The study of society's approach to civil commitment of the mentally ill is made particularly interesting by the strength of the values it finds in conflict. On one plane, “good” or “moral” people are supposed to provide care for those unable to care for themselves. The capacity to consider the needs of others helps define our “humanness.” In this context, this value manifests itself in the attempt to provide mental health care for those unable, because of their illness, to provide it for themselves.

On another plane, however, the oppression that drove many to immigrate to America and that resulted in our own revolution has left us with an abiding fear of governmental limitations on individual autonomy. Cries of totalitarianism and “big brotherism” often accompany governmental attempts to restrict that autonomy. In this context, this value manifests itself in the attempt to permit individuals to choose whether to receive mental health care.

In the 1950s and 1960s considerable attention was focused on the deleterious effects of prolonged hospitalization for mental illness. Sociologists such as Goffman and clinicians such as Wing identified the psychosocial and clinical processes that led patients to become increasingly dependent on the routine of the hospital and progressively less able to live in the community. Along with this concern came growing criticism of the legal processes by which individuals were committed to and retained in state hospitals and of the procedural protections afforded them.

Landmark court decisions such as Lessard v. Schmidt led to sweeping changes in commitment laws across the nation during the 1970s. California's Lanterman-Petris-Short Act served as a model for the laws of many states by narrowing the substantive grounds for commitment and imposing procedural safeguards on the commitment process.

The civil commitment hearing, accompanied by the panoply of due process rights, is important. However, it is what happens when an individual first enters the mental health delivery system that is of fundamental significance. It is then that decisions on hospitalization, treatment, and disposition are made. The commitment hearing represents not the beginning of a process but, rather, the middle stage or the final chapter. This essay reports the results of an observational study of the functioning of nine emergency rooms or crisis units, with particular emphasis on implications for the civil commitment process.

Every U.S. statute concerning commitment, as well as the English and Canadian statutes I have reviewed, reads as though the individual being considered for commitment is at liberty pending a hearing. Each jurisdiction also has a statute to take care of emergency situations.

The history of commitment law in the United States has been marked by a series of pendular swings corresponding to popular concerns of the day. From the inception of civil commitment law in the 1830s and 1840s. with a system in which discretion was lodged primarily in family members and physicians, there have been moves to restrict the ease of commitment when concerns about inappropriate admissions or institutional abuses were at their height (e.g., in the 1870s, 1930s, and 1970s) and countervailing efforts to increase the ease of commitment when concerns about the ready availability of treatment predominated (e.g., around the turn of the century and in the 1950s).

Students of the history of civil commitment will quickly recognize that these shifts in policy were based almost entirely on theoretical arguments about the relative desirability of one or the other approach, fueled by horror stories illustrating the pitfalls of the competing orientation.