Comments on Civil Commitment Changes being considered in Maryland.
By Dr. Kathryn Seifert, CEO of ESPS, Salisbury, MD
Civil commitment due to dangerousness has three concepts that must be fully defined and understood before making decisions about what should be included in any related regulatory or legislative changes. These concepts are dangerousness, civil commitment, the rights of the potential perpetrators vs. the rights of the public to be protected from harm, and the connection between mental illness substance abuse, and dangerousness.
The changes being considered are increases in the clarity of the definition of dangerousness and widespread education of healthcare providers on the issues surrounding dangerousness, mental illness, substance abuse and civil commitment. Much can be learned by reviewing the research literature on these topics.
A discussion on these issues should include an understanding and communication of the risk factors for dangerousness. The new definition of dangerousness also needs to inform healthcare providers of the importance of accuracy in determining who might be at risk for dangerousness and thus subject to the restrictions of their liberty engendered by being placed under a civil commitment order. To discuss risk factors for dangerousness, it is important to review the extensive research available on this topic. There are four categories of dangerousness toward others discussed here. These are perpetration of harm to others in a mass violence event, domestic violence within intimate relationships, workplace violence, and harm perpetrated as apart of criminal activity. The research on the risk factors for each of these categories is extensive.
For domestic violence in the home, the risk factors include (1) an emotionally volatile person (likely to have emotional dysregulation due to a history of trauma (ACES faST Fact) and likely to be diagnosed with Borderline or other Personality Disorder; (2) Suicide attempts which may be diagnosed as Major Depressive Disorder, a trauma related disorder, or Borderline or other Personality Disorder (3) A history of aggression toward others; (4) Heavy substance abuse; (5) Poor anger management; (6) A history of experiencing or witnessing childhood violence, particularly within the family which can be diagnosed as a trauma related mental health disorder or an Axis II Personality Disorder (The Anna Institute, 2006); (7) Poor non-violent problem-solving skills which may be a result of a history of developmental delays arising out of a history of childhood trauma (Van der Kolk, 2009); and (8) past violence toward others which can also be related to a history of childhood trauma and exposure to violence as a child (Van der Kolk, 2009) (Center for Substance Abuse Treatment (US)., 2014)
For workplace multiple victim violence, the risk factors include: (1) Highly impatient and hypersensitive behaviors which may include emotional dysregulation which may be a trauma related disorder (Van der Kolk, 2009)or a personality disorder; (2) High suspiciousness; (3) A person that intimidates, ridicules, and demeans others; (4) A history of violence toward others which may be related to a trauma history and exposure to violence as a child and a trauma related diagnosis, a substance abuse disorder which is often associated with a history of trauma and a trauma related diagnosis and trauma related mental health issues, and (5) problems dealing in a healthy way with authority figures, which can also be related to a history of trauma (Lee, 2007).
The risk factors for perpetration of events of mass violence have been described by Professors Peterson and Densley in an unprecedented study of mass murderers in the US since 1966 (https://madison.com/wsj/opinion/column/jillian-peterson-and-james-densley-why-mass-shootings-stopped-in-2020-and-why-they-are/article_087e40a0-0451-5ce4-9b5c-130e87ca9341.html ). They have identified the common factors associated with mass violence. Drs Peterson and Densley have determined that the majority of mass violence perpetrators had the following characteristics: nearly all mass shooters experienced early childhood trauma and exposure to violence at a young age (Densley, 2021); one out of three mass murderers were suicidal; greater than 80% of mass murderers in Peterson and Densley’s database were in psychological crisis without adequate services and supports when they harmed others; 60% had histories of mental health problems; and 67% showed increasing agitation or emotional dysregulation leading up to the mass violence event. They also determined that many mass murderers had a fascination or obsession with other mass murderers and firearms. Additionally, having 4 or more of the risk factors for violence was more highly related to commission of mass murder than having just one of these factors.
Among those committing criminal violence, commonalities include childhood trauma, mental illness, substance abuse, living in poorly resourced communities, past violence toward others, involvement in deviant peer groups and personality disorders among adults with criminal justice involvement.
Looking across groups, the connection between childhood trauma, mental illness, and substance abuse stand out as prime factors in the perpetration of all kinds of violence. This is also well documented in the research literature in this topic (Bloom, 2007). Childhood trauma is also highly associated with mental illness and substance abuse as has been established by the research on aversive childhood experiences (ACE’s, CDC.gov). If we look at trauma related mental health disorders, we return to the connection between mental illness and dangerousness to self and others. Additionally, persons with substance abuse and mental health problems are 7 times more likely to commit violence toward another person.
Validated risk assessments have become the standard of care in determining high, moderate, and low risk of violence emphasizing the need for treatment in moderate to high-risk cases. This emphasizes the need to include the research literature on risk assessments in this discussion. Quinsy, et al, established that clinical judgement without a knowledge of violence risk factors in determining the risk of dangerousness is no better than chance (ROC <50% correct classification probability). The most highly validated risk assessments have been established with 75-80% correct classification probability through an ROC analysis. To use clinical judgement alone without knowledge of established risk factors for violence is insufficient. Additionally, not abiding by the established standards of care are increasingly becoming the topic of civil liability lawsuits when an at risk person without sufficient services commits a violent act. Therefore, any civil commitment regulations should consider applying this literature to any decision making. Additionally, the standard for deciding cases of potential civil commitment should reduce the risk of false positives and false negatives by using the highest (ROC) standard of probability of committing a future violent act. This must be the standard that is used when addressing risk reduction planning. Validated risk assessments have been the standard in Canada for decades but is still in its infancy in the US. This needs to be addressed in these changes of regulations.
There must be a careful balance between the consideration of the rights of a person at risk to commit violence while protecting the rights of the public to not be harmed by another. In making these decisions, we must be careful, judicious, and as accurate as possible. One does not restrict another’s rights without just cause and the highest level of accuracy, nor does one knowingly place others in harm’s way.
The best way to stop violence is through prevention (Seifert K. , Connecting Child Maltreatment and Behavioral Health Problems. , 2016). Many persons at risk for future violence have had contact with the criminal or juvenile justice system or are under disciplinary action in the workplace. Many of these at-risk persons have been identified due to emotionally out of control behaviors that often fly below the radar of official or legal accountability but are recognized by supervisors or community members (Seifert K. ). Legal and workplace actions can be used to refer persons at risk for violence to treatment to reduce the risk of future violence before there is a need for civil commitment. The case being made here is that interventions to stop childhood trauma, and to provide treatment for trauma, mental illness and substance abuse throughout the lifespan should be widely available. This may reduce the need for civil commitment.
- Improving the clarity of the definition of dangerousness through a literature review is supported
- Using the highest standards of accuracy with validated risk assessments and risk reduction planning in determining less restrictive treatment options before civil commitment is supported
- Extensive training for healthcare providers on dangerousness, risk factors for dangerousness and the changes in regulation is supported.
- Using effective trauma treatment and skill building as an interim step before the use of civil commitment
- Training all Emergency department and crisis intervention personnel of the risk factors for violence and changes in regulation is supported.
- Making needed treatment readily available to all. There is sufficient literature that the CCBHC model supports the inter-agency coordination needed to increase the effectiveness of mental health and substance abuse services.
- Payment for improved client outcomes as a standard to improve behavioral health services and outcomes throughout Maryland
- Civil commitment should be a last resort and should be done thoughtfully and carefully to balance the rights of at-risk clients and the public. A civil commitment for outpatient therapy by a provider that understands these issues and has a proven track record of serving this population is to be considered before involuntary commitment to an inpatient facility.
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Dr. Kathryn Seifert