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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.

I did. On March 21, 2007, Holder wrote to United States Attorney Thomas Colantuono. Holder referred to a complaint he had submitted to the United States Attorney General about the custody proceeding, reiterating his view that the decision was racially discriminatory. He demanded that the United States Attorney investigate his complaint and bring a federal court action to terminate funding for the New Hampshire Marital Masters program. Holder stated that he would "not be denied vindication of the constitutional rights of [his] son and [Holder] against the black robed bigots." Dkt. no. 49-3. He wrote:It doesn't matter to me if the person is wearing stars, bars, stripes or a black robe. These bigots mean nothing to me. I will use any means necessary, including the use of deadly force, to protect the constitutional rights of my children against the state sponsored racism and unlawful discrimination. I urge your office act now to eliminate the racial bias and prejudice or anarchy will surely follow. I assure you I will be the one leading that rebellion if it becomes necessary.**After expressing dissatisfaction with the Committee's work, Holder wrote:So you can understand me, the next corrupt attorney, court or state official that seeks to infringe upon my rights and interests, he/she may suffer dearly due to the lack of action from your office. Honesty [sic], I don't care if the individual is wearing stars, bars, stripes, a badge or a black robe. If your office is not going to protect my rights and interest, I will gladly assert them on my own and in my own way, which means I will use any means necessary to accomplish that task. That also means I will use up to and including the use of deadly force to protect the constitutional rights of my children and I and against racial bias and discrimination.** Id.**NH STATE CONSTITUTION****[Art.] 2. [Natural Rights.]** All men have certain natural, essential, and inherent rights among which are, the enjoying and defending life and liberty; acquiring, possessing, and protecting, property; and, in a word, of seeking and obtaining happiness. Equality of rights under the law shall not be denied or abridged by this state on account of race, creed, color, sex or national origin.June 2, 1784,**Amended 1974 adding sentence to prohibit discrimination.****[Art.] 3. [Society, its Organization and Purposes.]** When men enter into a state of society, they surrender up some of their natural rights to that society, in order to ensure the protection of others; and, without such an equivalent, the surrender is void.**June 2, 1784**[Art.] 10. [Right of Revolution.] Government being **instituted for the common benefit, protection, and security, of the whole community, and not for the private interest or emolument of any one man, family, or class of men; therefore, whenever the ends of government are perverted, and public liberty manifestly endangered, and all other means of redress are ineffectual, the people may, and of right ought to reform the old, or establish a new government. **The doctrine of nonresistance against arbitrary power, and oppression, is absurd, slavish, and destructive of the good and happiness of mankind. June 2, 1784*In 1954. the Supreme Court handed down the landmark decision Brown v. Board of Education in which the Justices ordered the end of state-mandated segregation in public schools. Holder's son was ordered by the court to placed in a "high minority" and "inferior performing" inner city public school in a neighboring State that was plagued high crime and gang activity. In 1984 the high court ruled in Palmore v. Sidoti that the best interest of the child take precedent and proscribing race as the determining factor in custody dispute between two natural parents. The NH Justices apparently are not required to answer to anyone though Part I, Article 8 of the NH Constitution mandates otherwise because of a corrupt and racist Judicial Conduct Committee led by Robert O. Wilson, DDS, Chair.Judicial "errors" are supposed to be corrected through an appeal, but for their part, the NH Supreme Court Justices made quite plain: they were more interested in protecting the authority of the court of separating a Black father from his son than by following the goals of the Domestic Relations Laws and other well established prohibitions against racial discrimination..A State may not permissibly engage in deliberate conduct or deliberate omissions that have the foreseeable effect of perpetuating known segregation, where its acts or omissions are undertaken in response to and in accordance with the segregative wishes of others that were known to be racially motivated.” United States v. City of Yonkers, Docket No. 95-6182, 95-6206, U. S. Court of Appeal, (2nd Cir), 96 F.3d 600; 1996 U.S. App. LEXIS 24856.THE LIE"Race is never used as a determining factor in a custody decision. Absolutely not. This is the United States of America", said NH Family Court Administrative Judge Edwin Kelly-"The Wire, 5-9 Nov. 2005MANIFEST BIAS“A judge shall perform judicial duties without bias or prejudice. A judge shall not, in the performance of judicial duties, by words or conduct, manifest bias or prejudice, including but not limited to bias or prejudice based upon race, sex, religion, national origin, disability, age, sexual orientation or socioeconomic status, and shall not permit staff, court officers and others subject to the judge’s direction and control to do so.” Canon of Ethics, Canon 3 (5)THE OFFENSE“In A.J’s best interest I recommend that he attend the Burnham School in Haverhill (MA)… .Furthermore, the issue of diversity is real. A. J. would likely find it lonely being the only Black child in a school in NH. He has a rich Black Heritage of which to be proud. He can share with and learn from other children of his color and it can enhance his growing up years in numerous ways. In Haverhill (MA), he has that opportunity far more that it exists in NH.” –Patricia Frim, Esq., Court Appointed Guardian ad Litem, 07/14/03“As it relates to custody, the last question to be decided is what should A.J. attend first grade and who should be the parent with whom Andre resides for school placement purposes. On page 10 and 11 of her report, the Guardian ad Litem outlines the differences in the two school systems: each has its positives and negative qualities. Ultimately, the court finds that the most important factors are diversity and crime. Given the information presented on the issue of diversity...the Court concludes that the Burnham school in Haverhill (MA) would be the more appropriate placement for A.J.”- Marital Master Harriet J. Fishman- Case No. 02-M-0032 (Approved Judge Gerald Taube). 08/05/03 (Ruling was contrary to the facts, evidence and testimony and Diversity is more than just skin color).“No appeal, however, is declined except by unanimous vote of the court with at least three justices participating. No justice who considered this matter voted to accept this appeal. Accordingly, the appeal was declined. If any justice who considered this matter believed the appeal should have been accepted, this case would have been scheduled for briefing.Declined. Brock, C.J., and Broderick, Nadeau, Dalianis and Duggan, JJ., concurred. Case No. 03-0640, (Declining to hear appeal of Case 02-M-0032), 11/21/03) (No opinion published (intentionally) to hide the denial of equal educational opportunity from public and legislative scrutiny and prevent a high appeal)The NH Revised Statutes authorizes the Chief Law Enforcement Officer to investigate and file suit to vindicate the rights of NH residents. This did not occur in Holder's case. The public has a right to know why then State Attorney General Kelly Ayotte allowed and defended the Judicial officials involved for their role in the judicial racism when they plainly broke State Domestic Relations law, Federal civil rights laws, both State and Federal Constitutions, Judicial Canon of Ethics and U.S. Supreme Court precedent. To add insult to injury, Governor Maggie Hassan elevated the arrogant, corrupt and racist Linda Dalianis to Chief Justice in spite of knowing her role in the underlying act of racism and officials oppression as Holder's former NH State Senator. The NH Judicial and Executive Branches (State Attorney General Office) have engaged in a "high stakes" game of racial and judicial politics putting plaintiff and son's constitutional rights at risk.[2] The facts and documentation to support Holder's allegations of (organized) criminal and conspiratorial conduct perpetrated by NH judicial, criminal justice officials and others.THE THREAT PART ONEEnglish Language Arts-Rating-“Low”-Burnham Elementary Cycle III Accountability Report 2003. During 2000-2003, Haverhill Public Schools among the “below average” performing school systems in the Commonwealth. On the 2003 MCAS test,76.9% of the African American students and 83.9% of the Hispanic American students in Haverhill scored in the “Needs Improvement” and “Warning/Failing” categories.-Executive Summary-Mass Dept of Ed-Haverhill Exam Report, 2004THE THREAT PART 2“District Attorney Jonathan Blodgett offered assistance to Haverhill from the federal and state law enforcement agencies in fight local gangs…In Haverhill, there have been a lot of shootings since August, with most of the activity in the Arlington Street and Acre neighborhoods.” (GAL offered perjured testimony denying the existence of crime, drug and gang activity on Arlington Street. . They knowingly and recklessly put my son at risk physically and educationally.Crime rates in Haverhill are among the highest in Massachusetts cities, surpassing Lawrence in every category and even showing that city residents and businesses are the most susceptible to burglary of any major city in the state.” Church, Zach., “Haverhill crime high among state cities; Lawrence shows improvement’ October 01, 2007 Lawrence-Eagle Tribune.The record of repeated violations of the Judicial Canon of Ethics and Public Employee standards of conduct were grounds for disciplinary action but the disciplinary arms of the NH Judicial Branch refused to mandate accountability pertaining to Dalianis' history of failure to exercise proper and sound discretion in the manifest bias case pursuant to Part I, Article 8 of the NH State Constitution and the more recent unlawful conspiracy with the Nashua PD depriving Holder of his clearly established constitutional right under color of law. The evidence substantiates that the defendants conduct was not intimately associated with any judicial process. Their action was taken with reckless disregard for the effect on the plaintiff and caused him extreme emotional concern for the continued emotional and physical safety of his two school aged children, then ages 6 and 16..[1] Racial and Judicial politics: the practice of political figures and judicial actors exploiting the issue of race to forward an agenda.[2] "Discrimination within the judicial system is most pernicious because it is "a stimulant to that race prejudice which is an impediment to securing to [black citizens] that equal justice which the law aims to secure to all others." Strauder,100 U. S., at 308.Public officials sworn to uphold the Constitution may not avoid a constitutional duty bowing to the hypothetical effects of private racial prejudice that they assume to be both widely and deeply held." Palmer v. Thompson, 403 U.S. 217, 260 -261 (1971) (WHITE, J., dissenting).The Constitution cannot control such prejudice, but neither can it tolerate it. Private biases may be outside the reach of the law, but the law cannot, directly or indirectly, give them effect.” Palmore v. Sidoti. 466 U.S. 429 (Race cannot be used in a child custody case involving two natural parents.)*Master of Arts, Criminal Justice & Terrorism, Bachelor of Science, Criminal Justice (Cum Laude) and Associate in Science, Criminal Justice (Magna Cum Laude)I ENDURED 3 ARRESTS. ME VERSUS NH AND THE U.S. DOJ 3-0I DON’T DO JIM CROW. I GOT HIM BACK AND OUT OF THE PATH OF THE PHYSICAL AND EDUCATIONAL HARM.