in the case of parens patriae criteria and volitional
impairment in the case of police power criteria. It also
discusses the kinds of danger that may satisfy police
power criteria, the degree of imminence of such dan-
ger that is required, and the methods used by clinical
evaluators in predicting dangerousness. It then consid-
ers the medical appropriateness and least restrictive
alternative requirements for commitment. It concludes
by discussing the procedural due process hearing
requirements for commitment.The Impact and Consequences
of Civil Commitment
In the past 50 years, the use of civil commitment has
been reduced. The census of public mental hospitals
in 1955 was around 550,000. The policy of deinstitu-
tionalization, the shift of the locus of care from the
hospital to the community, and the tightening of civil
commitment criteria have reduced our reliance on
involuntary hospitalization. Only about 55,000 patients
are now hospitalized on any particular day. However,
patients once spent long periods and sometimes an
entire lifetime in the hospital, whereas most patients
today are discharged after 30 days or less, and many
within as few as 5 days. For many patients, civil com-
mitment has become a revolving door, whereby they
experience several periods of hospitalization each
year. Civil commitment thus continues to affect a
large number of patients, even if the duration of hos-
pitalization has been dramatically reduced.
Civil commitment results in a massive curtailment
of liberty. It intrudes on the fundamental interest in
being free of external restraint. Patients are subjected
to detailed regulation of their every activity, and they
are forced to submit to various forms of intrusive
treatment, including psychotropic medication, which
may cause severe and unwanted side effects that are
lasting. Involuntary hospitalization also imposes a
severe stigma, which produces continued social and
occupational disabilities long after discharge. As a
result, the criteria for involuntary hospitalization have
been limited, and the procedural protections required
before it may be imposed have been expanded.Justifications for Civil Commitment
There are two justifications for civil commitment. The
first is the government’s police power interest in pro-
tecting the community from those who are predicted tobe dangerous as a result of their mental illness. The
second is the parens patriae interest in protecting the
best interests of those whose illness deprives them of
the ability to make rational decisions on their own
behalf concerning their need for hospitalization and
treatment. The Fifth and Fourteenth Amendment due
process clauses place substantive and procedural limi-
tations on governmental deprivations of liberty. At a
minimum, such deprivations may not be arbitrary or
purposeless. Because the liberty interest in being free
of external restraint is a fundamental constitutional
right, an exceedingly heavy burden of justification is
placed on the government. To satisfy constitutional
requirements, civil commitment thus must be justified
as being necessary to accomplish one or more com-
pelling governmental interests. The state’s police
power and parens patriae power interests are both com-
pelling and in appropriate cases, therefore, will justify
commitment. These two justifications are reflected in
typical civil commitment statutory criteria. The indi-
vidual will be entitled to a hearing at which the state
must demonstrate satisfaction of the criteria and show
that there is no less intrusive alternative method of
achieving the government’s interests in protecting the
individual or the community. Then, commitment may
be authorized for a limited time period.Civil Commitment Statutory Criteria
Commitment statutes typically begin by requiring
“mental illness or disability” but define these terms
imprecisely or circularly. Often these illnesses or dis-
abilities are described as “significant, severe, substan-
tial, or gross impairments.” Some conditions are
expressly excluded from coverage, notably mental
retardation, epilepsy, developmental disabilities, drug
addiction, and alcoholism. Sometimes antisocial per-
sonality disorder is excluded. In practice, clinicians
applying these definitions typically limit hospitaliza-
tion to those with schizophrenia, major affective
depression, or bipolar disorder. Other psychiatric
diagnoses are sometimes thought of as justifying at
least brief hospitalization—borderline personality
disorder, narcissistic personality disorder, reactive
depression, and anorexia nervosa, for example, at
least when the patient is in crisis.
In addition to requiring mental illness, state civil
commitment statutes typically specify some degree of
functional impairment resulting from such illness.
An overwhelming majority of statutes use the phrase90 ———Civil CommitmentC-Cutler (Encyc)-45463.qxd 11/18/2007 12:41 PM Page 90