Civil Commitment Standards Across the States
California spent more than two years unable to agree with itself about who counts as gravely disabled. Senate Bill 43, signed in October 2023, added inability to provide for personal safety or necessary medical care, and a severe substance use disorder, to a definition of grave disability that had turned since the Lanterman-Petris-Short Act's original 1967 text on the narrower inability to provide food, clothing or shelter. Sacramento County adopted the new definition on January 1, 2025. Ventura County held off until January 1, 2026, the last date state law allowed a county to delay. For a full year, the same clinical presentation could support an involuntary hold on one side of a county line and not the other, inside a single state, under a single statute, because the legislature let counties choose their own start date rather than picking one for all of them.
That kind of gap is not a bug particular to California's rollout. It is what happens whenever a state leaves the operative word in its commitment statute undefined by anything above it. Addington v. Texas fixed how sure a factfinder has to be, requiring proof far stronger than an ordinary civil case demands before a state commits someone against her will. O'Connor v. Donaldson, 422 U.S. 563 (1975), fixed a substantive floor beneath that: a state cannot constitutionally confine someone who is not dangerous and who is capable of surviving safely in freedom, whether alone or with the help of family or friends willing to take him in. Neither case supplies the word a state actually has to work with in an emergency room at two in the morning, which is some version of dangerous, or disabled, or unable to care for oneself, defined however that state's own legislature chose to define it.
Kansas v. Hendricks added a floor on the far end of the same spectrum, permitting indefinite commitment after a criminal sentence has run its course only where the confinement rests on a diagnosed mental abnormality expected to leave the person dangerous going forward, and not on the underlying conviction by itself. Foucha v. Louisiana, 504 U.S. 71 (1992), had already supplied the mirror image of that rule for a narrower population, insanity acquittees: Louisiana could not keep a man committed on a finding of dangerousness alone once doctors agreed he was no longer mentally ill, because due process lets a state hold someone only as long as both mental illness and dangerousness are present, not either one on its own. Between them, Addington, O'Connor, Hendricks and Foucha rule out several ways a commitment statute could go wrong. None of them tells a legislature what dangerousness, or grave disability, has to mean.
New York fills that word differently than California does. Its mental hygiene law authorizes involuntary hospitalization on a finding that a person's mental illness makes serious harm to himself or others likely, and its emergency-admission provisions define that likelihood to include a substantial inability, caused by mental illness, to provide for basic needs including food, clothing, shelter, personal safety and necessary medical care. California's newly uniform standard asks simply whether the person can provide for those needs at all, with the medical care and safety additions layered on by SB 43 asking about consequences beyond mere provision. A patient who could technically feed and shelter himself, but whose untreated psychosis puts him at serious risk of a specific physical harm, might fit New York's formula more comfortably than California's older one and California's post-SB 43 one about equally. Run the comparison the other direction and it holds too: California's post-SB 43 definition now reaches someone whose severe substance use disorder leaves her unable to secure necessary medical care even absent the kind of imminent physical danger New York's own serious-harm language is written around, a category New York's own statute was never amended to add.
The expansion was not uncontroversial on its own terms, and the objection to it says something about what a broader definition actually does in practice. Disability Rights California opposed SB 43 throughout its passage, arguing that folding a severe substance use disorder into grave disability makes it easier to commit someone for drug use alone, that the population most affected skews toward unhoused Californians, who are disproportionately people of color, and that expanding who qualifies for a locked bed diverts funding from the community-based housing and outpatient services that might have kept some of those same people out of a hospital in the first place. Advocates on the other side of the debate had spent years arguing the opposite, that the pre-2024 definition left visibly incapacitated people on the street because the law would not let anyone intervene until harm was imminent. Both sides were arguing about the same three words, gravely disabled, and neither side was arguing about clinical practice at all.
None of this is a matter of one state having gotten the science right and another having gotten it wrong. Psychiatry did not change between 2023 and 2026. What changed was a legislature's own account of which forms of incapacity justify overriding a person's liberty, an account each state has to write for itself because the Constitution supplies only the outer boundary and the standard of proof, not the diagnostic content in between.
Every county in California now applies the same definition its legislature settled on more than two years ago. The clinicians filling out hold forms this year are checking different boxes than the ones they checked in 2023, for patients whose actual conditions have not changed at all.