A History of Civil Commitment and Related Reforms in the United States: Lessons for Today
Appelbaum, Paul S., Developments in Mental Health Law
I am pleased to be here with you today. The discussions conducted thus far have focused on Virginia's existing civil commitment statute and its procedures, and related successes and failures. My intent here is to add a historical dimension to your considerations by describing the history of commitment law in the United States. This law has evolved over time primarily through cycles of reform and reaction, which I will briefly describe. I will then address what we know about the consequences of the latest round of reform, which began in the 1970s, and end with a few thoughts about the implications of this research for future reform efforts, including changes that you are considering at this conference.
Colonial and Early America
During the colonial era of this country, individuals with a mental illness were generally not dealt with in a systematic manner. If possible, they were ignored. When it was not possible to ignore them, they were frequently confined in local jails. Colonies in New England also had a quaint custom that was called "warning out." Each township, the equivalent of counties in other colonies, was responsible for the people in that jurisdiction. If an individual with mental illness disturbed the peace, that individual was walked or bodily carried to the township line and "warned out," that is, told to get out and never come back. If you had a mental illness, you could see a good part of New England this way as you were transported from one town to another. (3)
If not warned out and not confined in a local jail, significantly incapacitated individuals with mental illness typically were subject to confinement under the poor laws. Each township or county generally had an almshouse and a set of poor laws based on those that existed in England at the time. Under these laws, an individual who failed to pay his or her debts could be placed in an almshouse until these debts were redressed. Because this placement generally precluded the individual from generating any revenue, confinement was often lengthy. Individuals with a severe mental illness, unable to work or otherwise support themselves, were often swept up by these laws and forced to reside for a long and indefinite time in an almshouse.
By the end of the Colonial Period and into the early years of the Republic, jails and almshouses were filled with people with mental illness. These individuals were subject to neglect when they were lucky and overt abuse when they were not.
There were a small number of people with mental illness who were treated in the few hospitals that existed at the time. Indeed, the second patient admitted to the Pennsylvania Hospital, which opened in 1751 in Philadelphia as the first hospital of any kind in the United States and which continues to exist today, was a mentally ill person. The facility found such a demand for care for people with mental illness that it soon devoted a whole floor to them and quickly thereafter opened what later became the Institute of the Pennsylvania Hospital, a separate campus just for the treatment of the mentally ill.
If persons with a mental illness required hospitalization during this era, they were dealt with as any other medical patient was, that is, they were usually signed in and out by their families. The only other routine requirement prior to admission was that a deposit be made to cover the costs of care.
One additional requirement that began to develop during this period was that of a doctor's concurrence. This requirement necessitated that a doctor agree that hospitalization was necessary and appropriate, often referred to as "signing-off" on the admission. There still exists a slip of paper signed by Benjamin Rush, one of the signers of the Declaration of Independence and the man whose image appears on the Seal of the American Psychiatric Association and who is often thought of as the founder of American psychiatry. Benjamin Rush's note on this scrap of paper said, "[p]lease admit this patient, B. …