This article will suggest that the U.S. should follow the legal framework of Italy’s involuntary commitment laws. Adding the “need for treatment” standard, coupled with increasing the number of verifications along the chain to commitment, could affect the rates of the mentally ill found on the street and thus in the U.S. homeless population overall.
Background on Homelessness and Mental Illness in the U.S. and E.U. States
Homelessness in the United States of America is a crisis. In 2020, it was found by the National Alliance to End Homelessness that greater than 580,466 people were experiencing homelessness in the United States, whether on the street or in a shelter. A study from the Canadian Observatory on Homelessness found that about 6.2% of the total population is homeless for life. Rates in the EU are much lower. For example, in Italy, a rate of lifetime homelessness at 4% is the center of the bell curve among the rest of EU nations. Homelessness interacts with many problems throughout society, but mental illness is one of the most prominent. In fact, 25% of homeless Americans have a “serious mental illness.” This is much higher than the overall U.S. rate for adults, where serious mental illness affects 4.2% of the population.
Involuntary commitment, the confinement of a person for mental health care without their consent, in the past the preferred mode of handling the mentally ill, has been reentering conversations of how to care for the homeless. Many governments have created laws and put forward statements on how this should be dealt with among the nations. The United Nations, for example, has set out “Principles for the protection of persons with mental illness and the improvement of mental health care.” In the US, laws on involuntary commitment vary by state, but in general are very uniformly restrictive against involuntary commitment for any reason besides “danger to self or others.”
Involuntary Commitment Laws in the United States
Involuntary commitment laws in the United States are promulgated on the state level, but are fairly uniform in practice today. Due to human rights abuses that lasted through the early 20th century, during the 1950s and 60s, these laws shifted from “a need for treatment model to a dangerousness model” in most states. This dangerousness model means someone must 1) have a mental illness and, 2) be an “imminent threat to the safety of him- or herself or others” to be a candidate for involuntary commitment. The need for treatment model authorize[s] court-ordered treatment when inability to access food, shelter or other basics [are] judged to imperil physical safety. “In some states, it is also employed where persons are unable to make informed medical decisions or to seek psychiatric care.” Currently, seventeen U.S. states have kept the need for treatment “to prevent further deterioration,” as a standard for evaluating continuing commitment.
In order to commit someone under the dangerousness standard, a process requiring three persons must be followed. First, involuntary commitment needs an initiator, someone who reports the mental health issue to the authority. Second, the patient must be evaluated by a medical professional. Finally, their case must be decided on at a commitment hearing. Different states vary on who may fulfill each role and which person may initiate or fulfill each step.
The dangerousness model leaves the families of those who refuse treatment without an option. Rather than narrow the options that can be brought under involuntary commitment to exclude need for treatment, the States in the U.S. should focus on requiring more verification for requests for commitment that are brought under the law.
Involuntary Commitment Laws in Italy
“A standardised and systematic analysis of commitment laws” is not currently present in the European Union at this time. There is a need “for further research in this field.” The correlation between mental illness and homelessness rates, as well as Italy’s lower homelessness rates than those of the U.S., are two reasons to take a closer look at their involuntary commitment laws.
In Italy, involuntary psychiatric hospitalisation (IPH) is regulated by Law 833 of 1978. The criteria for involuntary commitment is based on two standards: need for treatment, similar to that which was minimized in the U.S., and dangerousness. The criteria of need for treatment in Italy requires three steps to find someone as a candidate: 1) the patient is suffering from psychic alterations that need immediate treatment; 2) the patient refuses the treatment; and 3) the patient cannot be adequately treated by other non-hospital-based means. But, there is more to the story: in order to be involuntarily committed for mental illness in Italy, the decision has to pass between no less than five people: the initiator, a doctor to vouch for a proposal, another doctor to confirm that proposal, the city mayor, and the magistrate. The confirmation redundancies here protect persons from the horrific restrictions on their bodily autonomy seen in the earlier parts of U.S. history, while making sure that those who truly need specific care for their health, safety, and dignity, will receive it.
What Should Be Done (Legally)?
There are many other factors to homelessness besides mental health. This article is only one way of approaching a single cause of this crisis. However, there is a correlation between homelessness rates and mental illness, and Italy’s framework for involuntary commitment laws may help the United States affect those rates in a meaningful way.
Adding the “need for treatment” standard under involuntary commitment laws could affect rates of the mentally ill found on the street and thus the U.S. homeless population overall. However, it must be coupled with Italy’s legal framework requiring no less than 5 people involved in the chain to verify the commitment to a mental health care center. Each individual U.S. state should follow the guidance of Italy’s Law 833 of 1978 to reach people with a need for treatment under the law, while increasing the number of people involved in the validation process. If adopted, those who truly need treatment have the chance to be committed for care, but with large checks accompanying the process to lower abuses of health autonomy along the way. This is in contrast to most U.S. states who limit commitment to the dangerous standard, leaving people without opportunity for treatment, but then require fewer outside checks on the actual commitment process. The United States may also look at the current laws of the seventeen U.S. states allowing need-for-treatment as a reason for involuntary commitment, to see how it has been implemented in our own country.
There are many factors to be considered among mental illness and homelessness. Opening the possibility for loved ones with severe mental illnesses to be treated, if deterioration will otherwise result, is a good first step to making an effect in this area. Italy provides a guiding example for health and autonomy to be protected at the same time.
Author Biography: Samantha Hoover is a member of the International Law Society’s International Law and Policy Brief (ILPB) and is a J.D. candidate at The George Washington University Law School. She has a B.S. in Pre-Law Business Management and a minor in Spanish from Texas A&M University.