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U.S. Psychiatrists' beliefs and wants about involuntary civil commitment grounds
International Journal of Law and Psychiatry 29 (2006) 13 – 21
U.S. Psychiatrists’ beliefs and wants about involuntary civil commitment grounds Robert A. Brooks * Department of Criminal Justice, Westfield State College, Westfield, Massachusetts, U.S.A. Received 22 October 2003; received in revised form 18 June 2004; accepted 16 April 2005
Abstract This article presents results of a national U.S. survey of psychiatrists’ views about legal grounds for involuntary civil commitment. Data from 739 Respondents revealed strong support for bdanger to self,Q bdanger to others,Q and bgrave disabilityQ as grounds, but weak support for billness relapse.Q Psychiatrists did not support commitment for addiction to drugs or alcohol nor for sexual predators. Logit regression revealed few significant associations between Respondents’ choice of grounds and other variables, such as race, employment setting, experience with commitment, and political climate of the state. Respondents’ support for the various commitment grounds was found to be most significantly associated with what Respondents believed the law to be in their state; Respondents tended to support the grounds they believed to be the law. The reasons for the strong association between Respondents’ beliefs and wants concerning commitment grounds is explored. It is suggested that Respondents have adopted their states’ commitment grounds as their preferences through a process of internalization of norms. Implications of this hypothesis are discussed. D 2005 Elsevier Inc. All rights reserved.
Involuntary civil commitment has become entrenched and has achieved a taken-for-granted status. Today few argue for its abolishment, but the grounds for civil commitment have been a common subject of commentary, controversy, and reform over the past four decades. From the 19th century through the 1960s in the U.S., the most common standard for commitment was the existence of a bmental illnessQ along with a bneed for treatmentQ (Morrisey & Goldman, 1986). California was the first state to significantly reform its commitment grounds, in the late 1960s, by requiring the state to prove that a respondent was, due to a mental illness, either dangerous to oneself, dangerous to others, or unable to care for oneself (bgravely disabledQ). A process of legislative diffusion followed, and by the late 1970s nearly every U.S. state had adopted the bdangerousnessQ standard, with many states including a separate bgrave disabilityQ criterion as well. However, even before this reform period had ended, many called for the reinstatement of the old commitment standard, citing among other things increased homelessness and rising incarceration of persons with mental illnesses. One psychiatrist famously complained that persons with serious mental illnesses were bdying with their rights onQ (Treffert, 1975) because commitment laws had become too restrictive. There were also highly publicized cases of psychiatric patients committing homicides (see Pierce,
* Tel.: +1 508 929 8974/+1 617 947 1598; fax: +1 508 929 8144. E-mail address: [email protected]. 0160-2527/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2005.04.004
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Durham, & Fisher, 1986). Some state legislatures responded by creating a bfourth standardQ for commitment, typically stated in terms of either a brelapseQ of a severe and chronic mental illness, or a bdeteriorationQ toward either dangerousness or grave disability (herein referred to as the brelapseQ standard). By 2001, fifteen states had added such a fourth standard to their inpatient commitment statutes. Psychiatrists are seen as key stakeholders in the debates about involuntary commitment, and it is thus important to discern their level of support for various legal aspects of commitment. Generally, prior research suggests that psychiatrists support relatively looser grounds for commitment than do other professional groups (such as psychologists and social workers), and are less concerned with protecting civil liberties than in achieving optimal treatment (see Kahle & Sales, 1980). Put differently, psychiatrists are more willing to accept bfalse positives.Q (However, psychiatrists are generally less willing to commit persons to involuntary treatment than is the general public (see Pescocolido, Monahan, Link, Stueve, & Kikuzawa, 1999; Wild et al., 2001)). The American Psychiatric Association supports expanded commitment criteria, and has presented essentially a model law (see APA, 1985) containing the four commitment criteria discussed thus far — danger to self, danger to others, grave disability, and a bdeteriorationQ or brelapseQ standard. Some may assume that this position reflects the views of the majority of U.S. psychiatrists; however, only two national surveys (Kahle & Sales, 1980; Steinmark & Nagel, 1969) have been directed to psychiatrists to measure support for various commitment standards, and thus psychiatrists’ recent views are unknown. The first survey (Steinmark & Nagel, 1969) involved a sample based upon eight psychiatrists from each state, and included a question that asked whether a person should be involuntarily committed if the person was mentally ill but not dangerous to themselves or others (presumably the bneed for treatmentQ standard). Only 10% of responding psychiatrists supported commitment on that basis. This survey is limited because it was not based on a random sample, and also because it took place before comprehensive changes in the states’ civil commitment statutes. The study by Kahle and Sales (1980) was apparently more comprehensive, both as to the groups sampled and the depth of questioning. The authors surveyed 440 psychiatrists, 440 clinical psychologists, and 64 mental health lawyers regarding their support for several possible grounds for commitment. They reported (Kahle & Sales, 1980) that support for most commitment grounds was greater in the psychiatrist group compared to the other groups, though not always at a level of statistical significance. Psychiatrists strongly supported the grounds bdangerous to selfQ and bdangerous to others,Q but did not support bgrave disability.Q Psychiatrists also supported (albeit weakly) both a commitment ground based on bmentally ill onlyQ as well as bdangerous to self or othersQ alone (without the presence of mental illness) (Kahle & Sales, 1980). A more recent survey was directed to members of the Illinois Psychiatric Society (see Luchins, Cooper, Hanrahan, & Rasinski, 2004). Rather than ask about specific commitment grounds, the survey presented a series of vignettes involving different forms of mental illness and substance abuse as well as escalating risk of harm to others and inability to care for oneself. Results indicated that the Illinois psychiatrists were more likely to recommend involuntary treatment as the likelihood of harm increased (although they may have been more stringent than Illinois law would appear to require). They were also significantly more likely to recommend involuntary treatment for persons with serious mental disorders (bipolar disorder, schizophrenia) compared to substance abuse. This latter finding is consistent with a study from England (Roberts, Peay, & Eastman, 2002) finding relatively low levels of support among psychiatrists for involuntary treatment for substance abuse. While these studies provide important information about psychiatrists’ views regarding commitment grounds, they were limited in that they did not report many relationships with other variables. Thus, we do not know from these studies whether psychiatrists’ support for certain commitment grounds was relatively uniform, or varied according to, for example, the respondents’ age or experience, or according to other variables such as region of the country or political climate of the state. We might ask whether psychiatric norms about commitment grounds arise out of the professional culture — i.e., through training and occupational interaction — or whether these norms are more related to larger cultural forces, workplace setting, or even personal characteristics. This study sought to explore the relationships between psychiatrists’ support for various commitment grounds and a host of independent variables — some pre-existing and some created by the researcher. The independent variables comprise two groups — questionnaire variables (including Respondents’ age, race/ethnicity, attitudes, and experience) and state-level variables (including region of the country, state political climate, and relative stringency of the states’ commitment grounds). The goal of the research was to discover some of the apparent sources of psychiatric norms about commitment grounds.
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1. Method 1.1. The survey Questionnaires were mailed to 1500 randomly selected members of the American Psychiatric Association (APA) who resided in the fifty U.S. states and the District of Columbia. Members of two APA sections (Emergency Psychiatry and Suicide/Self Injury) who were assumed to have had more experience with involuntary commitment were oversampled in an attempt to increase responses. The first and second waves of questionnaires were mailed in, respectively, August and October 2001. Seven-hundred-thirty-nine surveys were completed and returned by Respondents, and twenty surveys were returned by the post office as undeliverable, resulting in an initial return rate of 49.3%. Twenty-three surveys were returned uncompleted with notations indicating that the Respondents were not interested in completing the survey, or were ill or retired. The useable surveys produced a return rate of 48.4%. The rate of return compares favorably with other mail surveys of psychiatrists regarding psychiatric hospitalization (see, e.g., Kahle & Sales, 1980 (60%); Laves & Cohen, 1973 (29% mean of three instruments); Luchins et al., 2004 (49%); Peszke, Affleck, & Wintrob, 1980 (D.C.: 24.9%; Connecticut: 54.6%); Simon & Cockerham, 1977 (29%)). The questionnaire was written by the researcher. Relevant questions for the purposes of this article covered the following areas: (1) what commitment grounds Respondents thought the law in their state contained; (2) what grounds Respondents wanted the law to contain; (3) attitudes about involuntary commitment; and (4) demographic variables. Respondents were first asked what they thought was the current law in their state, given the following eight choices: dangerous to oneself, dangerous to others, inability to care for oneself, relapse of severe and chronic mental illness, addiction to alcohol, addiction to drugs other than alcohol, sexual predator status, and other. (The choice botherQ provided a space where Respondents could write in their choice of additional grounds). Later in the survey, Respondents were asked what the grounds should be, given the same eight choices as above. Other questions focused on attitudes about involuntary commitment, and included statements about the role of psychiatrists, the rights of mental health care recipients, and the role of the courts in the commitment process. Respondents were instructed to mark their responses on a scale from b1Q to b7Q where b1Q meant bStrongly DisagreeQ and b7Q meant bStrongly Agree.Q (Respondents could also mark b0Q for bNo OpinionQ). Last, Respondents were asked to identify their sex, race/ ethnicity, years of experience, and work setting, and were asked other questions about their work experience (whether they had treated any patients in the past twenty-four months and whether they had had any experience with involuntary commitment in the past twenty-four months). 1.2. The variables There are five dependent variables, based on whether Respondents wanted grave disability, illness relapse, alcohol addiction, drug addiction, or sexual predator status to be grounds for commitment. These are referred to herein as the bWants as GroundsQ variables. The grounds bdanger to selfQ and bdanger to othersQ are excluded because (as reported below) nearly all Respondents supported those grounds, so analysis would not be meaningful. In addition, the ground botherQ is not considered because a clear consensus did not emerge from responses. The dependent variables are dichotomous (byes/noQ) variables. The independent variables consist of two groups: questionnaire responses and state-level variables. The questionnaire variables are: (1) sex, (2) race/ethnicity, (3) years of experience, (4) employment setting, (5) whether Respondents had treated any patients in the past twenty-four months, (6) whether Respondents had had any experience with involuntary commitment in the past twenty-four months, (7) attitudes about involuntary commitment (referred to herein as the Attitudes about Commitment variable), (8) APA section membership (general membership, Emergency Psychiatry section, or Suicide/Self Injury section), and (9) what Respondents believed commitment grounds to be in their state (referred to herein as the Believes is Law variable). The second category of independent variables (the state-level variables) contains four variables. The first, region of the country, used the United States Census Bureau classification in which each state (except Alaska and Hawaii) is placed into one of four regional categories: Northeast, North Central, South, or West/Transplains (see Sharkansky, 1970). A second variable (created for this research) was designed to measure each state’s relative political climate. The variable, Presidential Voting, reflects the percentage of votes for the Democratic candidate for U.S. president,
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averaged over the last three presidential elections prior to the survey (1992, 1996, and 2000). The three elections were chosen in order to minimize unusual results in a particular year while maintaining relatively close temporal proximity. Two other state-level variables were constructed for this research; both involved categorizing the commitment laws of all the states in 2001 (the year the questionnaires were mailed). The first of these variables measured the relative stringency of each state’s involuntary commitment law. This measure, Relative Expansiveness, is made up of three parts: grounds for commitment, time limits on commitment, and the extent of the state’s outpatient commitment law. A similar measure has been employed by others (e.g., Maloy, 1990; Ross, Rothbard, & Schinnar, 1996). Another variable, Relapse Criterion, is a dichotomous variable measuring whether a state’s commitment law included bdeteriorationQ or brelapseQ grounds. Fifteen states were found to have such expanded criteria in 2001. South Carolina was also included in this group due to its unique retention of the broad bneed for treatmentQ commitment standard. 1.3. Data analysis The independent variables were tested for initial significance with the five dependent variables. The method used was logit regression because each of the dependent variables (whether Respondents wanted particular grounds) is dichotomous. One of the benefits of logit analysis is that it allows the use of independent variables that are either Table 1 Significant ( p b 0.10) logit results for each of the five dependent variables odds ratios (b) Variable Believes is law Attitudes about commitment Race Asian Race Black Race Hispanic Years experience Experience with commitment Employment hosp/clinic Employment teaching Employment other Region Northeast Region South Region West Section–Emergency Section–Suicide Presidential Voting
Grave disability 7.230* (1.978) 1.076** (0.073) 1.527** (0.217) 1.315 (0.274) 0.749 (- 0.289) 0.976 (- 0.025) 0.995 (- 0.005) 1.394 (0.332) 1.428 (0.356) 0.780 (- 0.249) 0.802 (- 0.221) 0.603 (- 0.221) 1.229 (0.206) 1.382 (0.324) 2.093 ( 0.739) 1.010 (0.010)
Illness relapse
Alcohol addiction
Drug addiction
Sexual predator status
7.889* (2.066) 1.093* (0.088) 1.097 (0.093) 0.457 (- 0.784) 1.959 (0.673) 1.021*** (0.020) 1.320 (0.278) 0.892 (- 0.114) 1.171 (0.158) 0.857 (- 0.154) 0.589*** (- 0.529) 0.661 (- 0.415) 1.063 (0.061) 1.032 (0.032) 1.225 (0.203) 0.989 (- 0.011)
13.305* (2.588) 1.060** (0.058) 1.379 (0.321) 0.113 (- 2.182) 2.406 (0.878) 1.002 (0.002) 1.300 (0.263) 0.567 (- 0.567) 0.701 (- 0.335) 0.772 (- 0.259) 0.414*** (- 0.881) 0.853 (- 0.159) 0.882 (- 0.126) 0.639 (- 0.447) 1.401 (0.337) 0.990 (0.010)
13.496* (2.602) 1.048** (0.047) 1.302 (0.264) 0.104*** (- 2.268) 2.229 (0.832) 0.977 (0.005) 1.247 (0.221) 0.599 (- 0.513) 0.803 (- 0.220) 0.840 (- 0.174) 0.385** (- 0.995) 0.735 (- 0.307) 0.611 (- 0.492) 0.657 (- 0.420) 1.413 (0.346) 0.995 (- 0.005)
5.114* (1.632) 1.052** (0.051) 1.011 (0.011) 1.105 ( 0.100) 1.935 (0.660) 1.006 (0.006) 0.772 (- 0.259) 0.503** (- 0.688) 0.605 (- 0.502) 0.398*** (- 0.922) 1.346 (0.297) 1.281 ( 0.248) 0.732 (- 0.313) 0.922 (- 0.081) 1.595 (0.467) 0.983 (- 0.017)
The reference categories are as follows: for bRace,Q white; for bEmployment,Q private practice, for bRegion,Q central region; and for bSection,Q general membership in the APA. * p b 0.0001. ** p b 0.005. *** p b 0.05.
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Table 2A Relationship between beliefs and wants about grave disability (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
96.28 73.27 89.49 (614)
3.72 26.73 10.51 (72)
100.00 (484) 100.00 (202) 100.00 (686)
Pearson chi-square = 80.351 ( p b 0.0001). Goodman–Kruskal Gamma = 0.809.
continuous or categorical. Initial screening of the independent variables was based on whether the variable was significant at a chosen level ( p b 0.10) in a logit equation with any of the dependent variables. Methodologists (i.e., Affifi & Clark, 1990) recommend a more generous p-value cut-off in the initial screening than in the final model. Independent variables that had a significant relationship with at least one dependent variable were selected for inclusion in the final logit model. While this resulted in the inclusion of non-significant variables for some of the dependent variables, this was preferred because of the desire to use the same logit model for all five dependent variables. The same independent variables were used in each case; however, the Believes is Law variable was different in each case because it corresponded to the dependent Wants as Law variable. For example, the independent variable bbelieves grave disabilityQ was used with bwants grave disabilityQ and bbelieves illness relapseQ was used with bwants illness relapse,Q etc. Results from the initial significance tests showed that ten of the thirteen independent variables had a significant relationship with at least one of the dependent variables. The variables Sex, Section Membership, and Commitment Expansiveness resulted in non-significant relationships across all five dependent variables. However, the relationship between Section Membership and some of the dependent variables approached significance (with a p-value slightly greater than 0.10), and Section Membership was thus included in the final model because of the near significance of the term and because it was felt important to determine if the dependent variables were associated with the design method of oversampling. 2. Findings Nearly all Respondents wanted a commitment law that includes bdanger to selfQ (99.0%) and bdanger to othersQ (98.7%) as grounds. A conclusive majority (89.6%) also wanted bgrave disabilityQ to be grounds, while a bare majority (51.6%) wanted billness relapseQ as grounds. There was less support among Respondents for commitment for alcohol addiction (22.0%), drug addiction (22.3%), and sexual predator status (26.1%). Each of the five models was run with the ten identified significant independent variables. See Table 1. Most independent variables showed only scattered significance with the dependent variables. As to the questionnaire variables, Race and Employment Setting were significant in a few cases while Experience with Commitment had no significant relationship with any of the dependent variables. As to the state-level variables, the only significant relationship involved the Region variables — there were significant differences in the case of the Northeast region, where Respondents were less supportive of commitment for illness relapse, alcohol addiction, and drug addiction than were Respondents in the North Central region. Only two independent variables — Believes is Law (what Respondents believed were the commitment grounds in their state) and Attitudes about Commitment (the combined score on the twelve attitude questions) — were significant across all five dependent variables. In the case of Believes is Law, p-values were very small (b0.0001) in each case, and odds ratios were large — from 5.114 for sexual predator status to 13.496 for drug addiction. The relationship between each Believes is Law and Wants as Law set of variables is shown in cross-tab form in Tables 2A–2E. The Table 2B Relationship between beliefs and wants about illness relapse (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
89.47 47.05 51.83 (355)
10.53 52.95 48.18 (331)
100.00 (76) 100.00 (610) 100.00 (686)
Pearson chi-square = 48.713 ( p b 0.0001). Goodman–Kruskal Gamma = 0.811.
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Table 2C Relationship between beliefs and wants about alcohol addiction (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
68.13 15.13 22.19 (152)
31.87 84.87 77.81 (534)
100.00 (91) 100.00 (595) 100.00 (686)
Pearson chi-square = 128.571 ( p b 0.0001). Goodman–Kruskal Gamma = 0.846.
relationship in each case is highly significant. For example, although overall Respondents did not support commitment for alcohol addiction, the majority (68.1%) of those who believed alcohol addiction was a ground also wanted it as a ground, while among those who believed alcohol addiction was not a ground the majority (84.9%) also did not want it as a ground. See Table 2C. The same relationship holds true for the other grounds — grave disability, illness relapse, drug addiction, and sexual predator status. See Tables 2A, 2B, 2D, and 2E, respectively. In each case, there is a highly significant relationship between Believes is Law and Wants as Law; in all cases except grave disability, in each table row the majority of the responses are in cells where beliefs and wants are consonant. (Because there was strong support (almost 90%) for grave disability, only about one-quarter of those who believed grave disability not to be a commitment ground supported it. However, this compares to only 3.7% of those who believed that grave disability was a ground but did not want it as a ground, and the relationship involving grave disability was still highly significant. See Table 2A). The variable Attitudes about Commitment was also highly significant across all five dependent variables, with small p-values (ranging from b 0.0001 to 0.005). For each of the grounds, Attitudes about Commitment had a positive, significant ( p b 0.05) association with Wants as Grounds — the higher the score on Attitudes about Commitment (the more the Respondent supported psychiatric prerogative), the more likely a Respondent was to support each commitment ground. 3. Discussion Respondents’ nearly unanimous support for the grounds bdanger to selfQ and bdanger to othersQ echoes earlier findings (Kahle & Sales, 1980), and is reflective of other research that shows psychiatrists increasingly supporting commitment based upon a hypothetical increase in risk or danger (Luchins et al., 2004; Simon & Cockerham, 1977). Respondents’ weak support for brelapseQ as grounds is similar to psychiatrists’ less than unanimous endorsement (48%) of commitment based upon mental illness only (Kahle & Sales, 1980), but is greater than the 10% in another study (Steinmark & Nagel, 1969) supporting commitment for mental illness in the absence of danger. Respondents showed much stronger support for commitment based on bgrave disabilityQ than that found in an earlier study (Kahle & Sales, 1980). Respondents’ lack of support for commitment based upon substance abuse is consistent with psychiatrists’ views as found in other surveys in the U.S. (e.g., Luchins et al., 2004) and England (Roberts et al., 2002). Most independent variables did not have a significant relationship with the dependent variables. See Table 1. As to the state-level variables, only Region produced significant results, with those in the Northeast tending to be less supportive of three of the five commitment grounds than those in the North Central region. The demographic variables had few significant interactions as well — Respondents’ sex was not significant, and there were only two instances where Race produced a significant ( p b 0.05) relationship. Respondents’ prior experience with commitment also was not significant. Others (e.g., Luchins et al., 2004) have found that a respondent’s experience with commitment was not related to decisions to commit. This may be because experience with commitment in this case was a crude measure, documenting only whether a Respondent did or did not have experience. It may be that Table 2D Relationship between beliefs and wants about drug addiction (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
71.05 16.39 22.48 (154)
28.95 83.61 77.52 (532)
100.00 (76) 100.00 (610) 100.00 (686)
Pearson chi-square = 115.974 ( p b 0.0001). Goodman–Kruskal Gamma = 0.852.
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Table 2E Relationship between beliefs and wants about sexual predator status (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
56.00 23.27 25.69 (176)
44.00 76.73 74.31 (510)
100.00 (50) 100.00 (636) 100.00 (686)
Pearson chi-square = 26.034 ( p b 0.0001). Goodman–Kruskal Gamma = 0.615.
experience with commitment does not lead naturally to either support or opposition to certain grounds — perhaps the nature, quality, and setting of the experience may be more important contributors. By far, the strongest and most consistent relationships involved the independent variables Believes is Law and Attitudes about Commitment. The association between the Attitudes about Commitment and Wants as Grounds variables is perhaps not surprising given that both of those variables could be seen as a measure of psychiatric prerogative. However, the link between Believes is Law and Wants as Law is perhaps less obvious and merits some discussion. Economic rational actor theorists assume that personal preferences are given and fixed (Stigler & Becker, 1997) However, more sociological perspectives — even within economics (see Bikhchandani, Hirshleifer, & Welch, 1992) — recognize that a person’s preferences are subject to influence through social interaction. This internalization of norms has been described as a bremarkable process through which imposed obligations . . . become desiresQ (Etzioni, 2000). This process is frequently conceived of in terms of social rules that affect an actor’s behavior directly — initially the actor risks social sanctions for non-compliance, and after internalization experiences psychological costs as well (such as guilt) for non-compliance (Lessig, 1995; McAdams, 1996). Here, risks for disobeying the social norm (the state’s commitment law) are less direct. While psychiatrists (for the most part) are not at risk for involuntary commitment themselves (and therefore do not need to conform their personal behavior to the demands of the law in that sense), they are nevertheless subject to the law’s requirements when initiating commitment proceedings. They risk negative sanctions such as blosingQ the commitment proceeding as well as incurring damage to their professional reputation by initiating proceedings that do not conform to the law’s requirements. Thus, at least theoretically there is a strong motivation to internalize the law’s demands. (This is in addition to internalizing the bmeta-ruleQ that rules are to be obeyed). Others (e.g., Duster, 1970) suggest more broadly that changes in the law can result in increased public acceptance of the new legal classification. For example, making the use of narcotic drugs a crime may have caused people’s views of addiction to change — what had been thought of as a medical problem began to be seen as criminal behavior (Duster, 1970, 3–76). The findings from this study lend support to these internalization processes. The law (or at least what Respondents believed to be the law) has apparently conditioned Respondents desires. For every commitment ground, Believes is Law and Wants as Law were highly significantly related. Respondents appear to have internalized their bknowledgeQ (whether correct or incorrect) of existing law; when making choices, Respondents were significantly influenced by what they believed to be the law in their state. (Respondents were sometimes incorrect about the grounds for commitment in their state, particularly with regard to the bsexual predatorQ ground; others (e.g., Belter, Duer, & Stanny, 1999; Laves & Cohen, 1973; Peszke & Wintrob, 1974) have also found psychiatrists’ knowledge of the legal requirements of psychiatric hospitalization wanting in some respects). However, other causal explanations for the relationship should be considered. First, the directionality of the relationship could be the reverse — it may be that Respondents believed certain grounds to be law because they wanted those grounds as law. There is evidence from questionnaire responses that this is not the case. One Respondent from Iowa checked a number of grounds, including the botherQ category, and wrote in bemotional injury,Q which is an unusual commitment ground in Iowa’s statute. It seems unlikely that most psychiatrists would independently support such grounds for commitment, and certainly no Respondent not from Iowa proposed bemotional injuryQ as a commitment ground. Other Respondents also wrote in grounds contained in their own states’ laws. For example, a Respondent from the state of Washington checked botherQ and wrote bdamage to property,Q one of the grounds contained in Washington’s statute. A Respondent from New York wrote in bKendra’s lawQ (New York state’s outpatient commitment statute) as botherQ grounds they believed to be law in New York, and wrote in botherQ grounds they wanted for commitment as bnoncompliance with treatment regimenQ (the wording found in bKendra’s lawQ).
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This process of internalization is also illustrated, more broadly, by the increased support for bgrave disabilityQ as a standard between the time of the study by Kahle and Sales (the late 1970s) and the current study; in the interim period, many more states had adopted (whether legislatively or judicially) the bgrave disabilityQ standard. During this period, commitment for grave disability became the most commonly used commitment ground in the U.S. (Turkheimer & Parry, 1992). Of course, other changes also occurred during this period, including apparent increases in homeless persons with mental disorders, increased emphasis on psychiatric malpractice, and more public concern about safety. These all may have contributed to psychiatrists’ increasing support for bgrave disabilityQ as a standard. However, these social changes would not explain why the significant relationship persists between what psychiatrists believed was the law in their state and what they wanted as the law. In other words, while psychiatrists as a whole support bgrave disabilityQ as a commitment ground, they are less likely to do so if they believe grave disability is not the law. See Table 2A. It is also possible that the relationship between Respondents’ beliefs and wants is spurious, in either of two ways. The relationship could be an artifact of the questionnaire design because responses for both questions were the same eight choices. After answering the bbeliefsQ question many Respondents may have merely checked the same boxes by rote when answering the bwantsQ question. However, this appears unlikely, given that the two questions were separated physically in the questionnaire, with ten attitude questions in between them. The relationship could also be due to a more subtle causal mechanism. It may be that psychiatrists in different states wanted different laws, and were successful in enacting such laws. Thus, what psychiatrists want would reflect what they believe because each state’s psychiatrists were successful in enacting laws they wanted. This explanation is not highly plausible. First, there are many competing interest groups involved in crafting legislation (mental health consumers, civil rights advocates, and other mental health professionals), and even psychiatrists frequently disagree about what grounds should be included — thus, it is unlikely that psychiatrists regularly bgetQ the law they want. In addition, the argument that Respondents wanted the law because they were successful in enacting it would operate only if Respondents were actually correct about what the commitment grounds were in their state. As noted above, Respondents were sometimes not correct about the content of their states’ commitment statutes. This study is limited because psychiatrists’ attitudes and beliefs may not directly translate into behaviors. In addition, views of APA members may not reflect those of U.S. psychiatrists as a whole. Nevertheless, the findings from this study that appear to confirm that Respondents have internalized the dictates of the law — that they have largely accepted the content of their states’ commitment laws and have come to see the provisions as their own preferences — has potential implications for those engaged in reform efforts related to civil commitment. Even the highly educated professionals in this study showed strong preferences for what they believed to be the status quo. This process is consistent also with the traditional tendency of incrementalism in U.S. legislation. One of the reasons that there frequently is resistance to major legal reforms is that various actors in the process have internalized the existing norms and made them their preferences. Change thus typically comes in pieces, not from whole cloth. References Affifi, A. A., & Clark, V. (1990). Computer-aided multivariate analysis, 2nd ed. New York7 Van Nostrand Reinhold Company. American Psychiatric Association (1985). Guidelines for legislation on the psychiatric hospitalization of adults. American Journal of Psychiatry, 140, 672 – 679. Belter, R. D., Duer, J. D., & Stanny, C. (1999). Clinical judgments regarding involuntary commitment: A comparison of mental health professions. Journal of Psychological Practice, 5, 32 – 38. Bikhchandani, S., Hirshleifer, D., & Welch, I. (1992). A theory of fads, fashion, custom, and cultural changes as informational cascades. Journal of Political Economy, 100, 992 – 1026. Duster, T. (1970). The legislation of morality: Law, drugs, and moral judgment. New York7 Free Press. Etzioni, A. (2000). Social norms: Internalization, persuasion, and history. Law and Society Review, 34, 157 – 178. Kahle, L. R., & Sales, B. D. (1980). Due process of law and the attitudes of professionals toward involuntary civil commitment. In P. D. Lipsitt, & B. D. Sales (Eds.), New directions in psycholegal research (pp. 264 – 292). New York7 Van Nostrand Reinhold Company. Laves, R., & Cohen, A. (1973). A preliminary investigation into the knowledge of and attitudes toward the legal rights of mental patients. Journal of Psychiatry and Law, 1, 49 – 78. Lessig, L. (1995). The regulation of social meaning. University of Chicago Law Review, 62, 943 – 984. Luchins, D. J., Cooper, A. E., Hanrahan, P., & Rasinski, K. (2004). Psychiatrists’ attitudes toward involuntary hospitalization. Psychiatric Services, 55, 1058 – 1060. Maloy, K.A. (1990). Caring and controlling: The political and socioeconomic factors shaping state civil commitment laws. Ph.D. diss., Boston University.
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McAdams, R. (1996). The origin, development, and regulation of norms. University of Michigan Law Review, 96, 338 – 375. Morrisey, J. P., & Goldman, H. H. (1986). Care and treatment of the mentally ill in the United States: Historical developments and reforms. Annals of the American Academy of Political and Social Science, 484, 12 – 27. Pescocolido, B. A., Monahan, J., Link, B. G., Stueve, A., & Kikuzawa, S. (1999). The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 1339 – 1345. Peszke, M. A., Affleck, G. G., & Wintrob, R. M. (1980). Perceived statutory applicability versus clinical desirability of emergency involuntary hospitalization. American Journal of Psychiatry, 137, 476 – 480. Peszke, M. A., & Wintrob, R. M. (1974). Emergency commitment: A transcultural study. American Journal of Psychiatry, 131, 36 – 40. Pierce, G. L., Durham, M. L., & Fisher, W. H. (1986). The impact of public policy and publicity on admissions to state mental hospitals. Journal of Health Politics, Policy and Law, 11, 41 – 66. Roberts, C., Peay, J., & Eastman, N. (2002). Mental health professionals’ attitudes towards legal compulsion: Report of a national survey. International Journal of Forensic Mental Health, 1, 71 – 82. Ross, R. E., Rothbard, A. B., & Schinnar, A. P. (1996). A framework for classifying state involuntary commitment statutes. Administration and Policy in Mental Health, 23, 341 – 356. Sharkansky, I. (1970). Regionalism in American politics. Indianapolis7 Bobbs-Merrill Co. Simon, R. J., & Cockerham, W. (1977). Civil commitment, burden of proof and dangerous acts: A comparison of the perspectives of judges and psychiatrists. Law and Psychiatry, 5, 571 – 594. Steinmark, L., & Nagel, S. (1969). The impact of due process rules on commitment proceedings. Unpublished manuscript, University of Illinois. Stigler, G., & Becker, G. (1977). De gustibus non est disputandum. American Economic Review, 67, 76 – 95. Treffert, D. A. (1975). The practical limits of patients’ rights. Psychiatric Annals, 5, 91 – 96. Turkheimer, E., & Parry, C. D. H. (1992). Why the gap? Practice and policy in civil commitment hearings. American Psychologist, 47, 646 – 655. Wild, T. C., Newton-Taylor, B., Ogborne, A. C., Mann, R., Erickson, P., & MacDonald, S. (2001). Attitudes toward compulsory substance abuse treatment: A comparison of the public, counselors, probationers, and judges’ views. Drugs: Education, Prevention and Policy, 8, 33 – 45.
U.S. Psychiatrists’ beliefs and wants about involuntary civil commitment grounds Robert A. Brooks * Department of Criminal Justice, Westfield State College, Westfield, Massachusetts, U.S.A. Received 22 October 2003; received in revised form 18 June 2004; accepted 16 April 2005
Abstract This article presents results of a national U.S. survey of psychiatrists’ views about legal grounds for involuntary civil commitment. Data from 739 Respondents revealed strong support for bdanger to self,Q bdanger to others,Q and bgrave disabilityQ as grounds, but weak support for billness relapse.Q Psychiatrists did not support commitment for addiction to drugs or alcohol nor for sexual predators. Logit regression revealed few significant associations between Respondents’ choice of grounds and other variables, such as race, employment setting, experience with commitment, and political climate of the state. Respondents’ support for the various commitment grounds was found to be most significantly associated with what Respondents believed the law to be in their state; Respondents tended to support the grounds they believed to be the law. The reasons for the strong association between Respondents’ beliefs and wants concerning commitment grounds is explored. It is suggested that Respondents have adopted their states’ commitment grounds as their preferences through a process of internalization of norms. Implications of this hypothesis are discussed. D 2005 Elsevier Inc. All rights reserved.
Involuntary civil commitment has become entrenched and has achieved a taken-for-granted status. Today few argue for its abolishment, but the grounds for civil commitment have been a common subject of commentary, controversy, and reform over the past four decades. From the 19th century through the 1960s in the U.S., the most common standard for commitment was the existence of a bmental illnessQ along with a bneed for treatmentQ (Morrisey & Goldman, 1986). California was the first state to significantly reform its commitment grounds, in the late 1960s, by requiring the state to prove that a respondent was, due to a mental illness, either dangerous to oneself, dangerous to others, or unable to care for oneself (bgravely disabledQ). A process of legislative diffusion followed, and by the late 1970s nearly every U.S. state had adopted the bdangerousnessQ standard, with many states including a separate bgrave disabilityQ criterion as well. However, even before this reform period had ended, many called for the reinstatement of the old commitment standard, citing among other things increased homelessness and rising incarceration of persons with mental illnesses. One psychiatrist famously complained that persons with serious mental illnesses were bdying with their rights onQ (Treffert, 1975) because commitment laws had become too restrictive. There were also highly publicized cases of psychiatric patients committing homicides (see Pierce,
* Tel.: +1 508 929 8974/+1 617 947 1598; fax: +1 508 929 8144. E-mail address: [email protected]. 0160-2527/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2005.04.004
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Durham, & Fisher, 1986). Some state legislatures responded by creating a bfourth standardQ for commitment, typically stated in terms of either a brelapseQ of a severe and chronic mental illness, or a bdeteriorationQ toward either dangerousness or grave disability (herein referred to as the brelapseQ standard). By 2001, fifteen states had added such a fourth standard to their inpatient commitment statutes. Psychiatrists are seen as key stakeholders in the debates about involuntary commitment, and it is thus important to discern their level of support for various legal aspects of commitment. Generally, prior research suggests that psychiatrists support relatively looser grounds for commitment than do other professional groups (such as psychologists and social workers), and are less concerned with protecting civil liberties than in achieving optimal treatment (see Kahle & Sales, 1980). Put differently, psychiatrists are more willing to accept bfalse positives.Q (However, psychiatrists are generally less willing to commit persons to involuntary treatment than is the general public (see Pescocolido, Monahan, Link, Stueve, & Kikuzawa, 1999; Wild et al., 2001)). The American Psychiatric Association supports expanded commitment criteria, and has presented essentially a model law (see APA, 1985) containing the four commitment criteria discussed thus far — danger to self, danger to others, grave disability, and a bdeteriorationQ or brelapseQ standard. Some may assume that this position reflects the views of the majority of U.S. psychiatrists; however, only two national surveys (Kahle & Sales, 1980; Steinmark & Nagel, 1969) have been directed to psychiatrists to measure support for various commitment standards, and thus psychiatrists’ recent views are unknown. The first survey (Steinmark & Nagel, 1969) involved a sample based upon eight psychiatrists from each state, and included a question that asked whether a person should be involuntarily committed if the person was mentally ill but not dangerous to themselves or others (presumably the bneed for treatmentQ standard). Only 10% of responding psychiatrists supported commitment on that basis. This survey is limited because it was not based on a random sample, and also because it took place before comprehensive changes in the states’ civil commitment statutes. The study by Kahle and Sales (1980) was apparently more comprehensive, both as to the groups sampled and the depth of questioning. The authors surveyed 440 psychiatrists, 440 clinical psychologists, and 64 mental health lawyers regarding their support for several possible grounds for commitment. They reported (Kahle & Sales, 1980) that support for most commitment grounds was greater in the psychiatrist group compared to the other groups, though not always at a level of statistical significance. Psychiatrists strongly supported the grounds bdangerous to selfQ and bdangerous to others,Q but did not support bgrave disability.Q Psychiatrists also supported (albeit weakly) both a commitment ground based on bmentally ill onlyQ as well as bdangerous to self or othersQ alone (without the presence of mental illness) (Kahle & Sales, 1980). A more recent survey was directed to members of the Illinois Psychiatric Society (see Luchins, Cooper, Hanrahan, & Rasinski, 2004). Rather than ask about specific commitment grounds, the survey presented a series of vignettes involving different forms of mental illness and substance abuse as well as escalating risk of harm to others and inability to care for oneself. Results indicated that the Illinois psychiatrists were more likely to recommend involuntary treatment as the likelihood of harm increased (although they may have been more stringent than Illinois law would appear to require). They were also significantly more likely to recommend involuntary treatment for persons with serious mental disorders (bipolar disorder, schizophrenia) compared to substance abuse. This latter finding is consistent with a study from England (Roberts, Peay, & Eastman, 2002) finding relatively low levels of support among psychiatrists for involuntary treatment for substance abuse. While these studies provide important information about psychiatrists’ views regarding commitment grounds, they were limited in that they did not report many relationships with other variables. Thus, we do not know from these studies whether psychiatrists’ support for certain commitment grounds was relatively uniform, or varied according to, for example, the respondents’ age or experience, or according to other variables such as region of the country or political climate of the state. We might ask whether psychiatric norms about commitment grounds arise out of the professional culture — i.e., through training and occupational interaction — or whether these norms are more related to larger cultural forces, workplace setting, or even personal characteristics. This study sought to explore the relationships between psychiatrists’ support for various commitment grounds and a host of independent variables — some pre-existing and some created by the researcher. The independent variables comprise two groups — questionnaire variables (including Respondents’ age, race/ethnicity, attitudes, and experience) and state-level variables (including region of the country, state political climate, and relative stringency of the states’ commitment grounds). The goal of the research was to discover some of the apparent sources of psychiatric norms about commitment grounds.
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1. Method 1.1. The survey Questionnaires were mailed to 1500 randomly selected members of the American Psychiatric Association (APA) who resided in the fifty U.S. states and the District of Columbia. Members of two APA sections (Emergency Psychiatry and Suicide/Self Injury) who were assumed to have had more experience with involuntary commitment were oversampled in an attempt to increase responses. The first and second waves of questionnaires were mailed in, respectively, August and October 2001. Seven-hundred-thirty-nine surveys were completed and returned by Respondents, and twenty surveys were returned by the post office as undeliverable, resulting in an initial return rate of 49.3%. Twenty-three surveys were returned uncompleted with notations indicating that the Respondents were not interested in completing the survey, or were ill or retired. The useable surveys produced a return rate of 48.4%. The rate of return compares favorably with other mail surveys of psychiatrists regarding psychiatric hospitalization (see, e.g., Kahle & Sales, 1980 (60%); Laves & Cohen, 1973 (29% mean of three instruments); Luchins et al., 2004 (49%); Peszke, Affleck, & Wintrob, 1980 (D.C.: 24.9%; Connecticut: 54.6%); Simon & Cockerham, 1977 (29%)). The questionnaire was written by the researcher. Relevant questions for the purposes of this article covered the following areas: (1) what commitment grounds Respondents thought the law in their state contained; (2) what grounds Respondents wanted the law to contain; (3) attitudes about involuntary commitment; and (4) demographic variables. Respondents were first asked what they thought was the current law in their state, given the following eight choices: dangerous to oneself, dangerous to others, inability to care for oneself, relapse of severe and chronic mental illness, addiction to alcohol, addiction to drugs other than alcohol, sexual predator status, and other. (The choice botherQ provided a space where Respondents could write in their choice of additional grounds). Later in the survey, Respondents were asked what the grounds should be, given the same eight choices as above. Other questions focused on attitudes about involuntary commitment, and included statements about the role of psychiatrists, the rights of mental health care recipients, and the role of the courts in the commitment process. Respondents were instructed to mark their responses on a scale from b1Q to b7Q where b1Q meant bStrongly DisagreeQ and b7Q meant bStrongly Agree.Q (Respondents could also mark b0Q for bNo OpinionQ). Last, Respondents were asked to identify their sex, race/ ethnicity, years of experience, and work setting, and were asked other questions about their work experience (whether they had treated any patients in the past twenty-four months and whether they had had any experience with involuntary commitment in the past twenty-four months). 1.2. The variables There are five dependent variables, based on whether Respondents wanted grave disability, illness relapse, alcohol addiction, drug addiction, or sexual predator status to be grounds for commitment. These are referred to herein as the bWants as GroundsQ variables. The grounds bdanger to selfQ and bdanger to othersQ are excluded because (as reported below) nearly all Respondents supported those grounds, so analysis would not be meaningful. In addition, the ground botherQ is not considered because a clear consensus did not emerge from responses. The dependent variables are dichotomous (byes/noQ) variables. The independent variables consist of two groups: questionnaire responses and state-level variables. The questionnaire variables are: (1) sex, (2) race/ethnicity, (3) years of experience, (4) employment setting, (5) whether Respondents had treated any patients in the past twenty-four months, (6) whether Respondents had had any experience with involuntary commitment in the past twenty-four months, (7) attitudes about involuntary commitment (referred to herein as the Attitudes about Commitment variable), (8) APA section membership (general membership, Emergency Psychiatry section, or Suicide/Self Injury section), and (9) what Respondents believed commitment grounds to be in their state (referred to herein as the Believes is Law variable). The second category of independent variables (the state-level variables) contains four variables. The first, region of the country, used the United States Census Bureau classification in which each state (except Alaska and Hawaii) is placed into one of four regional categories: Northeast, North Central, South, or West/Transplains (see Sharkansky, 1970). A second variable (created for this research) was designed to measure each state’s relative political climate. The variable, Presidential Voting, reflects the percentage of votes for the Democratic candidate for U.S. president,
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averaged over the last three presidential elections prior to the survey (1992, 1996, and 2000). The three elections were chosen in order to minimize unusual results in a particular year while maintaining relatively close temporal proximity. Two other state-level variables were constructed for this research; both involved categorizing the commitment laws of all the states in 2001 (the year the questionnaires were mailed). The first of these variables measured the relative stringency of each state’s involuntary commitment law. This measure, Relative Expansiveness, is made up of three parts: grounds for commitment, time limits on commitment, and the extent of the state’s outpatient commitment law. A similar measure has been employed by others (e.g., Maloy, 1990; Ross, Rothbard, & Schinnar, 1996). Another variable, Relapse Criterion, is a dichotomous variable measuring whether a state’s commitment law included bdeteriorationQ or brelapseQ grounds. Fifteen states were found to have such expanded criteria in 2001. South Carolina was also included in this group due to its unique retention of the broad bneed for treatmentQ commitment standard. 1.3. Data analysis The independent variables were tested for initial significance with the five dependent variables. The method used was logit regression because each of the dependent variables (whether Respondents wanted particular grounds) is dichotomous. One of the benefits of logit analysis is that it allows the use of independent variables that are either Table 1 Significant ( p b 0.10) logit results for each of the five dependent variables odds ratios (b) Variable Believes is law Attitudes about commitment Race Asian Race Black Race Hispanic Years experience Experience with commitment Employment hosp/clinic Employment teaching Employment other Region Northeast Region South Region West Section–Emergency Section–Suicide Presidential Voting
Grave disability 7.230* (1.978) 1.076** (0.073) 1.527** (0.217) 1.315 (0.274) 0.749 (- 0.289) 0.976 (- 0.025) 0.995 (- 0.005) 1.394 (0.332) 1.428 (0.356) 0.780 (- 0.249) 0.802 (- 0.221) 0.603 (- 0.221) 1.229 (0.206) 1.382 (0.324) 2.093 ( 0.739) 1.010 (0.010)
Illness relapse
Alcohol addiction
Drug addiction
Sexual predator status
7.889* (2.066) 1.093* (0.088) 1.097 (0.093) 0.457 (- 0.784) 1.959 (0.673) 1.021*** (0.020) 1.320 (0.278) 0.892 (- 0.114) 1.171 (0.158) 0.857 (- 0.154) 0.589*** (- 0.529) 0.661 (- 0.415) 1.063 (0.061) 1.032 (0.032) 1.225 (0.203) 0.989 (- 0.011)
13.305* (2.588) 1.060** (0.058) 1.379 (0.321) 0.113 (- 2.182) 2.406 (0.878) 1.002 (0.002) 1.300 (0.263) 0.567 (- 0.567) 0.701 (- 0.335) 0.772 (- 0.259) 0.414*** (- 0.881) 0.853 (- 0.159) 0.882 (- 0.126) 0.639 (- 0.447) 1.401 (0.337) 0.990 (0.010)
13.496* (2.602) 1.048** (0.047) 1.302 (0.264) 0.104*** (- 2.268) 2.229 (0.832) 0.977 (0.005) 1.247 (0.221) 0.599 (- 0.513) 0.803 (- 0.220) 0.840 (- 0.174) 0.385** (- 0.995) 0.735 (- 0.307) 0.611 (- 0.492) 0.657 (- 0.420) 1.413 (0.346) 0.995 (- 0.005)
5.114* (1.632) 1.052** (0.051) 1.011 (0.011) 1.105 ( 0.100) 1.935 (0.660) 1.006 (0.006) 0.772 (- 0.259) 0.503** (- 0.688) 0.605 (- 0.502) 0.398*** (- 0.922) 1.346 (0.297) 1.281 ( 0.248) 0.732 (- 0.313) 0.922 (- 0.081) 1.595 (0.467) 0.983 (- 0.017)
The reference categories are as follows: for bRace,Q white; for bEmployment,Q private practice, for bRegion,Q central region; and for bSection,Q general membership in the APA. * p b 0.0001. ** p b 0.005. *** p b 0.05.
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Table 2A Relationship between beliefs and wants about grave disability (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
96.28 73.27 89.49 (614)
3.72 26.73 10.51 (72)
100.00 (484) 100.00 (202) 100.00 (686)
Pearson chi-square = 80.351 ( p b 0.0001). Goodman–Kruskal Gamma = 0.809.
continuous or categorical. Initial screening of the independent variables was based on whether the variable was significant at a chosen level ( p b 0.10) in a logit equation with any of the dependent variables. Methodologists (i.e., Affifi & Clark, 1990) recommend a more generous p-value cut-off in the initial screening than in the final model. Independent variables that had a significant relationship with at least one dependent variable were selected for inclusion in the final logit model. While this resulted in the inclusion of non-significant variables for some of the dependent variables, this was preferred because of the desire to use the same logit model for all five dependent variables. The same independent variables were used in each case; however, the Believes is Law variable was different in each case because it corresponded to the dependent Wants as Law variable. For example, the independent variable bbelieves grave disabilityQ was used with bwants grave disabilityQ and bbelieves illness relapseQ was used with bwants illness relapse,Q etc. Results from the initial significance tests showed that ten of the thirteen independent variables had a significant relationship with at least one of the dependent variables. The variables Sex, Section Membership, and Commitment Expansiveness resulted in non-significant relationships across all five dependent variables. However, the relationship between Section Membership and some of the dependent variables approached significance (with a p-value slightly greater than 0.10), and Section Membership was thus included in the final model because of the near significance of the term and because it was felt important to determine if the dependent variables were associated with the design method of oversampling. 2. Findings Nearly all Respondents wanted a commitment law that includes bdanger to selfQ (99.0%) and bdanger to othersQ (98.7%) as grounds. A conclusive majority (89.6%) also wanted bgrave disabilityQ to be grounds, while a bare majority (51.6%) wanted billness relapseQ as grounds. There was less support among Respondents for commitment for alcohol addiction (22.0%), drug addiction (22.3%), and sexual predator status (26.1%). Each of the five models was run with the ten identified significant independent variables. See Table 1. Most independent variables showed only scattered significance with the dependent variables. As to the questionnaire variables, Race and Employment Setting were significant in a few cases while Experience with Commitment had no significant relationship with any of the dependent variables. As to the state-level variables, the only significant relationship involved the Region variables — there were significant differences in the case of the Northeast region, where Respondents were less supportive of commitment for illness relapse, alcohol addiction, and drug addiction than were Respondents in the North Central region. Only two independent variables — Believes is Law (what Respondents believed were the commitment grounds in their state) and Attitudes about Commitment (the combined score on the twelve attitude questions) — were significant across all five dependent variables. In the case of Believes is Law, p-values were very small (b0.0001) in each case, and odds ratios were large — from 5.114 for sexual predator status to 13.496 for drug addiction. The relationship between each Believes is Law and Wants as Law set of variables is shown in cross-tab form in Tables 2A–2E. The Table 2B Relationship between beliefs and wants about illness relapse (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
89.47 47.05 51.83 (355)
10.53 52.95 48.18 (331)
100.00 (76) 100.00 (610) 100.00 (686)
Pearson chi-square = 48.713 ( p b 0.0001). Goodman–Kruskal Gamma = 0.811.
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Table 2C Relationship between beliefs and wants about alcohol addiction (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
68.13 15.13 22.19 (152)
31.87 84.87 77.81 (534)
100.00 (91) 100.00 (595) 100.00 (686)
Pearson chi-square = 128.571 ( p b 0.0001). Goodman–Kruskal Gamma = 0.846.
relationship in each case is highly significant. For example, although overall Respondents did not support commitment for alcohol addiction, the majority (68.1%) of those who believed alcohol addiction was a ground also wanted it as a ground, while among those who believed alcohol addiction was not a ground the majority (84.9%) also did not want it as a ground. See Table 2C. The same relationship holds true for the other grounds — grave disability, illness relapse, drug addiction, and sexual predator status. See Tables 2A, 2B, 2D, and 2E, respectively. In each case, there is a highly significant relationship between Believes is Law and Wants as Law; in all cases except grave disability, in each table row the majority of the responses are in cells where beliefs and wants are consonant. (Because there was strong support (almost 90%) for grave disability, only about one-quarter of those who believed grave disability not to be a commitment ground supported it. However, this compares to only 3.7% of those who believed that grave disability was a ground but did not want it as a ground, and the relationship involving grave disability was still highly significant. See Table 2A). The variable Attitudes about Commitment was also highly significant across all five dependent variables, with small p-values (ranging from b 0.0001 to 0.005). For each of the grounds, Attitudes about Commitment had a positive, significant ( p b 0.05) association with Wants as Grounds — the higher the score on Attitudes about Commitment (the more the Respondent supported psychiatric prerogative), the more likely a Respondent was to support each commitment ground. 3. Discussion Respondents’ nearly unanimous support for the grounds bdanger to selfQ and bdanger to othersQ echoes earlier findings (Kahle & Sales, 1980), and is reflective of other research that shows psychiatrists increasingly supporting commitment based upon a hypothetical increase in risk or danger (Luchins et al., 2004; Simon & Cockerham, 1977). Respondents’ weak support for brelapseQ as grounds is similar to psychiatrists’ less than unanimous endorsement (48%) of commitment based upon mental illness only (Kahle & Sales, 1980), but is greater than the 10% in another study (Steinmark & Nagel, 1969) supporting commitment for mental illness in the absence of danger. Respondents showed much stronger support for commitment based on bgrave disabilityQ than that found in an earlier study (Kahle & Sales, 1980). Respondents’ lack of support for commitment based upon substance abuse is consistent with psychiatrists’ views as found in other surveys in the U.S. (e.g., Luchins et al., 2004) and England (Roberts et al., 2002). Most independent variables did not have a significant relationship with the dependent variables. See Table 1. As to the state-level variables, only Region produced significant results, with those in the Northeast tending to be less supportive of three of the five commitment grounds than those in the North Central region. The demographic variables had few significant interactions as well — Respondents’ sex was not significant, and there were only two instances where Race produced a significant ( p b 0.05) relationship. Respondents’ prior experience with commitment also was not significant. Others (e.g., Luchins et al., 2004) have found that a respondent’s experience with commitment was not related to decisions to commit. This may be because experience with commitment in this case was a crude measure, documenting only whether a Respondent did or did not have experience. It may be that Table 2D Relationship between beliefs and wants about drug addiction (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
71.05 16.39 22.48 (154)
28.95 83.61 77.52 (532)
100.00 (76) 100.00 (610) 100.00 (686)
Pearson chi-square = 115.974 ( p b 0.0001). Goodman–Kruskal Gamma = 0.852.
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Table 2E Relationship between beliefs and wants about sexual predator status (percentages)
Believes is grounds Believes is not grounds Total (n)
Wants as grounds
Does not want as grounds
Total (n)
56.00 23.27 25.69 (176)
44.00 76.73 74.31 (510)
100.00 (50) 100.00 (636) 100.00 (686)
Pearson chi-square = 26.034 ( p b 0.0001). Goodman–Kruskal Gamma = 0.615.
experience with commitment does not lead naturally to either support or opposition to certain grounds — perhaps the nature, quality, and setting of the experience may be more important contributors. By far, the strongest and most consistent relationships involved the independent variables Believes is Law and Attitudes about Commitment. The association between the Attitudes about Commitment and Wants as Grounds variables is perhaps not surprising given that both of those variables could be seen as a measure of psychiatric prerogative. However, the link between Believes is Law and Wants as Law is perhaps less obvious and merits some discussion. Economic rational actor theorists assume that personal preferences are given and fixed (Stigler & Becker, 1997) However, more sociological perspectives — even within economics (see Bikhchandani, Hirshleifer, & Welch, 1992) — recognize that a person’s preferences are subject to influence through social interaction. This internalization of norms has been described as a bremarkable process through which imposed obligations . . . become desiresQ (Etzioni, 2000). This process is frequently conceived of in terms of social rules that affect an actor’s behavior directly — initially the actor risks social sanctions for non-compliance, and after internalization experiences psychological costs as well (such as guilt) for non-compliance (Lessig, 1995; McAdams, 1996). Here, risks for disobeying the social norm (the state’s commitment law) are less direct. While psychiatrists (for the most part) are not at risk for involuntary commitment themselves (and therefore do not need to conform their personal behavior to the demands of the law in that sense), they are nevertheless subject to the law’s requirements when initiating commitment proceedings. They risk negative sanctions such as blosingQ the commitment proceeding as well as incurring damage to their professional reputation by initiating proceedings that do not conform to the law’s requirements. Thus, at least theoretically there is a strong motivation to internalize the law’s demands. (This is in addition to internalizing the bmeta-ruleQ that rules are to be obeyed). Others (e.g., Duster, 1970) suggest more broadly that changes in the law can result in increased public acceptance of the new legal classification. For example, making the use of narcotic drugs a crime may have caused people’s views of addiction to change — what had been thought of as a medical problem began to be seen as criminal behavior (Duster, 1970, 3–76). The findings from this study lend support to these internalization processes. The law (or at least what Respondents believed to be the law) has apparently conditioned Respondents desires. For every commitment ground, Believes is Law and Wants as Law were highly significantly related. Respondents appear to have internalized their bknowledgeQ (whether correct or incorrect) of existing law; when making choices, Respondents were significantly influenced by what they believed to be the law in their state. (Respondents were sometimes incorrect about the grounds for commitment in their state, particularly with regard to the bsexual predatorQ ground; others (e.g., Belter, Duer, & Stanny, 1999; Laves & Cohen, 1973; Peszke & Wintrob, 1974) have also found psychiatrists’ knowledge of the legal requirements of psychiatric hospitalization wanting in some respects). However, other causal explanations for the relationship should be considered. First, the directionality of the relationship could be the reverse — it may be that Respondents believed certain grounds to be law because they wanted those grounds as law. There is evidence from questionnaire responses that this is not the case. One Respondent from Iowa checked a number of grounds, including the botherQ category, and wrote in bemotional injury,Q which is an unusual commitment ground in Iowa’s statute. It seems unlikely that most psychiatrists would independently support such grounds for commitment, and certainly no Respondent not from Iowa proposed bemotional injuryQ as a commitment ground. Other Respondents also wrote in grounds contained in their own states’ laws. For example, a Respondent from the state of Washington checked botherQ and wrote bdamage to property,Q one of the grounds contained in Washington’s statute. A Respondent from New York wrote in bKendra’s lawQ (New York state’s outpatient commitment statute) as botherQ grounds they believed to be law in New York, and wrote in botherQ grounds they wanted for commitment as bnoncompliance with treatment regimenQ (the wording found in bKendra’s lawQ).
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This process of internalization is also illustrated, more broadly, by the increased support for bgrave disabilityQ as a standard between the time of the study by Kahle and Sales (the late 1970s) and the current study; in the interim period, many more states had adopted (whether legislatively or judicially) the bgrave disabilityQ standard. During this period, commitment for grave disability became the most commonly used commitment ground in the U.S. (Turkheimer & Parry, 1992). Of course, other changes also occurred during this period, including apparent increases in homeless persons with mental disorders, increased emphasis on psychiatric malpractice, and more public concern about safety. These all may have contributed to psychiatrists’ increasing support for bgrave disabilityQ as a standard. However, these social changes would not explain why the significant relationship persists between what psychiatrists believed was the law in their state and what they wanted as the law. In other words, while psychiatrists as a whole support bgrave disabilityQ as a commitment ground, they are less likely to do so if they believe grave disability is not the law. See Table 2A. It is also possible that the relationship between Respondents’ beliefs and wants is spurious, in either of two ways. The relationship could be an artifact of the questionnaire design because responses for both questions were the same eight choices. After answering the bbeliefsQ question many Respondents may have merely checked the same boxes by rote when answering the bwantsQ question. However, this appears unlikely, given that the two questions were separated physically in the questionnaire, with ten attitude questions in between them. The relationship could also be due to a more subtle causal mechanism. It may be that psychiatrists in different states wanted different laws, and were successful in enacting such laws. Thus, what psychiatrists want would reflect what they believe because each state’s psychiatrists were successful in enacting laws they wanted. This explanation is not highly plausible. First, there are many competing interest groups involved in crafting legislation (mental health consumers, civil rights advocates, and other mental health professionals), and even psychiatrists frequently disagree about what grounds should be included — thus, it is unlikely that psychiatrists regularly bgetQ the law they want. In addition, the argument that Respondents wanted the law because they were successful in enacting it would operate only if Respondents were actually correct about what the commitment grounds were in their state. As noted above, Respondents were sometimes not correct about the content of their states’ commitment statutes. This study is limited because psychiatrists’ attitudes and beliefs may not directly translate into behaviors. In addition, views of APA members may not reflect those of U.S. psychiatrists as a whole. Nevertheless, the findings from this study that appear to confirm that Respondents have internalized the dictates of the law — that they have largely accepted the content of their states’ commitment laws and have come to see the provisions as their own preferences — has potential implications for those engaged in reform efforts related to civil commitment. Even the highly educated professionals in this study showed strong preferences for what they believed to be the status quo. This process is consistent also with the traditional tendency of incrementalism in U.S. legislation. One of the reasons that there frequently is resistance to major legal reforms is that various actors in the process have internalized the existing norms and made them their preferences. Change thus typically comes in pieces, not from whole cloth. References Affifi, A. A., & Clark, V. (1990). 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