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We had a patient come in to a community based crisis center voluntarily to get resources. He wanted to get help for symptoms of depression and anger. He agreed to come in for a 23 hour admission for evaluation but immediately after he was admitted he changed his mind and asked to leave. We attempted to talk him into staying but he declined. He did not want to undergo an evaluation prior to leaving. He was willing to let us contact a significant other who basically said please don't let him go and that he is going to have a meltdown soon which will likely end up with something bad happening to himself or someone else. He was described by collateral as violent, aggressive, and impulsive. When asked directly, there was no stated threat towards the collateral however the impression from the social worker was that there was some hesitance to directly report a threat (ie no he hasnt threatened me but please please dont let him go). He had recently gotten into a fist fight with stranger. He had recently been released from prison on a 15+ year sentence for attempted murder. He has made several suicide attempts in the past. He was mostly pleasant during our encounter but very guarded and evasive. He never made any reference that he was a having thoughts of ending his life, nor harming other people; only acknowledging he was feeling depressed and angry. He demonstrated no obvious psychotic symptoms nor manic symptoms. The general consensus from our staff was that they all had a bad feeling about this guy. At that point we had a discussion about what to do and I generally was of the thought that while I believe this guy to be high risk, I had no grounds to pursue involuntary commitment. I was told by one of our senior staff that there was a degree of implied danger to self and others that would justify commitment. I was also told that it's these individuals, who are so guarded, evasive, and reluctant to engage in interview, that we need to be most concerned about. While I agree with this sentiment, I struggle to understand how we can do this within the scope of the law. I certainly could have committed him out of an abundance of concern for his safety and the safety of the public likely without any legal ramifications. I would argue my action on his history of past violence, escalating incidences of violence preceding his visit, and the testimony of the collateral. My risk assessment would demonstrate numerous risk factors, with almost no protective factors. I would argue that he lacks insight and demonstrated poor judgment at the time of admission. Despite this, I do not know if I could argue that an actual danger exists.
My question is what are peoples thoughts on the "implied" danger and reading in between the lines when dealing with involuntary admission? Conversely, lets say I did I let him go and he did kill himself or someone else. Could the implied danger be used against me (I would assume this would be the crux of the case..."Dr. couldn't you see the writing on the wall!") even though he never uttered a specific word about danger to self or others to define an actual risk? The law where I am states that there has to be an immediate threat towards the self or others in order to start the involuntary commitment process.
What would you have done in this case? Lets discuss.
My question is what are peoples thoughts on the "implied" danger and reading in between the lines when dealing with involuntary admission? Conversely, lets say I did I let him go and he did kill himself or someone else. Could the implied danger be used against me (I would assume this would be the crux of the case..."Dr. couldn't you see the writing on the wall!") even though he never uttered a specific word about danger to self or others to define an actual risk? The law where I am states that there has to be an immediate threat towards the self or others in order to start the involuntary commitment process.
What would you have done in this case? Lets discuss.
