Involuntary commitment: An investigation of the clinician's decision-making process

To investigate clinicians' decision making regarding involuntary commitment, 18 clinicians in a community mental health center completed 169 questionnaires on patients they deemed to present some degree of risk. Forty-two of those evaluations resulted in detention, the first step in the involuntary commitment process. Two aspects of clinical decision making were addressed in this study: (a) the actual process by which clinicians arrive at decisions regarding commitment and (b) the effects of patient and clinician characteristics and bed availability on that process. Factor analysis revealed three underlying constructs that produced significant direct effects on the clinician's rating of the patient's overall risk: a danger to self factor, a danger to others factor, and a substantial inability to care for self factor. The patient's overall risk rating was a significant predictor of whether or not he or she would be detained. None of the patient characteristics tested (diagnosis, sex, age, insurance) produced significant direct effects on the patients' risk ratings or the detention decision. Analysis of the effects of clinician characteristics produced unexpected results. Greater clinician experience resulted in higher overall risk ratings, suggesting that experience may sensitize, rather than desensitize, clinicians' responses to risk factors. Experience level did not, however, have direct effects on the detention decision. Instead, a new variable, reflecting the clinician's past behavior regarding commitment (the Clinician Detention Ratio), did significantly predict the detention decision, indicating that the clinician's general tendency to detain patients plays a significant role in commitment decisions. The setting in which decisions were made also had relevance. Significant differences were obtained in both overall risk ratings and the detention decision between an in-house Emergency Service and a Mobile Crisis Unit. Not surprisingly, the availability of detention beds within the community significantly affected whether or not a patient would be detained. These findings are discussed in terms of the interplay between what the patient brings to an evaluation and the clinician's unique perceptions of that patient. The possibility that clinicians may be unaware of some influences on their decision making is discussed, as is the significant effect of community resources on clinical decision making.