How does your state handle involuntary commitment?

[nancysinatra]

Ok I am discouraged. Today I was forced by a county in my state to discharge a patient who I know is a danger to his/her community and family. The way commitment works in my state is that any doctor can place the patient on a 72 hour hold, and once that's in place a psychiatrist can apply for commitment. A community member can also apply through a separate process. The application goes to the county of the patient's primary residence, where it is screened by a social worker and then either approved or denied by the local county attorney. If it's approved, the process goes forward and a judge hears the case. If the judge orders commitment, the patient leaves our hospital and goes to a local public facility. The county gets the bill for both hospitalizations.

Our state is large geographically with many small counties, some in very remote areas with tiny staffs that almost never deal with mental health issues. Other counties are deluged with these cases. The patients come to our hospital from the entire state, at a tremendous cost. So I am dealing with county bureaucrats who have varying levels of mental health knowledge but whose concern always comes down to saving money. Sometimes they "screen out" patients without even seeing them. Other times they "screen in" people who are not mentally ill but simply a local nuisance. (This is much rarer, and usually happen when a community member initiates the petition. It's like the consult from hell, because there's no refusing a judge's order - and believe me I have tried.) One time we were stuck with a person who had been civilly committed for treatment of seizures, which a judge felt made the patient a driving hazard. I don't think the judge understood that neurology and psychiatry are different.

I would say that 60% of my applications in the last 6 months have been DENIED by county "screeners." Counties have a strong incentive to "screen out" as many cases as they can. Their medical judgment is so bad I think it is actually causing a danger to society. The screen in the people who don't need commitment, and they screen out the ones who do!

I called the county attorney in this case today to appeal the decision, and here's how the conversation went:

Me: "this patient is actively hallucinating and a danger to herself/himself and others, including young children. This patient is extremely high risk in my medical opinion."

Attorney: "Well we believe that the patient doesn't need to be in the hospital because he/she has an outpatient plan."

Me: "Yes but that plan consists of counseling and family support. In my medical opinion that is inadequate to treat this patient's condition." Then I tried to explain about the Tarasoff warnings I might have to file, etc.

Attorney: "We still plan to screen this out. Goodbye."

Ugh. Meanwhile my state went to the reverse extreme of over-committing people with its sex offender program, and now they're in federal court over that.

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[OldPsychDoc]

I feel your pain...though at least by being in one of those "deluged counties", our judges and county attorneys are a bit more savvy about it all. I'm sure the rural counties are worse.
(Would your hospital admins be any help? Our local department chiefs and veeps will actually meet with legal folks from the county on a regular basis to review how things are going...)

 

[st2205]

In Texas there the order of emergency detention, which is filed by police, and a mental health warrant, which is filed by a judge when someone brings a case to them. They're both good for 48 hours. After this point, any physician may file an order of protective custody which is good for 14 days. On top of this, or in place of it, you can seek a court commitment (up to 90 days) with medications. We typically commit people to our facility (private hospital). The other option is committing them to the state hospital, which is a rare occurrence but one I did last week.

We don't get people committed to us. That sounds like non-sense. We do, however, get an inordinate amount of pour souls dumped on us by police from far away because our hospital I the only one that does not require police to stay with them until evaluated. A lot of these people don't need to be in the hospital. A decent portion of them need to be in jail, really.

 

[xlithiumx]

I think we're in the same state, Nancy. What part of the state are you working? I'm in the northeast by the big lake.

 

[whopper]

The devil is in the specific writing. I recommend any psychiatrist (or any physician in a field where a hold is realistic such as an ER doctor) learn the local laws to the letter regarding this. Even in outpatient this is important because you will get times where you have to write for a hold from a patient that shows enough signs of danger in a private office or other outpatient setting.

While medstudents learn the general jist of "danger to self or others," there's a lot of details that will haunt you if you do not know them. In Missouri where I'm now in, there's 96-hour holds not 72-hour holds like most states. I've only worked in the jail so far so I haven't worked in-the-field yet in inpatient but from what I've read one can also hold someone for substance abuse while the person is withdrawing (this is not kosher in most states).

In Ohio, you could hold someone even if psychiatrically stable at the time if you believe they will become an "immediate danger." E.g. a patient with a known history of violence due to non-compliance and non-compliant several times, presenting as stable in the ER.

In NJ, one could hold someone not just in addition to the danger to self or others just but also if they could be a danger to property.

In Wisconsin, (unless this has changed and I don't know about it), instead of the usual "clear and convincing" evidence needed to hold someone (meaning in English, the data is convincing enough with some evidence to meet a 75% certainty, but no smoking gun), they require "beyond reasonable doubt." That level is to the degree needed to find a defendant guilty of a crime, in other words, fingerprint, forensic evaulation, etc. level evidence.

I've seen several patients released when they should have not been because someone messed up on a technical issue not specifically related to their treatment. E.g. the court clerk did not stamp a form within 72 hours.

 

[nancysinatra]

Thanks! Yes we are in the same state, but a different part. I don't want to give out too much info - I am moving to a new job in a new part of the state next week anyway. It's a rural area, however. I am a bit coy about my specifics because this forum is where I come to vent all my complaints and if you ever met me in person I would be embarassed!

It's just discouraging to see that my job is being done for me by social workers and lawyers. The worst, actually are sometimes the judges. One time we had a patient on the unit where seriously, this poor patient was being kept like a prisoner. He was sort of known locally as a nuissance in the community because of his unconventional lifestyle, which I think caused some discomfort to the locals. The locals may have good intentions but the purpose of involuntary commitment is not to assuage the discomfort of nervous small town folks about their neighbors. Anyway he had no mental illness , and wanted to leave our unit. The judge wanted the case closed and didn't want this person to be "bothering" the local community anymore. So he ordered the committment. I am positive that must have been his motive! It stretched on for weeks.

I wonder if there has ever been a case of a psychiatrist going to jail as a result of refusing to carry out a judge's order to hospitalize someone on a psych ward? In this case it crossed my mind that I could be a conscientious objector to this ridiculous order. In fact, ethically, I probably should have because I'm pretty sure it's just plain wrong to participate in committing people who are not mentally ill.

 

[nancysinatra]

The devil is in the specific writing. I recommend any psychiatrist (or any physician in a field for a hold is realistic such as an ER doctor) learn the local laws to the letter regarding this. Even in outpatient this is important because you will get times where you have to write for a hold from a patient that shows enough signs of danger in a private office or other outpatient setting.

While medstudents learn the general just of "danger to self or others," there's a lot of details that will haunt you if you do not know them. In Missouri where I'm now in, there's 96-hour holds not 72-hour holds like most states. I've only worked in the jail so far so I haven't worked in-the-field yet in inpatient but from what I've read one can also hold someone for substance abuse while the person is withdrawing (this is not kosher in most states).

In Ohio, you could hold someone even if psychiatrically stable at the time if you believe they will become an "immediate danger." E.g. a patient with a known history of violence due to non-compliance and non-compliant several times, presenting as stable in the ER.

In NJ, one could hold someone not just in addition to the danger to self or others just but also if they could be a danger to property.

In Wisconsin, (unless this has changed and I don't know about it), instead of the usual "clear and convincing" evidence needed to hold someone (meaning in English, the data is convincing enough with some evidence to meet a 75% certainty, but no smoking gun), they require "beyond reasonable doubt." That level is to the degree needed to find a defendant guilty of a crime, in other words, fingerprint, forensic evaulation, etc. level evidence.

I've seen several patients released when they should have not been because someone messed up on a technical issue not specifically related to their treatment. E.g. the court clerk did not stamp a form within 72 hours.

Well the problem in this state is that the commitment laws were written when state hospitals still existed. The 72 hour hold form, for example, requires the "Head of Facility" to sign it. There's no ER in this state that has psychiatric administrators sitting in some back room 24 hours a day, "managing" the "facility." There is no way to ever comply with the letter of the state law as it stands now whether for commitment or holds. So we're always breaking the law with every hold and every commitment. I am sure the legislature does not care enough to fix this, either. The law also doesn't specify what the level of proof required is. (I'm sure the lawyers know though.) The attorney yesterday told me that the reason she was rejecting the application was that the patient hadn't been arrested. I've never heard of arrest being required to civilly commit a patient, but that's what she said. The medical chart documents the unanimous agreement of the treatment team that this patient is extremely high risk based on symptoms and on actions. The attorney said she did not care WHAT the medical chart said. She kept going back to the lack of an arrest record and the fact that the patient's family promised to look after her.

 

[alina_s]

In Washington, physicians can't detain anyone. If someone shows up in the ED or clinic and we think they need to be involuntarily hospitalized, we have to call the county designated mental health professionals, who have 6 hours to show up. If a family member or case worker calls from the community, they have 24 hours. The MHP makes a decision and the first hold is for 72 hours during the week (Thursday night hold means a hearing as late as Tuesday, or Wednesday if Monday is a holiday). Patients have court-appointed lawyers, they often meet them the day of the hearing. There has been a lot of controversy lately and lots of cases get thrown out on technicalities. If the MHP's are overworked and show up in 6 hours and 5 minutes, the patient gets released at the court hearing. There's also a legal battle going on now about the shortage of psych beds in the state- lots of patients were being detained and then "boarded" in ED's for lack of beds anywhere. The supreme court ruled that unconstitutional but the ruling didn't make any more beds available and there has been a delay to enforcing the ruling. It could mean that patients who are deemed gravely disabled etc are automatically discharged for lack of beds, but everyone is hoping it somehow doesn't come to that.

 

[whopper]

Well the problem in this state is that the commitment laws were written when state hospitals still existed. The 72 hour hold form, for example, requires the "Head of Facility" to sign it.

Wow. I really need to follow my own advice and read up the specific laws. I haven't yet because I did a search and only saw sites designed for patients describing in layman's terms what the laws are. I want to read the actual legislation.

We're in the same state? I thought it's a 96 hour rule. Again, I'm not yet on top of the local rules.

I hate saying it but if the laws are archaic you still have to follow them. This is where the local state APA needs to get involved, or other groups such as NAMI to get the laws changed.

 

[OldPsychDoc]

Wow. I really need to follow my own advice and read up the specific laws. I haven't yet because I did a search and only saw sites designed for patients describing in layman's terms what the laws are. I want to read the actual legislation.

We're in the same state? I thought it's a 96 hour rule. Again, I'm not yet on top of the local rules.

I hate saying it but if the laws are archaic you still have to follow them. This is where the local state APA needs to get involved, or other groups such as NAMI to get the laws changed.

I believe Nancy is in the same state as xlithiumx, not you.

 

[whopper]

Thanks for the clarification.

From personal experience I've seen about 5% of patients that needed to stay in get out. This was in Ohio. In another state such as Wisconsin I figure the number is dramatically higher because the burden of proof the state must provide is that on the order of a criminal hearing.

Most of the time the patient got out it was due to a technicality. Happened about once every 2-3 months.

On the other hand I occasionally saw some patients get trapped in the hospital when they shouldn't have. In Ohio, a citizen can initiate a hold if it's reviewed by a judge and approved. We'd get lame excuses such as the case manager wanted the patient in the hospital because she yelled. She was yelling because she didn't want to live in the housing the case manager got her and preferred to be homeless. No psychosis, depression, just a lady who enjoyed her freedom. She had to stay in the hospital until her hearing that was about 5 days later.

 

[SuperSoccer19]

In Washington, physicians can't detain anyone. If someone shows up in the ED or clinic and we think they need to be involuntarily hospitalized, we have to call the county designated mental health professionals, who have 6 hours to show up. If a family member or case worker calls from the community, they have 24 hours. The MHP makes a decision and the first hold is for 72 hours during the week (Thursday night hold means a hearing as late as Tuesday, or Wednesday if Monday is a holiday). Patients have court-appointed lawyers, they often meet them the day of the hearing. There has been a lot of controversy lately and lots of cases get thrown out on technicalities. If the MHP's are overworked and show up in 6 hours and 5 minutes, the patient gets released at the court hearing. There's also a legal battle going on now about the shortage of psych beds in the state- lots of patients were being detained and then "boarded" in ED's for lack of beds anywhere. The supreme court ruled that unconstitutional but the ruling didn't make any more beds available and there has been a delay to enforcing the ruling. It could mean that patients who are deemed gravely disabled etc are automatically discharged for lack of beds, but everyone is hoping it somehow doesn't come to that.

I just moved here and am like, WTF?!? The other day the MHP would not even see a patient who they felt over the phone was ok for discharge. I've heard from co-workers they basically discharge everyone. In reality, a lot of it is axis II drama and the person ends up okay, but at the same time that's not a chance i really like taking.

 

[SuperSoccer19]

they have to see everyone, it's against the law for them to refuse. you can ask to speak to the supervisor in that case. A few months ago they were detaining everyone (even the bogus ones I thought wouldn't go anywhere) but since the supreme court ruling they haven't been detaining anyone because there's no beds for them to go to.

Oh really, interesting. Thanks. Im still learning the system and this didn't sound right, but the situation had de-escalated by the time I arrived and we were able to come up with what we thought was an acceptable discharge plan, but the idea that they could refuse seemed weird.

 

[Wednesday]

Hi fellow Washingtonians! At least we have the power to release a hold when we have an inpatient, although that is small consolation for dealing with MHPs. I think the worst part is how hard the defense attorneys try to get patients out when they go to court. Often it's people who really need to be there. Sometimes they leave court and walk right back to the ED to start the entire process again! Over time you can learn to use the system as best as it can be used. Sounds like there are problems everywhere with commitment laws.