CLINICAL HANDBOOK OF SCHIZOPHRENIA

Commitment in Different Jurisdictions49. Involuntary Commitment 517The legal structures that govern the use of involuntary commitment vary in their detailedapplication between jurisdictions, resulting in differences between countries and states;however, broad themes are common to all jurisdictions.First, it is commonly the case that a specific law regulates the commitment of mentallyill persons. Therefore, from a legal point of view they are distinguishable from otherpeople who may require medical treatment but are unable to consent to treatment due totemporary or permanent mental incapacity, such as dementia or learning disability. However,as the core concept of mental illness has changed over time, so lawmakers must decidewhether to leave the definition entirely to clinical judgment or to circumscribe it insome way. This might involve inclusion criteria, such as a diagnosis included in a formalclassification system, or exclusion criteria, such as substance abuse problems or unusualsexual behaviors.Second, the law must state the criteria for commitment. The criteria that are usuallyincluded are considered further below. A distinction is usually made also between thestringency of the criteria applied in an emergency or to detain someone for a short periodof assessment, and those applied for longer term treatments, and additional safeguardsmay be required for controversial or irreversible treatments, such as electroconvulsivetherapy (ECT) and psychosurgery.Third, the law must describe the way in which compulsion will be exercised, theroles assigned to police, doctors, other professionals (e.g., social workers or nurses), andthe role of the courts. In different jurisdictions, the courts may have the primary role inauthorizing detention, or this may be left to mental health professionals, who have varyingdegrees of police powers to exercise physical restraint. However, even in systems inwhich mental health professionals are given wide discretion to manage commitment, theyare likely to rely on the police to support them in physically removing patients to hospital.Fourth, the law will include mechanisms of appeal whereby a committed patient, oran authorized representative, can challenge professional decisions, and relatives or caregiversare also likely to have specified rights either to seek commitment or to oppose it.Fifth, a distinction is usually made between the application of mental health legislationto people with mental disorders who have committed criminal offenses, with compulsorypsychiatric treatment being one of the “disposal” options available to the courts,and to those who have not committed offenses and are therefore subject to civil commitmentmeasures.Criteria for CommitmentCriteria for commitment, although they do vary in different jurisdictions, also have commonthemes. It is usual for them to include the presence of mental illness, a consequentrisk to the patient or to others, and the likelihood of treatment having a positive effect.The least restrictive principle, that treatment should be given with the least restriction ofliberty possible, may be stated.A useful version of these criteria is that prepared by the World Health Organization(WHO) in its Resource Book on Mental Health, Human Rights and Legislation, whichrecommends minimum standards to be applied in all jurisdictions (see Table 49.1).Although these are desirable criteria, and most appear in some form in jurisdictionsin which mental health legislation is well developed, there is room for debate. For example,WHO criteria include both the concept of mental illness as judged by an expert prac-