Commitment Process: When a Person is a Danger to Self or Others

In the United States approximately one out of four adults, age 18 or older, suffers from a mental disorder. This figure, from the National Institute of Mental Health, (NIMH), has not been updated since 2004. According to John Grohol, PsyD, the author of the article, Mental Health Statistics , (World of Psychology, psychcentral.com ), these numbers are outdated. His prediction is a much higher 75 million people, not the 57.7 million stated by NIMH, which equates to 1:3 Americans, and includes diseases such as alcoholism and drug addiction.

As the numbers of the mentally ill population grow, it is evident in our society that not everyone receives treatment or is hospitalized. Treatment can occur in an outpatient clinic where a ‘client’ may have a session with a qualified therapist, or an inpatient basis, in a free standing psychiatric facility, state hospital, or special unit in a general hospital.

If a person seeks help in an outpatient clinic a psychiatrist-a medical doctor specializing in mental disorders, will treat the patient with medication and evaluate the effectiveness of the medications prescribed. A therapist meets with the person for a ‘session’ in which cognitive therapy, group therapy, or other variations of therapy are used.

These therapy modalities are used to support the client’s ability to resolve the problem and bring her to a higher level of functioning. A set number of sessions are usually initiated on the first meeting, often dictated by a client’s ability to pay-or whether she has an insurance case manager ‘assign’ a designated number of sessions. The licensed therapist could be a psychologist, a social worker, or a nurse. Their educational paths may be different, but the common denominator for each of these professionals is their area of expertise, and advanced level of education, which is in the specialty of psychological disorders and mental health.

However, what happens if a person cannot afford to see a clinician and his mental condition continues to deteriorate? When payment, through self pay or insurance, disqualifies one for private sessions, how does one get the help or hospitalization he needs?

What is the process of hospitalizing someone with a mental illness? The broad terms of inpatient involuntary commitment status is that the person is deemed a ‘danger to himself, a danger to others, or is incapable of taking care of his needs’. If a person meets any of these criteria he or she can be detained in a psychiatric hospital or mental health unit for observation and examination.

When a person is committed it is usually because they do not recognize their need for treatment or do not agree with it. Although they may protest being hospitalized they must follow the decision of the magistrate who has signed the legal affidavit which claims the terms of the hold. On this form the date, time, number of days for the hold and explanation of the person in question’s behavior is filled in. It will also state the name and address of the person who has taken out the involuntary commitment, (IVC).

Once the form is signed by the magistrate it is brought to the police department who will send an officer to transport the person to the closest hospital emergency room for an initial medical exam. That documentation will be considered the first mental health exam and the physician’s findings, which include a psychiatric diagnosis, will be documented and accompany the person to the accepting psychiatric facility.

On admission, the psychiatrist has 24 hours to conduct a mental status exam on the patient to determine if this person indeed, meets criteria to continue the commitment. This is referred to as the second exam and the findings are faxed to the judge at the county courthouse.

Other times a person may enter the hospital emergency department with a medical complaint and a staff will alert the E.D. physician that a psychiatric evaluation is warranted, based on the patient’s threats of suicide, homicide, or psychotic behavior. In these cases the patient may be given the choice to be transported to the unit as a voluntary patient, if he should agree to sign himself in for treatment, or as an involuntary patient. If the person refuses to sign him or herself in and meets the requirements for commitment, the medical personnel is required by law to process an IVC form, especially in cases of suicidal or homicidal threats.

How the mental health laws serve the disabled

In the United States the mental health laws ideally protect people from getting lost in the system, forgotten, or unable to receive treatment. Ideally, because one can find infractions, abuse through loopholes, and manipulation of information to suit certain parties in any governmental system.

Laws that were erected to protect the mentally ill have been known to be misused by people to hospitalize family members whose behavior is eccentric, or whom they stand to lose the control of their property to. The Florida Mental Health Act of 1971, (also referred to as the Baker Act, named after state representative, Maxine Baker who advocated for the mentally ill), was created because of numerous cases in which family members committed the elderly and left them there for years, while they took over their estates. This warehousing in state mental facilities is identified as a form of elderly abuse.

Any person, regardless of age, who has been detained through an involuntary commitment process, has to be brought before a judge for a hearing within a set date. Usually the date is within 10 days of admission. The patient has the right to be present and appeal the commitment individually or with counsel representation. If unable to afford counsel, one has the right to be delegated one by the courts.

During the hearing the judge will listen to testimony and review documentation presented by the psychiatrist, first examiner, or other staff, who have evidence that the patient’s condition warrants further treatment. He or she will then listen to the patient. Questions may be asked and the circumstances leading to the lock up reviewed, at which time the judge will make a decision to release the patient based on inability to meet the criteria for commitment, or to extend the treatment by determining how many more days the patient will be expected to stay-usually an additional ten to fourteen. A follow up date for a court review is made to ensure that the patient is not stuck endlessly in a locked facility.

From state to state there are variations to the statutes that surround the mental health laws, but each state has an obligation to follow the process through the legal system. Since the ruling from the Supreme Court in 1975, in the case decision of O’Connor v Donaldson, it is unlawful to withhold a person against his will without a timely evaluation and release if there is no evidence to substantiate the need for continued hospitalization. This case was brought to the attention of the Supreme Court due to the suit of Kenneth Donaldson who had been a patient at the Florida State Hospital for fifteen years.

An example of the ‘checks and balance’ system

As a psychiatric nurse, I’ve had the opportunity to be present at these hearings on occasion. It is an important process of protecting a patient from being held unfairly by people who do not have the best interest of the patient at heart. On one occasion, in the courts of Detroit, I sat in as a student nurse. We watched as several cases were presented and my instructor would ask for our decision prior to hearing which way the judge would determine.

One case that has stood out in my memory from 1983 was that of an elderly, African-American female who was being committed by her daughter. She was a skinny, animated woman who looked disheveled in her crumpled clothes. The odd looking colorful knit hat on her head created a bizarre look that made one take pause. Going by appearances alone, it was an easy call.

The daughter alleged that her mother was exhibiting paranoia and was delusional because she locked herself in her house, barricading the door and attempted to take a baseball bat to anyone approaching the house. After listening to the facts most of the students were convinced that she was committable.

However, as the judge questioned her she had a logical and reasonable explanation for everything the daughter had said, countering the allegations and insisting that the daughter was attempting to take guardianship of her finances. The eccentric hat: it was cold at night in her house and it kept her head warm; the locked doors and barricade: she lived in a bad neighborhood and was afraid at night; the baseball bat: protection for “any fool who would come knocking on a door in the middle of the night”.

The judge ruled her competent and dismissed the case.