734 CHAPTER 16
Do you think that Smith was dangerous? Did he make a threat regarding an
identifi able—or foreseeable—victim? Could Smith’s statements be taken in a way to
indicate to the psychologist that Brown was the target? If so, the psychologist might
be obligated to take steps to warn the victim or to restrain Smith through a civil
commitment (although the extent of this obligation differs among various states).
But as you can see from this example, some components related to dangerousness—
severity, imminence, probability of potential harm, and past frequency of dangerous
behavior—are not always known or knowable. (In fact, the article that presented
the case of Mr. Smith did not provide information about what the psychologist de-
cided or about what happened to Smith.) Mental health clinicians must base their
judgments as best they can, in part on known risk factors.
Civil commitments can confl ict with individual rights, so guidelines have been
created to protect patients’ rights by establishing the circumstances necessary for
an involuntary commitment, the duration of such a commitment—and who decides
when it ends—as well as the right to refuse a specifi c type of treatment or treatment
in general (Meyer & Weaver, 2006). It may seem that civil commitments are always
forced or coerced, but that is not necessarily so. Some civil commitments are volun-
tary (that is, the patient agrees to the hospitalization); however, some “voluntary”
hospitalizations may occur only after substantial coercion (Meyer & Weaver, 2006).
Most people who are civilly committed belong to a subset of the mentally ill
population—those who are overrepresented in the revolving door that leads to jails
or hospitals. This revolving door evolved because lawmakers and clinicians wanted
a more humane approach to dealing with the dangerous mentally ill, by treating
them in the least restrictive setting before their condition deteriorates to the point
where they harm themselves or others (Hiday, 2003).his persecutory ideation was increasing. The psychologist considered the possibility that a
joint session with Smith and Brown might help reduce the risk of another assault. Specifi cally,
Smith might consider alternate interpretations and become reassured that these remarks
were innocent, or Brown might realize that it would be advisable to discontinue making such
remarks to Smith. Smith responded to the psychologist’s suggestion for a joint meeting by
becoming increasingly agitated, and he yelled that he had thought their conversations were
secret and that he would never again see the psychologist if their conversations were shared
with anyone.
The psychologist considered the following [types of] interventions, some of which are mu-
tually compatible: (a) increase the frequency of therapy sessions; (b) emphasize a cognitive
reframing of Smith’s interpretations of Brown’s comments; (c) encourage Smith to explore al-
ternative means of protecting himself from the perceived danger, such as always leaving work
at the same time other people leave or always walking home from work on well-lit streets; (d)
refer Smith to the clinic psychiatrist for medication review; (e) encourage Smith to consider
voluntary inpatient care, particularly if the apparent deterioration worsens.
The psychologist realized that if such approaches failed to ameliorate Smith’s deteriora-
tion, or if she believed that the risk of another assault was severe or imminent, delegated pre-
ventive action [such as civil commitment] might be warranted. Because Smith’s functioning
seemed unlikely to meet the jurisdiction’s criteria for civil commitment, a warning of some
kind would be the available delegated intervention. She would be hesitant to warn, however,
because she knew of no empirical evidence that warnings reduce violence, and she believed
that Smith would view such action as a betrayal and discontinue therapy. Further isolation
might also occur if the warning resulted in his dismissal from his job or in counterproduc-
tive responses from Brown. The psychologist’s prior clinical interventions, primarily cognitive
reframing and support, had been effective in ameliorating her client’s inclination toward
persecutory interpretations of events and in managing the risk associated with exacerbation
of these tendencies. She realized that she had no [step-by-step procedure] that allowed her to
measure the absolute severity of the risk or the effectiveness of warnings or of these clinical
interventions. She weighed the potential costs and benefi ts of various interventions as she
monitored the risk represented by Smith’s current functioning.
(Quattrocchi & Schopp, 2005)