Alternatives to civil commitment
This Letter to the Editor of the Canadian Journal of Psychiatry was published in the April 1992 edition.
Citation: Bishop M, Olders H. Alternatives to civil commitment.[letter]. Can J Psychiatry 1992;37(3):223.
Download a pdf of the letter and a reply by Drs. Brouillette and Paris.
1 August 1991
The Editor
The Canadian Journal of Psychiatry
294 Albert Street, Suite 204
Ottawa, Ontario KiP 6E6
Dear Sir:
The article by Drs. Brouillette and Paris (1) effectively highlights the quandaries faced by psychiatrists who deal with dangerous patients. However, a point not emphasized sufficiently was that there are often alternatives to civil commitment, options which may have a number of advantages.
Discussions usually center about the criteria which must be met before a person can be committed. Rarely is there mention of the fact that the law (at least in Quebec) does not require the person to be committed if the criteria are met; rather it is worded to prevent commitment unless the person is judged to be dangerous. (2).
Psychiatrists who are fearful of legal or civil consequences for failing to commit a possibly dangerous person might keep in mind that legal precedents such as the California Tarasoff decision (3) refer not to the necessity to commit, but to protect the intended victim. The point is that the physician should be concerned with safety, rather than commitment, Safety concerns can be addressed in a number of ways, for example: warning the victim; calling the police to put the person into custody; arranging for potential victims to be protected, eg in shelters for battered women; or (in Quebec) contacting the Department of Youth Protection when children are involved.
It is also necessary to consider the possible consequences of failing to use appropriate mechanisms. For example, if a person is shielded from the usual and appropriate consequences of their behaviour, that behaviour may increase if there are any reinforcers present. A person who makes threats or assaults someone would, in the absence of mental illness, normally be charged with a criminal offence and dealt with by the judicial system. This legal process can be initiated, whether or not the person is committed. A failure to initiate judicial proceedings, if based on the belief that mental illness renders the person less responsible for their behaviour, is tantamount to the psychiatrist’s assuming the role of prosecutor, judge, and jury, a role which he or she is ill-equipped to perform by training and (usually) by disposition. Furthermore, if the aggressive behaviour is not adequately dealt with, others may be put at risk.
Finally, there is the question of implicit or explicit collusion between the psychiatrist and the family. Again, in Quebec, the police now must press charges in cases of wife-battering even when the victim refuses to lay a complaint. Should not the psychiatrist insist that a similar process take place in other cases of family violence, such as the authors’ example of the 23 year old man who repeatedly assaulted his parents? Is failure to do so a form of collusion with a malfunctioning family system? Perhaps in such cases one might even consider committing those victims of family violence who, because of guilt feelings or other impediments, are unable to take appropriate steps towards their own safety and therefore might be considered dangerous to themselves!
References:
- Brouillette M-J, Paris J. The dangerousness criterion for civil commitment: the problem and a possible solution. Can J Psychiatry 1991; 36(4): 285-289.
- Mental Patients Protection Act. R.S.Q., c. P-41. As amended by: 1989, c. 54 ss. 181 to 183. 1990 Oct 1
- Wettstein RM. Psychiatry and the Law. In: Talbott JA, Hales RE, Yudofsky SC, eds. Textbook of Psychiatry. Washington DC: American Psychiatric Press Inc., 1988. p 1081.
Martha Bishop
Secretary, Douglas Hospital Beneficiaries’ Committee
Verdun, Quebec
Henry Olders, MD, FRCPC
Director, Psychogeriatrics Programme, Douglas Hospital
Verdun, Quebec