Journal of Health Politics, Policy and Law

Civil Commitment as a “Street-Level”

Bureaucracy: Case-Load, Professional
ization and Administration
James S . Wunsch and Larry L. Teply, Creighton University;
Joel Zimmerman, National Center for State Courts; and
Geoffrey W . Peters, William Mitchell College of Law

Abstract. This article applies street-level bureaucracy theories to ‘‘coping”

patterns of behavior that developed in an involuntary commitment system. Daily
procedures and routines of five Nebraska county boards of mental health and the
attitudes of their members were studied. The results showed that the urban, high
case-load, professionally-oriented board informally modified statutory procedures
significantly to reduce face-to-face client contact, limit the scope of its decisions,
and displace responsibility for the most ambiguous decisions to the treatment
facility and board psychiatrist. Rural, low case-load, less professionally-
specialized boards also modified the statutory procedures, but conducted the
commitment process in a far more ambiguous, open-ended, and tense system with
substantial face-to-face client contact. Both urban and rural boards had multi-
faceted role definitions; rural boards, however, had a more open-ended perception
of their functions, and attempted more actively to modify antisocial behavior and
redirect board subjects to sources of social counseling. Therefore, understanding
street-level “coping” behavior in an actual commitment context is important to
develop realistic changes in civil commitment systems and to preclude informal
procedures that reduce a commitment system’s effectiveness or undermine a
proposed patient’s rights.

Researchers from a variety of disciplines have increasingly focused

attention on policy implementation and modification by the “lowest”
level administrative actors. For example, political scientists have noted
that legislative and judicial decisions become public policy only after

The empirical research on which this article is based has been supported by a PHS
Grant (No. 1 R01 MH 27438-01) from the National Institute of Mental Health. Points of
view expressed herein are those of the authors and do not necessarily represent the official
position or policies of the National Institute of Mental Health or Creighton University.
Further support was provided by the Deans of the Graduate and Law Schools of Creighton
University.
Journal ofHealth Politics, Policy andLaw, Vol. 6, no. 2, Summer 1981. Copyright@ 1981
by the Dept. of Health Administration, Duke University.

285

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decisions regarding the affected citizen-consumer-subject are authori-

“

tatively allocated” by ‘‘street-level” public actors. They have also found

that these actors -social workers, teachers, policemen, probation
officers, and others-often act at substantial variance with legal prescrip-
tion. Sociologists and organization theorists studying human services
organizations in varied circumstances have similarly observed that ‘‘line”
actors can become the principal determinants of agency policy and per-
formance. In order to accomplish their required tasks, accommodate
demands, and confront personal and organizational limitations, these
actors modify agency goals, ration the “services” they offer, redefine
their clientele, control their clients, and develop routines and priorities
that allow them to process their These findings suggest that those
concerned with assessing and improving existing public services, as well
as developing new ones, must carefully consider these street-level admin-
istrative actors and their strategies for coping with the stresses and de-
mands of their tasks.4
Prior research has identified several characteristics associated with
systems in which extensive street-level policy implementation and modifi-
cation is likely to occur. In these systems: (1) decisions are often initiated
through direct citizen contact and are frequently made in the presence of
those affected; (2) decision makers usually have wide discretion due to
ambiguities in the decision making criteria; (3) time or resource pressures
tend to limit decision makers’ ability to explore all pertinent data or to
satisfy all potential “consumers” of these services or decisions; (4) con-
sumers tend to be socially, economically and politically marginal and
therefore usually lack resources to control or monitor decisions; and (5)
the ambiguity of the decision making criteria renders intra-agency or
bureau supervision pr~blematic.~ It is not yet clear which of these, or
other characteristics, if any, are necessary to stimulate or facilitate exten-
sive street-level modification of policy.
The civil commitment system in Nebraska prior to 197fi7 appears to
have had many of the characteristics associated with the street-level
model. As in a number of states, the commitment process in Nebraska was
(and technically still is) administrative rather than judicial. * County boards
of mental health, consisting of the clerk of the district court, a physician
and an attorney, were authorized to hear complaints, conduct investiga-
tions, order involuntary examinations, and determine whether a person
should be committed to a state mental hospital. Board action was initiated
primarily through direct citizen contact and board members frequently
dealt directly with the proposed patient during the decision making pro-
cess. The boards were not provided with clear criteria for use in their
decision making. According to statute, persons who were “mentally ill
and in need of hospitalization” were subject to commitment. l o Mental

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illness was ambiguously defined to “include persons suffering from any

type of mental illness whatsoever, whether hereditary or acquired by
internal or external conditions, diseases, narcotics, alcoholic beverages,
accident or any other condition or happening.” l 1 The proposed patients
who appeared before the boards were generally persons who had few
personal ties and resources and who appeared to be more “socially iso-
lated.” l 2 While the statutes authorized appeal of board decisions to the
state court system, interviews with board members and judges revealed
that virtually no appeals had been made prior to 1976. Thus, in practice,
board actions were not monitored or contested by an effective supervising
agency or an organized clientele group. l3
This article explores whether the street-level model is useful in explain-
ing the actual operation of a commitment system. In particular, it de-
scribes the general coping patterns developed by the line personnel among
five civil commitment boards and explores the possible impact of varying
levels of case-load and professionalization on the daily procedures and
routines of the boards and the operational priorities and societal goals set
by them.
In this analysis, control for case-load and professionalization cannot be
kept separately. The limited number of cases in the sample also precludes
formal testing of hypotheses and precise attribution of sources of vari-
ance. Instead, the purpose of this article is to describe the kinds of coping
attitudes, routines, and behaviors that have developed in this social ser-
vices system and to utilize the street-level bureaucracy model to explore
their variation under different patterns of case-load and professionaliza-
tion.14 We hope that this analysis will contribute to the understanding of
civil commitment systems, the delineation of the street-level bureaucracy
model, and the development of ways to improve the performance of this
and other bureaucracies.

Background information
Among the five otherwise similar Nebraska boards of mental health
studied by the authors, two characteristics varied substantially: case-load
and board professionalization. l5 In 1974, 755 cases were filed in Douglas
County, compared to 55 in Dodge County, seventeen in Washington
County, fifteen in Sarpy County, and nine in Cass County.I6 In degree
of professionalization of board members and access to professional re-
sources among the boards, the same pattern emerged. The physician
member of the urban Douglas County board was a locally respected prac-
ticing psychiatrist; general practitioners, three of whom were retired or
semi-retired, staffed the four rural boards. The Douglas County board had
access to major psychiatric hospital services, specialized private agencies

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for treating numerous mental and physical disorders, two medical school
hospitals, and several dozen local psychiatrists. In contrast, the four rural
counties had no comparable facilities and, indeed, had limited access to
the facilities of Douglas County because of distance as well as legal and
financial complications. l7

Daily board procedures and routines

Theoretical predictions. Based on the street-level bureaucracy model,
one might expect to find several types of coping behavior by the board
members. A higher case-load ought to encourage a variety of behaviors
aimed at controlling psychological threat, simplifying work procedures
and minimizing external criticism and internal uncertainty. High case-load
board members should develop working procedures, attitudes toward
board subjects and personal role definitions that “rationalize” l8 the
system, resolve or prevent role conflict, and diminish, depersonalize, and
limit contact with board subjects. These tendencies should be less pro-
nounced among lower case-load boards.
The relationship one might expect between professionalization and line
behavior has been less clearly drawn. In theory, professionalization of
services has long been held to be a means by which skilled and effective
practitioners of ‘‘scientific” disciplines provide more personalized and
effective delivery of services. More recently, however, research in several
areas has suggested that professionalization carries with it norms that
reduce legitimized client input and allow the professional to establish a
more predictable and stable work environment. Thus, professionalization
may lead an agency to process larger numbers of cases more rapidly and
securely, but on terms defined by the professional staff and with less
attention to each case.2o

Coping attitudes, routines, and behaviors developed in actual practice. Ex-

tensive analysis of interviews with all board personne121indicated that
they lacked clear criteria with which mental health might be evaluated and
that no explicit or specified procedures of inquiry and decision making
existed. In general, each board sought consensus in an impressionistic,
discussion-interview format. Commitment criteria included a mix of such
factors as danger to others, need for care and ability to function in society.
It is evident from the board members’ vague and varying decision making
criteria that none of them, and by inference none of the boards, developed
systematized, explicit, and specific principles and rules to identify those
persons in need of mental health care. In this sense, boards had not
“rationalized” their procedures. Instead, the boards responded to their
tasks by reducing the scope of their responsibility and the extent of their
activity from that suggested by the legislation.22

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The rural boards. Among low case-load, nonprofessional (rural) boards,

filing an “information” alleging mental illness was nearly always a
routine, semiclerical act. Upon filing, boards would automatically detain
the proposed patient and hold an “exam” and hearing to evaluate if the
subject was “mentally ill” and fit for commitment. In practice, each of the
rural boards collapsed the legally mandated exam and hearing into one
proceeding; the exam thus became essentially a group interview of the
proposed patient. At the end of the interview, the subject of board action
was either released or committed. Commitment, generally to a state
mental hospital, was usual.
The low case-load, nonprofessional (rural) board members focused on
that portion of the statutes which reserved the “final” decision on civil
commitment for state hospital superintendents. Several of these board
members were even hostile to reference to their function as that of making
commitments; rather, they defined their function as providing a means by
which people who might be mentaUy ill would receive a professional
“evaluation” at the state hospital. This attitude was expressed by
members of each rural board and by a majority of members of three rural
boards. One rural board member, for example, described the board’s role
as sending the subject “for a short rest.” Several rural board members
also mentioned that they believed the professionals in the state hospitals
would “catch” and correct “in a few days” any errors the boards had
made.23Such a role redefinition, while not major, could be interpreted as
reducing tension in several respects. The ambiguity and uncertainty ap-
parent in decision criteria and procedures were made more tolerable to the
board by reducing the significance of the decision for the subject. Further-
more, de-emphasizing the impact of board actions on the commitment
subject helped the board members cope with the tension generated by the
clash of a process that committed 90 percent of the persons evaluated, and
an articulated goal of protecting individual rights. 24
The urban board. The high case-load, professional (urban) board
modified the statutory system substantially more than the rural boards.
Like the rural boards, it did not “rationalize” the statutory structure, but
it systematized and simplified its tasks by reducing the scope of board
activity and by placing responsibility for most decisions concerning ques-
tions of mental health on either board support personnel or professional
mental health actors and facilities. Potential informants first came into
contact with the urban board by talking with one of the district court
clerk’s secretaries. The secretaries acted as important sources of informa-
tion regarding board procedures, routines, and alternative actions infor-
mants might take; in doing so, they also screened informants. Once a
person had decided to file an information, the board secretary noted
responses to questions on the proposed patient’s basic characteristics,
medical history and alleged symptoms. The informant would then be

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interviewed by the board at its daily meeting. During this interview, the
board members’ primary function was to evaluate the credibility of the
informant’s testimony. They considered inconsistencies in the infor-
mant’s oral presentation and statements taken by the secretary prior to the
hearing and pursued matters which did not “ring true” through follow-up
questions. During the year under study, board records indicated that eight
percent of those coming before the board had their informations refused.
For the remaining 92 percent of the proposed patients, the urban board
ordinarily issued a warrant ordering the sheriff to deliver the proposed
patient to the custody of the county hospital. The board rarely had any
further contact with the informant or the proposed patient. Upon delivery
to the hospital, each subject was admitted to the psychiatric ward, ex-
amined and included on the next general rounds (daily exams) by the
regular hospital psychiatric-psychological staff. Within a period ranging
from a few hours to several days, the board physician, a psychiatrist, also
examined the subject and reported his diagnosis to the board. According
to board records, his findings were always confirmed by the board, appar-
ently without the statutorily-required “final hearing.” The subject was
then either released, left in the custody of the hospital superintendent, or
transferred to a state mental hospital.
The urban board had thus simplified its proceedings in several ways. Its
only real task was one of assessing the veracity or credibility of the
informant’s testimony. While this was hardly a simple and automatic
administrative task, it was certainly more familiar to the board attorney
and district court clerk than diagnosing mental illness; it was also a much
more limited and well defined task. The ambiguity in “diagnosing” mental
illness was eliminated, in part, by displacement to hospital staff. Further-
more, the urban board reduced personal contact by 50 percent by inter-
viewing only actual informants, and only rarely interviewing the proposed
patients.
Urban board members were like rural board members in emphasizing
their concern for protecting individual rights. The urban board, however,
clearly addressed fewer issues in deciding each of the many more cases it
hears. The psychiatrist and hospital staff were responsible for dealing with
such issues as danger, level of illness, need for and benefit to be derived
from hospitalization. Thus, the urban board functioned primarily as an
initial judge of mental competence through an ex parte hearing of com-
plaints brought by second parties.

Theoretical implications. Regardless of how one might assess their ef-

fectiveness, rural boards met, interviewed, and“examined” the primary
party concerned-the proposed patient. At the same time, rural board
members doubted their ability to diagnose mental illness, were aware of

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their lack of psychiatric skills, and failed to “rationalize” an informal,

impressionistic, undefined, and largely ad hoc decision making process.
Thaf they could operate such a system modified only by the subjective
redefinition of board activity without apparent tension may relate to their
low case-load. Three boards handled an average of only one case monthly,
and the fourth informally disposed of nearly half of its somewhat higher
case-load (55 during the year studied) into local outpatient facilities. The
infrequency of rural board hearings may have also inhibited “rationaliza-
tion” of the vague statutory system because of the difficulty of developing
an extensive body of agency “case law” with so few and infrequent cases.
The urban board became far more structurally integrated into the treat-
ment facility, the county hospital. The hospital and the psychiatrist
member communicated regarding ultimate patient disposition and gener-
ally shared the decision. On the other hand, rural boards were almost
completely isolated from all treatment facilities and were essentially inde-
pendent from all other mental health decision making structures. It is
suggestive, though by no means conclusive, to observe that the single
rural board that had the highest case-load occasionally consulted mental
health care personnel in its decision making.
In sum, rural boards retained, with slight changes, a system which
brought them into substantial contact with persons who might be expected
to be under great stress, and which required them to make ambiguous
decisions under vague guidelines. Urban boards, with immensely higher
case-loads and far greater professional facilities, utilized a substantially
different system of processing cases. It seems plausible to suggest that
high case-load was the impetus to these modifications, and that the profes-
sional facilities were a necessary, though probably not a sufficient, condi-
tion for their evolution. In all respects the revisions of the urban board
reduced their personal contact with board subjects, clarified and reduced
the scope of the responsibilities they retained, and externalized the most
ambiguous decisions.

Board operating priorities and societal goals

While Nebraska law provided the legal means of committing persons
who were found to be mentally ill and in need of hospitalization, the
statutes failed to guide civil commitment boards in setting priorities and
choosing among competing goals. Were the boards to commit all persons
who might benefit from the care offered by mental facilities, or to commit
only those who clearly needed care, or those who were likely to do
physical harm to themselves or to others? Were they to concern them-
selves only with “mental illness,” or were they to attempt to refer mal-
adjusted persons to an appropriate social agency? Were they to see them-

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selves as general crisis resolvers for persons or other social agencies? In

short, once the legislature had established civil commitment boards, what
operating roles and priorities did they set for themselves?
By comparing urban and rural board member role definitions, this sec-
tion will consider how case-load and professionalization may have
affected operating roles and priorities. As we suggested previously, the
street-level model predicts that civil commitment boards would probably
respond to the ambiguity, face-to-face contact, and potential personal
threat in their task by: (1) simplifying the system; (2) resolving or prevent-
ing member role conflict; and (3) reducing, depersonalizing and delimiting
contact with board subjects. The street-level model further suggests that
higher case-load might intensify the tendency of boards to modify their
operations. Professionalization entails norms that would be expected
to increase the stability and predictability of board operations, and
would lead to diminished legitimate client input and limited contact with
individuals.

Societal roles and priorities of board members. The data for this (and
the subsequent) analysis were gathered from interviews with all members
of the five Each subject was interviewed in an open-ended
schedule. The interviews were taped and transcribed, and all observations
pertaining to roles and attitudes were identified and isolated. Four coders
were trained to code the items in a staggered format, ensuring that each
item was coded by three individuals. The “coefficient of reliability” ( 1
minus “errors” divided by total items coded) for the analysis of all boards
was 0.88. The results are presented in the table below.
Passive delivery role. As the table illustrated, role perceptions of both
urban and rural boards were multifaceted.26For both types of boards, the
most frequently stated board role (34 percent for each board) was the
passive provision of access to mental care facilities; i.e., providing a
linkage by which possibly ill individuals might be provided with expert
evaluation and care. The following comments are typical of individuals
with this role perception:
The board of mental health is basically established to help those
people who for some reason do not want to help themselves or cannot
help themselves.
We look at it that we are trying to perform a service for people [trying]
to get an unfortunate person into a situation where there is more
expertise that can be exerted upon him to see if you could help him.
We are trying to assist unfortunate people and that’s the main thrust
of our function.

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Table 1. Board Societal Roles

~~~ ~~

Rural Boards Urban Boards All Boards

n =79 n =35 y = 114

Protecting society 11% (9) 6% (2) 10% (11)

Protecting individual liberties 20% (16) 29% (10) 23% (26)

Providing access to mental health

facilities (passive delivery of
services) 34% (27) 34% (12) 34% (39)

Delivering whatever care

necessary to those with
mental or general behavioral
problems (aggressive delivery
of services) 15% (12) 3% (1) 11% (13)

Responding to public disturbances 0% (0) 3% (1) 1% (1)

Resolving or responding to social-

welfare agency crises 1% (1) 11% (4) 4% (5)

Resolving or responding to
family crises 15% (12) 11% (4) 14% (16)

Providing a definitive medical

diagnosis 0% (0) 3% (1) 1% (1)

Ambiguous or other 3% (2) 0% (0) 2% (2)

99% (79) 100% (35) 100% (114)

Aggressive delivery role. Fifteen percent of the rural board members’

role perceptions reflected an aggressive care delivery role. In this role,
board members defined the scope of their activities to include intervening
in instances of general disruptive behavior (family disorder and excessive
drinking), pressuring subjects to “improve” behavior, and following-up
on subjects after treatment was completed:
I think after a certain point of continuous drinking, the person
gets to the place where they cannot, in and of themselves, without
some outside help, get away from drinking. When they get to that
stage, they have to be confined for this outside help because if we
discharge them, they will go right across the street and start drinking
again. There are those who get drunk over the weekend and sober up
Monday morning and go to work and don’t take a drink for a week.
If they want to, they can quit drinking without being confined. And

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those people who have jobs realize the seriousness of it-we will
frequently let them go with an admonition that you stay off this; and
if you don’t and you come back in front of us, we’ll know then that
you can’t quit it and will help you quit it.
Sometimes we play God and try to put a little fear into them and
tell them well, we are going to let you go, but we are not going to
close this case, we may open it again, if we think there is good reason
to do it.

In contrast, aggressive role perceptions were almost entirely absent in

urban board members. The urban board did not see itself as responsible
for solving the many genuine social and human problems it confronted that
had no mental health component, and no urban board member approved
of the use of informal or extra-legal pressure. For example, urban board
members did not consider appropriate a nonstatutorily authorized
“suspension” of the proceeding with the threat of “reopening” and com-
mitment if the problems of family neglect or drunkenness recurred.
Protecting individual liberties. The second most frequently mentioned
role perception by both types of boards was the protection of individual
liberties:
That’s one of the misconceptions that people have. They think they
can come down here and just sign a statement and it’s automatic.
It’s not. Those people come in here and we interrogate the informant
because we want to make sure we have enough basis to, number
one, pick a person up and, number two, to make sure that there is
someone mentally ill, either direct mental illness, or alcoholism, or
drug incapacitation or something. We just sit here, we sit right here
and talk it over. The informant will give us all the information, we will
question the informant. It’s not like a court proceeding because
it’s not adversary, you know, but we just keep cross-examining
that person.

This role was more frequently mentioned by urban board members than
rural ones (29 percent urban, 20 percent rural).
Resolving or responding t o family crises. Another perceived role
was that of resolving or responding to family crises (fifteen percent
mral, eleven percent urban). This role, however, troubled board
members: they felt they were often drawn into essentially domestic dis-
putes and hostilities in which husbands and wives, or sometimes parents
and children, brought nonillness, family-related problems to them:
There seems to be a trend for-for example, for a wife can’t under-
stand why her husband doesn’t want to come home after work to the

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family but would rather go down to the bar and gulp down ten or
eleven beers with the boys, so she concludes that he must be insane.
In other words, we get a lot of cases which are really marital problems
and not pure cases of insanity; and the same thing seems to be with
the people who have children and perhaps don’t do what they think
they should. The girl gets caught smoking pot behind a garage and
their rationale is [she] must be crazy. [They think] ‘That’s my kid and
they wouldn’t do that otherwise.’
The boards responded to these cases in a variety of ways: sometimes,
particularly when divorce proceedings were underway, they simply
refused to accept the information. At other times, board members, espe-
cially rural ones, attempted to mediate and settle such family problems.
But it appears they more often simply recommended that the parties take
their dispute elsewhere.
Protecting society. The role of protecting society was mentioned more
often by rural board members (eleven percent) than by urban ones (six
percent). For both groups, this role was also a difficult one because it
frequently appeared to conflict with protecting individual liberties and
required decision making in ambiguous circumstances:
I can conceive of a place where a guy is shrewd enough to fool the
board [garbled], and then the other thing is well, I either turn this guy
loose and, like the guy down in Texas who went to a psychiatrist and
he says there is nothing wrong, then here you got a guy that maybe
is running loose and is going out and shoot[ing] down fifteen people
and then you of course have got a problem because you let him go,
and the easy way is maybe to send them down to the state [hospital].
Another board member observed:
The cases that trouble me and I guess would trouble the doctor, and
the young clerk couldn’t [help but] notice it, you have cases where the
relatives come in and tell wild, wild stories about the behavior of this
person and who want you [to] bring them in to see this person. [You
think he’s] about ready to wack you over the head, you know, and he
comes in very docile, very neat, very polite, you talk to him for
one-half hour and you see nothing and get the Sheriff that says if this
guy is crazy, I’m nutty too . . . actually, however, in some cases he
was. He was somewhat clever enough to cover it up. Those are the
ones that we agonize over. You know, what should we do about
them. And frankly do you sell them an axe and send them. One
memorable case-the wife wanted to commit the husband and we
ended up committing the wife because all this was her imagination
and she was getting kind of wild.

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Still another board member reflected:

If we have no information that the person [has] ever been dangerous,
if you think he is just peculiar or something, we don’t send to Norfolk
[State Hospital] if we have any doubts. If he has made threats, such
as a fellow did the other day, he’s still making threats-he is going
to cut himself and his family, we think we would probably commit
him. Just in case something goes wrong. If we are wrong, we have
taken away some of his rights; that’s too bad but it is restored to him,
or course, so it is only temporary. If we are wrong we may not sleep
for a couple of nights, [but] if he is just going to wipe out his own
family . . .
Responding to social welfare agency crises. Urban boards (eleven
percent), much more than rural boards (one percent), also viewed their
function as assisting social welfare agencies:
We’ve had a lot of contact with them [social agency personnel] be-
cause people who may be on welfare and they are checking them out
and they find them in these ah . . . ungodly states, you know people
sitting in waste, you know, drunk, they got beer and wine-you
know-around them, empty bottles all around them, and they
haven’t moved from the chair for two, three days,-all they are doing
is drinking sitting there in their waste-these people have to go out
and check on it and they come in here and say, ‘These people need
help, can you commit them?’

Observations. Rural boards generally shared similar perceptions of

their roles with urban boards, but they took a more positive, assertive
approach to cases. While urban boards regarded their role as primarily
providing care to those who were mentally ill and releasing all others, rural
ones were inclined to act whenever individuals with serious problems
appeared before them. Some were committed; others were threatened
with commitment unless they “improved”; others were referred to social
agencies or counselors. Finally, rural board members were somewhat
more likely to mention the roles of protecting society and resolving family
crisis than urban board members. The latter, on the other hand, were
substantially more likely to mention protecting individual liberties and
assisting social welfare agencies than were rural board members.
While these findings are not conclusive, they do support several obser-
vations. First, both rural and urban boards found their work sufficiently
variable and multifaceted to develop several role definitions.
Second, perhaps because of their much smaller case-load, greater face-

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to-face contact with board subjects, and lower professionalization, rural

boards were more likely to see board-client relationships as open-ended
and not merely limited to making statutorily specified judgments. Con-
versely, urban boards were more likely to adopt a binary decision making
process: a board subject was either committed or released, without board
follow-up in either case.
Third, the greater number and diversity of professional social welfare
agencies found in urban areas may explain the tendency of urban boards
to respond to the needs of such agencies. Urban boards had frequent
contact with representatives from social welfare agencies, primarily as
filers of informations, while rural boards rarely had such contact other
then with their local police or sheriffs offices.
Fourth, rural board members mentioned more frequently two roles
that appeared to them to require more ambiguous and difficult decisions.
They mentioned resolving family crises and protecting society somewhat
more often than did urban members, who mentioned protecting individual
liberties much more often than rural board members (a role described in
the interviews with much less apparent tension than any except the pas-
sive care delivery role). A theoretical argument could be appended to this
pattern: “protecting society’’ is a vague goal, given the need it creates to
conjecture regarding possible mental states, future behavior, and dangers
to society; resolving family crises is also an ambiguous area, given the
powerful emotions associated with intra-familiar problems. Protecting in-
dividual liberties, however, can be, and was, specifically defined in terms
of systematized rights and procedures.
In sum, differences between urban and rural boards in societal roles
were not great; the ambiguity of their legislative mandate along with
the exigencies of real-world operations appear to have affected them simi-
larly. The variation between the boards was generally consistent with
street-level bureaucratic theory, particularly as it releates to open-ended
and ambiguous roles versus defined, circumscribed and clarified roles.
Theoretical predictions regarding both professionalization and case-load
are consistent with these data.

Summary and conclusions

This article has explored the “coping” patterns that developed in a
system of involuntary civil commitment; i.e., whether and how dramatic
variations in case-load and professionalization affected the operations of
five county mental health boards and the attitudes of their members. The
aspect of board operation most dramatically affected was procedure. The
urban, high case-load, professionally-oriented board developed a process-

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298 Journal of Health Politics, Policy and Law

ing system that reduced face-to-face client contact, circumscribed the

scope of decisions made, and externalized the responsibility for the most
ambiguous of these decisions. Rural boards operated a far more ambigu-
ous, open-ended, and tense system, incorporating face-to-face contact
modified only by the definition of their tasks as evaluation, not commit-
ment. Board social roles were less clearly affected. All boards had multi-
faceted role definitions, but rural ones had a more open-ended perception
of their functions. They attempted to modify antisocial behavior and to
redirect board subjects to sources of social counseling. Urban boards had
withdrawn somewhat from the most ambiguous societal roles that rural
boards had retained. These findings, in general, support theories dis-
cussed in the street-level bureaucracy literature.
These conclusions indicate that effective policy and program reform
must take into account line level administrators’ environments. In design-
ing a system in which commitments are responsive to patient conditions
and needs, and in which essential substantive and procedural due process
requirements are met, several changes might be considered. For example,
one strategy would be to specify commitment criteria in much greater
detail. Similarly, the number and variety of disorders for which commit-
ment could be sought could be limited in order to reduce frivolous or
inappropriate filings, ease overloads, and reduce the number of assess-
ment systems required by boards.
Another strategy might involve the development of a state-wide in-
dependent authority, agency, or mental health officer empowered to
investigate the operation of the mental health system and to intervene in
commitment proceedings. Such an approach might assist rural committing
authorities in establishing their working rules and procedures and pre-
clude informal procedures that reduce patient rights or nullify clear legis-
lative intent.
Another response might be to allow varying administrative struc-
tures, rather than imposing the same administrative structure on each
county regardless of population, case-load, and availability of professional
facilities. 27
Finally, patterns that developed in urban boards could be changed by
reducing their case-load substantially. It should be noted, however, that
such a reduction might affect the type of coping behavior engendered, but
coping behavior by board personnel would still exist and would still affect
the operation of the system.
Whatever strategies are developed to deal with inadequacies in the
system, policymakers must be careful to avoid making unrealistic de-
mands on street-level actors. In demanding the impossible, they are likely
to cause a breakdown of the new system or encourage the development of
an informal system vulnerable to many of the failings of the old.

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Wunsch et al. Civil Commitment 299

Notes
1. One might view empirical behavioral research in the general area of public administra-
tion as composed of two waves. Perhaps the most well known of the first wave is James
March and Herbert Simon, Organizations (New York: John Wiley, 1963). Other works
include Anthony Downs, Inside Bureaucracy (Boston: Little, Brown, 1967); James
Thompson, Organizations in Action (New York: McGraw-Hill, 1967); and Gordon
Tullock, The Politics of Bureaucracy (Washington, D.C.: Public Affairs Press, 1965).
These works describe and analyze the internal operations of bureaucracies. More re-
cently, a second wave, often described as public policy analysis, has expanded the study
of public administration to focus more on the actual delivery and nondelivery of services
to the public. Contributors in this area include Herbert Jacob and Michael Lipsky,
“Outputs, Structure and Power: An Assessment of Changes in the Study of State and
Local Politics,” Journal of Politics 30 (May 1968): 510-38; Theodore Lowi, The End of
Liberalism (New York, Norton, 1968); and Jeffrey Pressman and Aaron Wildavsky,
Implementation (Berkeley: University of California Press, 1973).
2. See, for example, Elihu Katz and Brenda Danet, eds., Bureaucracy and the Public: A
Reader in Official-Client Relations (New York: Basic Books, 1973); Yeheskel Hasenfeld
and Richard A . English, eds., Human Service Organizations: A Book of Readings (Ann
Arbor, Michigan: The University of Michigan Press, 1974); Michael Lipsky, “Toward
a Theory of Street-Level Bureaucracy ,” in Theoretical Perspectives in Urban Politics,
eds.: Willis Hawley et al. (Englewood Cliffs, New Jersey: Prentice-Hall, 1976), pp.
186-212; and David Perry and Paula A. Sornoff, Politics at the Street Level: The Select
Case of Police Administration and the Community (Beverly Hills, California: Sage
Professional Papers. 1973).
3. Michael Lipsky and Richard Weatherly , “Street-Level Bureaucrats and Institutional
Innovation: Implementing Special Education Reform in Massachusetts” (Paper pre-
sented at the 1976 Annual Meeting of the American Political Science Association), p. 2.
4. The extent to which this approach differs from conventional public policy analysis was
stated in a recent paper: “The usual study of implementation [is turned] on its head, for
we now regard the lowest levels of the policy ‘chain’ as the ‘makers’ of policy, and the
‘higher’ level of decision making as circumscribing (albeit in important ways) the lower
level policymaking context.” Ibid., p. 3.
5 . Excellent summaries of this research in Michael Lipsky, “Street-Level Theory;” Willis
Hawley et al., Theoretical Perspectives, pp. 196-208; Michael Lipsky and Richard
Weatherly , “Street-Level Institutional Innovation,” pp. 1 4 ; and Yeheskel Hasenfeld
and Richard English, “Human Service Organizations: A Conceptual Overview ,” in their
Human Service Organizations, pp. 1-24.
6. Elihu Katz and Brenda Danet, Bureaucracy and the Public; Yeheskel Hasenfeld and
Richard English, “Human Service Organizations”; see also Michael Lipsky, “Street-
Level Theory,” in Hawley et al., Theoretical Perspectives.
7. On December 24, 1975, a three-judge federal court declared that the Nebraska statutes
failed to provide constitutionally sufficient commitment standards and adequate pro-
cedural safeguards in the case of Doremus v . Farrell, 407 F. Supp. 509, 517 (D. Neb.
1975). In response to this decision, the Nebraska legislature has since revised its commit-
ment law. The new legislation, however, retains an “administrative,” decision making
body. For further discussion, see Geoffrey W. Peters et al., “Administrative Civil
Commitment: The Nebraska Mental Health Commitment Act of 1976,“ Creighton Law
Review 10 (March 1977): 243-78.
8. Procedures for extended involuntary civil commitments have traditionally been
classified as either: (1) judicial; or (2) nonjudicial; consisting of either (a) hospitalization
after an investigation and hearing authorized by an administrative board or commission,
or (b) hospitalization by medical certification. See American Bar Foundation, The
Mentally Disabled and the Law, eds.: S. Brake1 and R. Rock (Chicago: University of
Chicago Press, 1971), pp. 41-43,4%59,72-97. For a bibliography of law review articles,
cases, case notes, and book reviews covering recent legal developments in involuntary
commitment, see “Mental Health Law Bibliography,” University of Toledo Law Review
6 (Fall, 1974): 31440.

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9. For a detailed description of the legal structure and operation of this system, see
Geoffrey W. Peters et al., “Administrative Civil Commitment: The Ins and Outs of the
Nebraska System,” Creighton Law Review 9 (December 1975): 266-85. See also
Geoffrey Peters et al., Final Report: Mental Health Commitment in Eastern Nebraska
(unpublished report submitted to the National Institute of Mental Health).
10. Neb. Rev. Stat. Q 83-328 (Reissue 1971) (repealed 1976).
11. Neb. Rev. Stat. 0 83-306(4) (Cum. Supp. 1974) (repealed 1976).
12. Geoffrey W. Peters et al., “Administrative Civil Commitment: The Ins and Outs of the
Nebraska System,” pp. 27678, 280.
13. In some respects, the proposed patients and their attorneys, when a proposed patient had
one, might be considered to have “challenged” the commitment system. Attorney
involvement occurred in only about four percent of the cases, however, and the con-
frontations that did occur appear to be ad hoc and limited to the dispositions of individual
cases. Issues pertaining to general board policies were apparently not raised and, in
some instances, the attorney served as an advocate for commitment. See Geoffrey W.
Peters et al., “Administrative Civil Commitment: The Nebraska Experience and Legis-
lative Reform Under the Nebraska Mental Health Commitment Act of 1976,” Creighton
Law Review 10 (March 1976): 26W2.
14. This report has carefully chosen to present an exploratory and suggestive framework
for its findings. It proposes to point out a fruitful area for further research rather than
present necessarily conclusive findings. Our desire to present these data was enhanced
by our belief that the street-level bureaucracy model is a highly promising analytical
tool for remedying many of the pathologies that afflict public serviceipublic authority
performance.
15. “Board professionalization” is used here to refer to the extent that board members,
particularly the physician member, had specialized training in the diagnosis and treat-
ment of mental illness, and to the extent that the board had access to, and utilized other
professionals who were specialized in the diagnosis and treatment of mental illness.
16. For a detailed description of the appearances before the boards, see Geoffrey W. Peters
et al., “Administrative Civil Commitment: The Ins and Outs of the Nebraska System,”
pp. 270-71.
17. Classification of the five counties required a critical analytical decision. Because of
the low number of cases, a nominal “high/low” distinction was chosen. The three
lowest case-load counties (17, 15 and 9 cases) clearly belonged in one category, while the
high volume county (755 cases) obviously fit in the other. The “middle” range county
(55 cases) was placed in the ‘‘low’’ case-load category. This placement was made for
several reasons: first, the difference between its activity and that of the most active
county was twenty times the difference between it and the lower range counties; second,
it “informally” disposed of nearly half its cases into a local “clinic” on grounds of
“good” behavior, bringing its actual case-load even closer to the lowest counties; and
third, it was much closer to the other rural counties than to the urban county on the
professionalization variable. As a check on this decision, its patterns of operations were
separately computed and were found close in all respects to the other rural counties.
Such factors as case-load/population ratios have, of course, no bearing on the theoretical
or empirical issues considered here.
18. The term, “rationalization” to describe board procedures is used here in a manner
consistent with the Weberian model of rational-legal bureaucracy. This model suggests
that the most efficient and predictable administrative system is one based on general
principles clearly articulated in law which can then be applied with minimum uncertainty
and maximum predictability to each case coming to the bureau. Rationalization, or
bridging the distance between general law and specific application by bureaucrats, is, in
the ideal-typical model, the product of logical and systematic derivation of operating
rules and procedures from the general principles enumerated in statutes. It simplifies,
clarifies and specifies bureau operation. The Nebraska statutes on civil commitment,
however, do not appear to provide a framework clear enough for such a logical and
systematic process of rationalization to occur. “Policy” in these circumstances is likely
to be somewhat distant from “law” and to develop in some measure in response to the
working environment. See Theodore Lowi, The End of Liberalism.

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Wunsch et al. Civil Commitment 301

19. Michael Lipsky, “Street-Level Theory,” in Hawley et al., Theoretical Perspectives, pp.
196-208; Michael Lipsky and Richard Weatherly, “Street-Level Institutional Innova-
tion,’’ p. 2; and Anthony Downs, Inside Bureaucracy, particularly pp. 191-95, and
208-10, regarding “performance gap.”
20. See Amitai Etzioni, ed., The Semi-Professions and Their Organization (New York: The
Free Press, 1969).
21. The narrative summary of board procedures in the text is based on interviews with all
board members, county and juvenile court judges, county (prosecuting) attorneys,
defense attorneys, mental hospital and board clerical personnel. It also draws on direct
observation of board procedures, a statistical analysis of all cases processed by the
boards in 1974, and data presented in Table 1 in the text. A less “abstracted”
presentation of the evidence can be found in Chapter I11 of the Final Report to the
National Institute of Mental Health on the research project. Responsible parties inter-
ested in further analysis of the research material may contact the authors.
22. The modifications referred to here do not in any sense imply malfeasance or misfeas-
ance; they must be considered in the context of any public administration system’s need
to “flesh-out’’ statutes with working procedures, priorities and practices. The works
cited above, especially in note 1, are concerned with this process.
23. This response was elicited from eight of twelve rural board members when asked “how
they thought they fit into the mental health system in Nebraska.” By statute, the
superintendent of the state hospital was required to certify to the committing board prior
to the end of an “observation” period of 60 days whether the patient was mentally ill and
in need of hospitalization. If he so certified, commitment for an indefinite period was
complete. Neb. Rev. Stat. § 83-328 (Reissue 1971) (repealed 1976).
24. On only one of the rural boards studies was there any apparent disharmony or conflict.
There, the board attorney refused to accept the limited definition of board impact held
by his comembers and seriously doubted the competence of the board physician. The
attorney emphasized the impact commitment had on subjects’ personal lives and its
influence on any mental board or agency decisions in the future regarding the subject,
and was unable to resolve the conflict among the competing goals of protecting society,
protecting individual rights, and getting mental care to those who needed it. For this
actor, board service appeared to be an unpleasant task which led him to self-doubt,
unsought conflict, and serious reservations regarding the entire state system. He re-
signed from the board shortly after the period researched.
25. Another critical issue in this research was how to systematically present the highly
interesting, informative and valuable data elicited by the open-ended interviews. Use of
a structured interview instrument had previously been rejected because of its incapacity
to elicit fuller description and unanticipated material. Content analysis, even with its
limitations, was chosen to assess actor perceptions. Because of the low number of
respondents (fifteen), and because the number of codable responses was fairly compara-
ble across respondents, summaries of all perceptions by type of board were prepared.
This approach allows more subtle patterns of perceptions and attitudes to appear in the
data, but does not, we feel, distort the evidence. In discussing social roles of boards,
most board members mentioned most of the roles; what varied among them was the
emphasis they placed on particular roles, as indicated by how many times they men-
tioned a role. In several instances, as a self-check, data were also analyzed by individual
(i.e., what he or she mentioned most often). The results of this analysis followed the
board level patterns, but were naturally much less subtle. Finally, since all respondents
were assured of anonymity, and there were only three urban board members, individual
presentations would not be entirely ethical. The number of codable perceptions for each
actor is presented in the following table:
Total Number of Codable Perceptions
Rural Member 1 19
Rural Member 2 16
Rural Member 3 27
Rural Member 4 24
Rural Member 5 29

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Rural Member 6 26
Rural Member 7 9
Rural Member 8 33
Rural Member 9 32
Rural Member 10 32
Rural Member 11 45
Rural Member 12 22
Rural Member 13 12
Rural Member 14 27
Rural Member 15 48
26. This discussion is a summary of the comprehensive analysis of board member role
definitions presented in Geoffrey W. Peters et al., Final Report (1976), Chapter 111,
“Integrative Summary of Interview Data.”
27. An Exploration of several possible reforms is presented in detail in Geoffrey W. Peters
et al., ‘‘Administrative Civil Commitment: The Nebraska Experience and Legislative
Reform Under the Nebraska Mental Health Commitment Act of 1976,” pp. 266-77.

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