dangerousness and disability as predictors of psychiatric patients' legal status

Dangerousness and Disabilityas Predictors of PsychiatricPatients' Legal Status

Lois Pokorny, Robert D. Shulland Robert A. Nicholson*

In a sample of patients admitted to two state psychiatric

facilities, discriminant analyses were used to predict (1)

legal status at admission (voluntary versus emergency

detention), and (2) the subsequent decision to commit

patients initially admitted under an order of emergency

detention (court commitment versus release). Measures

of preadmission dangerousness, followed by variables

re¯ecting degree of disability or impairment, accounted

for most of the variance in legal status at admission.

Personal resources and demographic characteristics

added little to the discrimination. Measures of disability

accounted for most of the variance in the later decision to

commit, whereas indices of dangerousness, personal

resources, and demographics added little to discrimi-

nation of discharged and court-committed patients.

These ®ndings re¯ect the gap between legal standards

and the practice of civil commitment, and support the

argument that degree of disability plays a more import-

ant role than dangerousness in decisions to extend the

hospitalization of involuntary patients. Copyright # 1999

John Wiley & Sons, Ltd.

Research on civil commitment of the mentally ill has proliferated during the last25 years, as documented by several reviews of the literature (Bagby & Atkinson,1988; Hiday, 1988, 1992; Lindsey & Paul, 1989; Nicholson, 1986, 1999; Turkheimer& Parry, 1992). One common research strategy has been to explore di�erences

CCC 0735±3936/99/030253±15$17.50Copyright # 1999 John Wiley & Sons, Ltd.

Behavioral Sciences and the Law

Behav. Sci. Law 17: 253±267 (1999)

* Correspondence to: Robert Nicholson, Department of Psychology, Lorton Hall 307c, University ofTulsa, Tulsa, OK 74104, USA.

Dr Pokorny is director of the Northwest Child Health and Guidance Clinic in Oklahoma City. Dr Shullis a psychologist with the Oklahoma Department of Corrections. Dr Nicholson is associate professor inthe department of psychology at the University of Tulsa. At the time of the research, Dr Pokorny waswith the Oklahoma Department of Mental Health and Substance Abuse Services at Gri�n MemorialHospital and Dr Shull was with University Computing Services at the University of Oklahoma. Datacollection for the original study was supported by an NIMH grant awarded to the OklahomaDepartment of Mental Health and Substance Abuse Services. The authors gratefully acknowledge thesubstantive contributions of Dr Martha K. Wilson, Cynthia J. Kelly, and Dalisey Moore from theSchool of Social Work at the University of Oklahoma.

Contract grant sponsor: NIMH.Contract grant number: R19#MH46324.

between involuntary and voluntary groups on various patient characteristics(e.g., Beck & Golowka, 1988; Gove & Fain, 1977; Hoge et al., 1997; Isohanni &Nieminen, 1990; Kjellin & Nilstun, 1993; Kjellin et al., 1993; Lindsey, Paul, &Mariotto, 1989; McClure, 1978; McEvoy, Appelbaum, Apperson, Geller, & Freter,1989; NeeSmith, 1993; Nicholson, Ekenstam, & Norwood, 1996; Nicholson &Horn, 1986; Nicholson,Mojtabai, & NeeSmith, submitted manuscript; Okin, 1986;Rofman, Askinazi, & Fant, 1980; Rossi et al., 1986; Rubin &Mills, 1983; Shannon,1976; Spence, Goldney, & Costain, 1988; Spengler, 1986; Spensley, Edwards, &White, 1980; Sto�elmayr, Roth, & Parker, 1982; Sto�elmayr, Roth, Parker, &Dillavou, 1983; Sussman & Nietzel, 1989; Szmukler, Bird, & Button, 1981; Toews,el-Guebaly, Leckie, & Harper, 1974; Westrin et al., 1990; Zwerling, Karasu,Plutchik, & Kellerman, 1975). Such comparisons suggest possible antecedents ofcommitment, and may clarify the roles played by demographics, personal resources,psychiatric disability, and legally relevant behavioral characteristics in the pathwayto either voluntary or involuntary psychiatric admission. A second research strategyhas been to focus on the conduct of civil commitment hearings and/or the variablesassociated with clinical or judicial decisions to commit, including the legal relevanceof the bases for those decisions (e.g., Hiday, 1977, 1983; Hiday & Scheid-Cook,1987; LeBu�e, Granger, &Wise, 1979; Lelos, 1981; Mahler & Co, 1984; Monahan,Ruggiero, & Friedlander, 1982; Parry & Turkheimer, 1992; Parry, Turkheimer, &Hundley, 1992; Rothman & Dubin, 1982; Segal, Watson, Gold®nger, & Averbuck,1988; Shore, Breakey,&Arvidson, 1981;Tomelleri, Lakshminarayanan,&Herjanic,1977; Warren, 1977; Yesavage, Werner, Becker, &Mills, 1982). Such investigationsmay provide important evidence concerning the extent to which procedural safe-guards are observed and commitment standards are appropriately applied.

Although these and other research strategies have advanced our knowledge ofthe practice of involuntary hospitalization, two factors have limited the potentialyield from many prior investigations. First, extant studies are characterized by anunfortunate reliance on univariate statistical analyses. Such analyses hinder ourability to assess the relative importance of various patient characteristics inpredicting legal status at admission or the later decision to commit patients fortreatment. Second, much of the research comparing voluntary and involuntarypatients has ignored the likely heterogeneity of these patient groups. Suchheterogeneity is suggested by changes in legal status during the course ofhospitalization (e.g., Cu�el, 1992; Nicholson, 1988), di�erences between initiallycommitted and recommitted patients in demographics, clinical characteristics, andlegal basis for commitment (Parry, Turkheimer, Hundley, & Cresko�, 1991), andoverlap between voluntary and involuntary groups in perceptions of the degreeof coercion in psychiatric hospitalization (Ekenstam, 1997; Lidz et al., 1995;Monahan et al., 1995, 1996; Nicholson, 1999; Nicholson et al., 1996).1 Moreover,many studies of civil commitment have identi®ed patients only as involuntary, andhave failed to assess the impact of type of involuntary commitment (e.g.,emergency detention versus court commitment pursuant to a judicial hearing)on study ®ndings (Nicholson, 1986).

1 Recent research has suggested that approximately 25% of involuntary patients could be considered``nonprotesting'' and that 5 to 15% of voluntary patients report feeling coerced into the hospital(Ekenstam, 1997; Lidz et al., 1995; Nicholson et al., 1996).

254 L. Pokorny et al.

Copyright # 1999 John Wiley & Sons, Ltd. Behav. Sci. Law 17: 253±267 (1999)

The present study extended the research base on civil commitment in three ways.First, we examined both legal status at admission as well as the later decision tocommit patients admitted initially on an emergency order of detention. Suchchanges in legal status have signi®cant clinical, legal, and ethical implications(Nicholson, 1988). For example, variables associated with court commitment ofpatients initially hospitalized under emergency procedures should re¯ect appli-cation of the appropriate statutory standards governing such a change in status.Second, we used multivariate analyses in order to compare the groups on a broadrange of patient characteristics, including demographics, personal resources,degree of disability/impairment, and dangerousness to self or others. These analy-ses allowed us to evaluate the relative importance of these characteristics inpredicting initial legal status as well as the later decision to commit. Third, ourstudy provides information about the practice of civil commitment in a jurisdiction(Oklahoma) not often investigated.

Our hypotheses were guided by several ®ndings from prior research. First,quantitative reviews of studies comparing voluntary and committed patients(Nicholson, 1986, 1992; Nicholson & Roach, 1990) suggest that the correlates ofcommitment status have changed over time. Di�erences between voluntary andinvoluntary patients, most notably in the domain of personal resources, appearsmaller in recent investigations. Second, Turkheimer and Parry (1992) documen-ted the gap between the letter and practice of the law in civil commitment, notingthat reforms in civil commitment legislation enacted during the late 1960s and1970s did not translate into changes in the conduct of commitment hearings.Statutes in most jurisdictions emphasize a police power rationale for involuntaryhospitalization under which commitment decisions should be governed primarilyby patients' dangerousness to self or others. In practice, such decisions appear tobe based primarily on criteria of ``grave disability'' which largely re¯ect parenspatriae considerations (Parry et al., 1991). Moreover, the impact of disability oncommitment decisions appears to increase as patients remain hospitalized forlonger periods of time. Third, in an earlier investigation of changes in legal statusduring hospitalization, Nicholson (1988) found that patients who were admittedunder an order of protective custody and subsequently committed by the court hadmore severe psychiatric disability and fewer personal resources than patients whowere discharged from the hospital at or before the court hearing. However, withoutdata on patients' dangerousness, Nicholson (1988) could not compare the impact ofthat class of predictor variables on commitment decisions with those of clinicalstatus, personal resource, and demographic variables.

Given the foregoing pattern of research ®ndings, we hypothesized that danger-ousness and degree of disability or impairment would make larger contributionsthan demographic characteristics and personal resources to discrimination ofvoluntary and involuntary patients at admission. Additionally, in line with recentresearch, we expected any di�erences between groups in demographics andpersonal resources to be small and not statistically signi®cant. Further, wehypothesized that when changes in legal status were taken into consideration(e.g., as re¯ected by the subsequent decision to commit or release patients initiallyadmitted on emergency detention), the contribution of patients' disability todiscrimination of groups would increase, whereas the impact of dangerousnesswould be reduced.

Prediction of legal status 255


METHOD

Setting

The setting for this study was a 240-bed state psychiatric facility serving a29-county catchment area in central and southeastern Oklahoma, and a 20-bedcrisis intervention center (CIC) serving a metropolitan area within the statehospital's larger service region.2 The CIC was established in 1988 to provide acutecare, including initial intake and stabilization, to patients previously served byacute wards at the state hospital. Patients whose conditions required extended carewere to be transferred to the nearby state hospital or other inpatient facility.Residents from the portion of the hospital's catchment area not served by the CICcontinued to receive the full range of treatment services (acute and extended care)at the state hospital. Admissions to either facility are considered instances ofadmission to state supported inpatient care.

Oklahoma commitment statutes (43A O. S. 1991, }} 1±103 et seq., as amended)establish two primary forms of involuntary hospitalization, emergency admissionand court-ordered commitment. Emergency admission occurs when a police o�certakes a patient into protective custody and ®les an a�davit describing the rationalefor detaining the patient. Within the ®rst 12 hours of detention, the patient must beevaluated by a licensed mental health professional (LMHP). A petition for com-mitment submitted by that LMHP permits continued detention for a total of 72hours, during which time the patient must be evaluated by a second LMHP.During this initial 72-hour period of the commitment process, three outcomes arepossible: (1) the patient may accept voluntary treatment; (2) the patient may bedischarged; or (3) the patient may be scheduled for a hearing or six-person jurytrial based on certi®cation by the LMHPs that the patient meets the criteria forinvoluntary admission. Commitment pursuant to the formal judicial inquiry per-mits up to 28 days of treatment at an appropriate facility. Under Oklahoma statute,both the initial 3 day admission and the subsequent commitment for inpatienttreatment are referred to as emergency detention.

Court-ordered commitment is initiated when any citizen (usually a relative) ®les apetition alleging that the prospective patient requires treatment. The ®ling of thepetition constitutes the authority to detain the alleged mentally ill person at a publicor private psychiatric facility. As in the case of emergency detention, within 3 daysthe patient must be evaluated by two mental health professionals and a hearing ortrial must be held to determine whether the individual should be committed. How-ever, in the case of court-ordered commitment, the period of treatment is inde®nite.3

2 As part of the ODMHSAS's attempts to cut operating costs and improve service delivery, the numberof beds at the state hospital was subsequently reduced from 240 to the current level of 180.3 In the remainder of the paper, our terminology departs somewhat from that used in Oklahoma statute.Although court-ordered inpatient treatment for up to 28 days is technically an emergency detentionunder the statute, we use the term ``court commitment'' (or ``court-ordered commitment'') to refer toany commitment to inpatient treatment which requires a judicial hearing or trial. Conversely, we use theterm ``emergency detention'' to refer to involuntary hospitalization which is based solely on acerti®cation procedure and does not require a determination by the court at a hearing or trial. Thisterminology corresponds to the coding procedure used by the state department of mental health: EDrefers to emergency detainees hospitalized without a court hearing, CC-28 refers to patients court-committed for a maximum of 28 days of treatment (an emergency detention under the statute), and CCrefers to patients committed by the court for an inde®nite period.



Both emergency admission and court-ordered commitment utilize the samecriteria for involuntary admission. The threshold condition is the presence ofmental illness or drug or alcohol dependence. Additionally, the proposed patientmust pose a threat of serious physical harm to self or others within the near future,or must be unable to attend to basic physical needs in order to avoid serious harm.The latter components of the commitment statute require evidence of a recentovert act or signi®cant threat, or evidence of recent failure to obtain food, clothing,or shelter.4

Procedure

As part of a larger investigation of the operations of the state hospital and a�liatedCIC, data were collected on persons admitted to either facility during threeperiods, each lasting about 1 month (October 15±November 16 1990; February15±March 21 1991; and June 15±July 16 1991). Only patients whose care at theCIC and/or state hospital represented their entire inpatient episode were includedin this study. Thus, patients who were admitted directly following admission toanother inpatient facility were excluded from the study, as were patients who weretransferred from either of these facilities to another hospital for inpatient care.Finally, patients whose primary problem was alcohol or drug abuse were excluded.This sampling procedure yielded a total of 490 admissions.

Data were obtained from patients' charts after discharge using prepared codingforms which structured the data collection process. Six students from the master'sdegree program of the School of Social Work at a major state university served ascoders for this study. They were trained in data collection methods and the use ofthe coding instrument. During the ®rst 12 months of data coding, approximatelyone form per month was reviewed with each coder to assure adherence to trainingstandards. Data collection for each coder was counterbalanced across state hospitaland CIC; each coder alternated work at the two facilities.

Of the 490 patients, 192 (39.2%) were voluntary, 263 (53.7%) were admitted onorders of emergency detention, and 35 (7.1%) were court committed. Because thenumber of patients initially admitted by court commitment was small, thesepatients were excluded from the analyses. Patients' subsequent legal status wascoded as voluntary, court committed, or released, creating a total of six combin-ations of initial and subsequent legal status. Some of the groups formed by thecombination of initial and subsequent legal status did not contain large enoughnumbers of patients to be retained in the analyses. Thus, patients who changedfrom voluntary to involuntary (n � 37 or 7.6%) and involuntary to voluntary status(n � 47 or 9.6%) also were excluded from the analyses. The remaining com-binations of initial and subsequent legal status, emergency detention±released

4 In 1992, Title 43A was amended to incorporate a third standard for involuntary hospitalization. Thenew criteria include (1) a previously diagnosed history of schizophrenia, bipolar disorder, or majordepression with suicidal intent or (2) the appearance of symptoms of one of these disorders, in anindividual for whom (3) treatment is reasonably believed to prevent progressively more debilitatingmental illness. Because this ``deterioration in clinical condition'' standard has not been tested in thecourts, mental health examiners and judges have been reluctant to invoke it absent evidence ofdangerousness or grave disability.



(REL), emergency detention±court committed (CC), and voluntary±voluntary(VOL), provided the subsamples for the present investigation. These combinationsincluded 73, 143, and 155 patients, respectively, and accounted for 75.7% (371 of490) of the patients in the total sample.

Predictor Variables

Information on 25 patient characteristics, identi®ed from the literature as potentialcorrelates of legal status, had been collected as part of the original, larger study.This information was obtained from several sources in the patients' charts. Data for10 characteristics were obtained from a face sheet (FS) which had been completedby an admitting clerk. Information on seven characteristics had been recordedinitially by a mental health professional; four were coded from a list of presentingproblems (PP) and three from a description of the patient's condition (PC).Finally, a review of all relevant documentation (RD) in the patients' charts pro-vided data on seven potential precipitating factors of the current admission and onein-hospital variable. The variables coded from these four sources in the charts canbe grouped conceptually into four classes of patient characteristics:

Demographics

Standard demographic variables obtained from the face sheet included age, gender,and race. The average age of the patients at the time of admission was 35.3 years(SD � 11.3). Of the total, 206 (56.1%) were male and 161 (43.9%) were female. Inaddition, 279 (76.9%) of the patients were Caucasian; the overwhelming majorityof the remainder were African American. For purposes of data analysis, race wastreated as a dichotomous variable (white versus nonwhite).

Personal Resources

Six personal resource characteristics were coded from the face sheet, includingmarital status (recoded as ever versus never), educational level (less than 12 yearsversus 12 years or more), employment at admission, veteran status, homelessness,and prior outpatient care (all coded as yes versus no). A seventh resource variable,lack of personal resources (yes versus no), was obtained from the sections of thechart examined for potential precipitating factors. Not surprisingly, the patientsincluded in this study had limited individual and social resources. Most (204 or56.2%) had never been married. Only 56 (15.4%) were employed; 128 (35.7%) hadless than a high school education; 42 (11.5%) were homeless. Lack of personalresources was judged to be a factor precipitating the admission in 102 (27.8%) ofthe cases. Of the total, 38 (10.7%) were veterans and 71 (19.3) had received prioroutpatient care.

Dangerousness

Nine variables were used as indicators of the patient's level of dangerousness.Eight of these indexed preadmission dangerousness. Three were coded from the



list of presenting problems: Homicidal Intent, Suicidal Intent, and AssaultiveBehavior. Five were coded as factors precipitating admission: Suicide Attempt,Hostile Behavior (e.g., threatening, assaultive), Property Destruction/Damage,Unmanageable Behavior (e.g., volatile, disruptive, uncontrollable at home), andCriminal/Antisocial Behavior (e.g., criminal act, arrest for criminal act, antisocialbehavior). Fifteen patients (4.1%) presented with homicidal intent, 128 (34.9%)with suicidal intent, and 23 (6.3%) with assaultive behavior. Further, 66 (18.0%)had made a suicide attempt, 106 (28.9%) had shown hostile behavior, 20 (5.4%)had destroyed or damaged property, 10 (2.7%) had engaged in potentially criminalbehavior, and 13 (3.5%) had become unmanageable. In addition to the eight pre-admission indicators, one variable, whether the patient had been placed in rest-raints or seclusion within 72 hours of admission, was used as an indicator ofpatients' degree of dangerousness in the hospital. Twenty-nine patients (8.1%) hadto be secluded or restrained at least once during the ®rst 3 days of hospitalization.

Degree of Disability/Impairment

Three of the six indicators of degree of impairment were coded from thedescription of the patient's condition: Psychotic Disorder (yes versus no), OrganicDisorder (yes versus no), and score on the Global Assessment Scale (Endicott,Spitzer, Fleiss, & Cohen, 1976).5 A fourth variable, Prior Inpatient Care (yesversus no), was coded from the face sheet. The list of presenting problems provideda ®fth index of degree of impairment: Psychotic Symptoms (yes versus no).Finally, one variable, Fails to Perform Activities of Daily Living (yes versus no),which perhaps most closely approximates the statutory standard for ``grave disa-bility,'' was coded from the list of potential precipitating factors. In sum, althoughwe did not have direct ratings of ``grave disability'' from patient charts, we did haveavailable to us several indices of patients' overall degree of impairment.

One hundred and twenty-two patients (33.6%) had a diagnosis of psychosis,and 146 (40.2%) exhibited psychotic symptoms as a presenting problem. Only12 patients (3.3%) had a diagnosis of organic mental disorder. Most patients(266 or 75.1%) had a history of prior psychiatric hospitalization. In addition, forjust over one-half of the patients (183 or 51.1%), failure to perform activities ofdaily living was coded as a factor precipitating the current admission. The averagescore on the GAS at admission was 28.9 (SD � 10.7). Thus, at a minimum, thesepatients exhibited serious psychiatric impairment, including impairment in realitytesting and communication or major impairment in several areas such as work,family relations, judgment, thinking, or mood.

5 Scores on the GAS range from 1 to 90, with lower scores indicating greater impairment in functioning.At the low end of the scale (i.e., 1 to 20), anchors for the ratings re¯ect extreme disability and/ordangerousness to self or others. Hence, this measure could be considered an indicator of both thedisability and dangerousness dimensions. We grouped the GAS with the disability measures becauseGAS scores showed stronger correlations with other measures of disability than with indices ofdangerousness. Moreover, classifying the GAS as a measure of dangerousness or as a combineddangerousness/disability index would not have altered the conclusions from our study.



Analyses

Stepwise discriminant analyses were used to predict the criterion variable, patient'slegal status. In the ®rst analysis, 24 of the patient characteristics described pre-viously were used to predict legal status at admission (VOL versus ED). The solein-hospital variable, occurrence of seclusion or restraint, was excluded from this®rst analysis. In the second analysis, all 25 patient characteristics were included aspotential predictors of the subsequent decision to release or commit emergencydetainees (REL versus CC). In each analysis, variables were selected for the dis-criminant function using a .15 probability level. Cross-validation parametric dis-criminant analyses were then conducted to determine the ability of the selectedvariables to classify patients accurately.

RESULTS

In the ®rst analyses, 13 of 24 patient characteristics were selected for entry intothe discriminant function by the stepwise procedure. The linear combinationof 13 variables had signi®cant discriminating power, Wilks' lambda � .72,F(13, 336) � 9.98, p5 .01. Together the variables accounted for 28% of the vari-ance in patients' initial legal status. In the cross-validation analysis, these 13variables correctly classi®ed 68.2% of the patients.

Table 1 lists the 13 variables selected for the discriminant function and displaysthe proportion of variance explained by each variable at the point of entry in thediscriminant function. Six of eight dangerousness variables, three of six degree of

Table 1. Contributions of patient characteristics to discrimination of legal status groups at admission(VOL versus ED)

Classes of predictor variables

Predictor DangerousnessDegree ofdisability

Personalresources Demographics

Suicide attempt .061Hostile behavior .047GAS at admissiona .037Age .025Fails to perform ADLb .019Unmanageable behavior .019Suicidal intent .016Psychotic symptoms .014Criminal/antisocial acts .012Lack of resources asprecipitating factor

.011

Gender .008Property damage .007Prior hospitalization .006

Sum .163 .075 .011 .033

Note. The reported values indicate the amount of variance in group membership that was explained byeach of the predictors at its point of entry into the discriminant function.aGAS � global assessment scale.bADL � activities of daily living.



impairment variables, two of three demographic variables, and one of sevenresource variables entered into the discriminant function. The variables within thedimension of dangerousness accounted for the largest percentage of variance,followed by variables re¯ecting degree of impairment. Demographic characteristicsand resource variables made considerably smaller contributions to discriminationof the groups.

On the dimension of dangerousness, suicide attempts, hostile, unmanageable,and potentially criminal behavior, and damage to property were more likely to becited as speci®c factors precipitating the current admission for ED patients. Incontrast, VOL patients were more likely to have suicidal intent noted as a present-ing problem. On variables re¯ecting degree of disability, ED patients generallyexhibited more impairment; they had lower GAS scores at admission and they weremore likely to have psychotic symptoms as a presenting problem. However, VOLpatients more often had failure to perform activities of daily living cited as a factorprecipitating admission. ED patients were typically older and more likely to bemale, and they were less likely to have lack of personal resources cited as a factorprecipitating admission than VOL patients.

In the second analysis, nine of the 25 patient characteristics were selected by thestepwise procedure for entry into the discriminant function. The linear combina-tion of nine variables had signi®cant discriminating power, Wilks' lambda � .77,F(9, 177) � 5.79, p5 .01. Together the variables accounted for 23% of thevariance in group membership. In the cross-validation analysis, these ninevariables correctly classi®ed 67.7% of the patients.

Table 2 lists the nine variables that entered into the discriminant function alongwith the contribution to variance for each predictor at the point of entry. As can beseen, four of six degree of impairment variables and two of three demographicvariables, but only one of the nine dangerousness variables and two of sevenresource variables, entered the discriminant function. Variables within the degreeof disability cluster accounted for a much larger proportion of variance than diddemographics, personal resources, or dangerousness. CC patients were more likely

Table 2. Contributions of patient characteristics to discrimination of court-committed and releasedgroups (CC versus REL)

Classes of predictor variables

Predictor DangerousnessDegree ofdisability

Personalresources Demographics

Prior hospitalization .054Veteran .032Organic diagnosis .024Gender .021Fails to perform ADLa .020Suicidal intent .018Age .018Psychotic diagnosis .014Education .012

Sum .018 .112 .044 .039

Note. The reported values indicate the amount of variance in group membership that was explained byeach of the predictors at its point of entry into the discriminant function.aADL � activities of daily living.



to have a history of prior hospitalization, to have failed to perform activities of dailyliving prior to admission, and to have psychotic or organic diagnoses. In addition,CC patients were older and more likely to be male. REL patients were more likelyto have a high school education, to be veterans, and to have suicidal intent noted asa presenting problem at admission.

DISCUSSION

The present study of patient characteristics associated with legal status was designedto redress some of the limitations of past research on civil commitment. Weused multivariate statistical methods to predict legal status at admission and thelater decision to commit patients initially hospitalized on an emergency basis.We hypothesized that dangerousness and disability would contribute most todiscrimination of voluntary and involuntary patients at admission and that thecontribution of demographic and personal resource characteristics would besmall. In addition, we hypothesized that disability would be more important thandangerousness in discriminating court-committed and released patients. The®ndings from two discriminant analyses, considered together, are consistent withthese hypotheses.

The ®rst analysis demonstrated that voluntary patients and patients admittedunder an order of emergency detention could be discriminated reliably by a linearcombination of 13 patient characteristics. In the cross-validation analysis, pre-diction of group membership was accurate for 68.2% of the patients. A correctclassi®cation rate of 57.4% would be achieved by classifying all patients asinvoluntary. Hence, the ®ndings from this discriminant analysis yielded animprovement in prediction beyond that obtained using the base rate alone.

Given our research hypotheses, the most important ®nding from the ®rstanalysis was that variables re¯ecting the dimension of dangerousness accounted formost of the explained variance in group membership. Di�erences betweenvoluntary and involuntary patients on these variables were generally in theexpected direction. Involuntary patients were more likely to have made a suicideattempt and to have engaged in behavior prior to admission that could beconsidered dangerous to others. Notably, voluntary patients were more likely to berated as having suicidal intent as a presenting problem at admission. The pattern of®ndings for suicidality suggests that patients admitted on a voluntary basis weremore likely to verbalize thoughts of suicide, re¯ecting the signi®cant personaldistress and concern about self-harm which led those individuals to seekhospitalization. On the other hand, actual suicide attempts prior to admissionprompted responses from others which resulted in emergency hospitalization.These ®ndings argue against use of a single index of danger to self in commitmentresearch.

The dimension of psychiatric disability made the second largest contribution todiscrimination of voluntary and involuntary patients at admission. Involuntarypatients had more severe overall impairment (as indicated by a lower score on theGAS scale) and were more likely to have signi®cant psychotic symptoms atadmission. Surprisingly, failure to perform activities of daily living, the variablethat most closely re¯ects the ``grave disability'' standard for commitment, was cited



as a precipitant to admission more often for voluntary than involuntary patients.Although noted more often for voluntary patients, impairment in the ability to carefor self was the most frequent precipitating factor for patients in both groups.Indeed, among involuntary patients, failure to perform activities of daily livingwas noted in 46.6% of the admissions. For purposes of comparison, the mostfrequently cited precipitants to involuntary admission re¯ecting the dimension ofdangerousness were hostile (i.e., threatening, assaultive) behavior, noted in 39.0%of the cases, and suicide attempts, noted in 22.1% of the cases. Other precipitantsto admission grouped under the dangerousness rubric were rare.

The second analysis demonstrated that a linear combination of nine variablescould reliably discriminate patients who were subsequently committed by the courtfrom those who were discharged. However, the cross-validation classi®cationestimate of 67.7% did not represent an increase over the base rate of 69.5% whichwould be obtained by classifying all patients as court committed. Indices ofpatients' disability accounted for the most of the explained variance. Court-com-mitted patients were more likely to have had prior psychiatric hospitalization, weremore likely to be diagnosed as having a psychotic or organic disorder, and weremore likely to have failure to perform activities of daily living cited as a factorprecipitating admission. Dangerousness indices added relatively little to discrimi-nation of the groups. Indeed, none of the measures of dangerousness to othersmade a signi®cant contribution to discrimination of the groups. In addition, theonly indicator of dangerousness to self that contributed to the discriminant func-tion was suicidal intent; released patients were more likely to have verbalizedsuicidal intent at admission than court-committed patients. Hence, in this regard,emergency detainees released from the hospital bore a greater similarity to volun-tary admissions than to emergency detainees who were committed by the courts.

Two demographic characteristics, age and gender, and two personal resourcevariables, veteran status and education, also contributed to discrimination of RELand CC patients. CC patients were older and more often male. Released patientshad higher levels of education and, not surprisingly, were more likely to be veteransand hence, eligible for veterans' bene®ts. The decision to discharge such patientsmay have been based, in part, on the consideration that they were eligible forfollow-up treatment at a Veterans Administration facility.

Because all of the patients in our second analysis had been admitted initially onan emergency detention order, some might point to limited variability in thepatient sample as an explanation for the negligible contribution of dangerousnessto prediction of court-commitment. However, the patients in our ED sample wereby no means uniform with regard to preadmission and in-hospital dangerousness.As noted previously, impairment in the ability to care for self was the mostcommon precipitant to admission for ED patients. Moreover, any purportedrestriction in variability should apply to measures of psychiatric impairment aswell, yet several of the latter measures made signi®cant contributions to predictionof commitment and together accounted for a larger percentage of variance in thedecision than did indices of dangerousness.

In a recent review, Turkheimer and Parry (1992) noted that civil commitmentappears to serve di�erent purposes for two populations of patients, functioning toprotect society from acutely ill, possibly dangerous patients and to provide treat-ment to chronically ill, largely nondangerous patients. They further argued that



patients' degree of disability increasingly drives decision-making as involuntarypatients remain in the hospital for longer periods of time. Although they initiallymade this proposal with regard to recommitment of patients who had already beencourt-committed, the ®ndings from the present study suggest that their proposal isequally descriptive of the transition from emergency detention to an initial courtcommitment.

The pattern of ®ndings obtained in this investigation is also consistent withrecent arguments that reforms in civil commitment standards and procedures havenot translated into reforms in practice. According to Oklahoma statute, the criteriafor involuntary admission are identical under emergency detention and courtcommitment procedures. However, the ®ndings from our study suggest thatindices of preadmission dangerousness and an index of in-hospital dangerousnesshad little impact on the decision to release or commit patients hospitalized under anemergency detention order. Instead, the decision to discharge emergency detaineesor commit such patients for up to 28 days of treatment was in¯uenced primarily byclinically relevant indicators of patients' overall degree of impairment.

Information on the practice of civil commitment is crucial to the development ofinformed social policy. The present investigation redresses some de®ciencies inprevious research and adds to our knowledge of commitment practices. Neverthe-less, the limitations of this investigation should be borne in mind in interpreting the®ndings. First, the study was archival in nature, involving review of hospital records.The judgments of the mental health professionals who initially recorded informa-tion about patients' clinical condition, presenting problems, and precipitatingfactors may have been biased by knowledge of patients' legal status (e.g., see Lindsey& Paul, 1989, for a discussion of the limitations of archival measures of danger-ousness and disability). Although such bias may have been operative in our study,their possible impact is limited to the ®ndings from our ®rst analysis involving VOLand ED patients; they could not have accounted for the ®nding that disability wasmore important than dangerousness in discriminating REL from CC patientsbecause the information had been recorded prior to changes in legal status.Moreover, it is unclear why such biases would impact indices of dangerousness anddisability di�erentially across the analyses in our study. Finally, it should be notedthat data coders were not aware of the hypotheses to be tested in this study becausethe data had been collected originally for another purpose, thereby reducing thepossibility of rater bias at the stage of data collection.

A second limitation of our study, also deriving from the archival nature of theinvestigation, is that we did no have information about the commitment hearingitself. All court-committed patients were retained in the hospital based on a judicialorder following the requisite hearing. However, we did not have data on whetherthe released patients were discharged by the treating physician or by the judge atthe required judicial hearing. In future research, heterogeneity in the releasedgroup could be explored by measuring the clinical and judicial decision-makingcomponents separately.

Finally, the information available in patients' charts provided for more detailedmeasurement of the dangerousness component than the grave disability compo-nent of the commitment statute. We had available only a single index of gravedisability, ``failure to perform activities of daily living,'' as a factor precipitating theindex admission. Other indices of disability, such as psychiatric diagnosis or degree



of overall impairment, are only indirect indicators of whether or not a patienthas been able to obtain basic physical needs such as food, clothing, and shelter(Lindsey & Paul, 1989). Future research should incorporate more detailed assess-ment of the grave disability standard for involuntary hospitalization of the mentallyill (see also Turkheimer & Parry, 1992).

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dangerousness and disability as predictors of psychiatric patients' legal status

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