who truly want to be in recovery of their own accord, the practice of committing addicted individuals who have not broken laws is rare.43Go to:Outpatient Civil CommitmentOutpatient civil commitment is a relatively modern trend in the United States. In contrast to inpatient civil commitment, which involves separation of a mentally ill person from society through placement behind a locked door, outpatient civil commitment allows people suffering from mental disorders to remain in their communities. It is an alternative means of mandating the treatment of individuals who could potentially become dangerous to themselves or others without forcing them to be hospitalized.Although by the year 1999, outpatient commitment had been around for decades, the state of New York brought national attention to this issue with the passage of Kendra's Law. The impetus for Kendra's Law was the occurrence of a tragedy in New York City—a man with untreated schizophrenia shoved a young woman into the path of a city subway, causing her untimely death. The law enacted outpatient commitment standards for the state of New York with the hopes of preventing similar tragedies from occurring in the future. The state passed the law to ensure that persons with mental illness who were in need of treatment that would prevent them from becoming dangerous in society got the treatment they needed.4Currently, outpatient commitment statutes exist in most states.8The goal of these statutes is to ensure that psychiatric care is provided to individuals who have a need not only for mental health services but also for supervision.4Outpatient civil commitment depends on several criteria. First, the individual considered for outpatient commitment must be diagnosed with a mental disorder. Second, the individual needs to clearly be in need of treatment and have a history of poor insight regarding his need for care leading to periods of treatment nonadherence. This in turn indicates that he would not be likely to reliably access psychiatric care on a voluntary basis. Third, there must be evidence indicating that the individual is likely to decompensate into a state that would prove dangerous to him or herself or others if treatment nonadherence were to occur.8If the criteria are met, the individual can be mandated to outpatient psychiatric treatment, however, not necessarily forced to take prescribed medications.4,8The benefit of outpatient commitment comes with the monitoring of committed individuals and the requirement of adherence with outpatient mental health visits. Persons who are civilly committed to the outpatient mental health system are easier to involuntarily hospitalize at earlier stages of psychiatric deterioration because they are carefully managed by the community mental health system. Families also often find it easier to access needed care for mentally ill relatives who are subject to outpatient commitment.21Outpatient commitment results in fewer arrests of people with mental illness.25Additionally, outpatient commitment has been shown to be effective in improving patients' psychiatric outcomes,44decreasing rates of hospitalization and lengths of inpatient psychiatric stays,44,45as well as increasing participation in community psychiatric treatment.44,45Go to:ConclusionLiving with a mental illness can be a difficult experience because of the effects that the disorders can have on the perception of reality and the distortion of an individual's judgment. These alterations may place the patient and others in danger. The practice of civil commitment—involuntary hospitalization of a patient—predates the profession of psychiatry itself, however remains a controversial part of psychiatric practice.Often involuntary hospitalization is the first step in establishing psychiatric treatment for individuals who are desperately in need of mental health services, and the original commitment standards in the United States reflected the recognition of a right to treatment for individuals with mental disorders. However, abuse of treatment-based standards led, in some cases, to institutionalization of individuals without mental disease whose hospitalization could benefit unprincipled spouses or relatives. The United States movement of deinstitutionalization during the civil rights era, with concurrent shift in commitment standards to standards based on dangerousness, was meant to protect psychiatric patients from unjust violations of autonomy. This shift created different problems, including a shift of people with mental illness from asylums to prisons, and creation of an epidemic of homelessness among persons with mental disorders. Today, we still face the challenge of striking a balance between assuring that patients have access to psychiatric care, through involuntary hospitalization if necessary, without allowing the practice of psychiatry to be used as a force for social control.The United States Supreme Court has addressed the issue of civil commitment in numerous landmark cases. In deciding O'Connor v. Donaldson, Addington v. Texas, and Lake v. Cameron, the Court established the criteria for and burden of proof needed to justify civil commitment, and established a right to treatment in the least restrictive environment for patients facing hospitalization against their will. The Court has also answered questions about the purpose of involuntary hospitalization, not only for typical psychiatric patients, but for special populations such as sex offenders (Kansas v. Hendricks) and NGRI acquitters (Jones v. United States) as well. Despite the progress the Supreme Court has made in resolving the controversies surrounding civil commitment, many controversies remain. Areas in which consensus is needed regarding civil commitability include personality disorders, eating disorders, and substance use disorders.