Interesting philosophical scenario from patient today, but no answer.

[flight24]

During rotation today, the husband of a patient called and notified us that his wife who has a history of mania with psychosis (I personally think she has schizophrenia with paranoia, but that's a whole different topic) ran away from home leaving him and his 5 children behind. Pt was non-compliant with medications and instead blamed all the issues on demonic possessions. This brought up an interesting debate with our attending and I'm curious to hear your input.

So in the state of California, there are obvious strict guidelines for a 5150, but an adult with history of mental health disorders leaving home voluntarily isn't one of them. Even though this patient was placed on a 5150 several years ago, currently she is not YET a threat to harm herself or others therefore the police will not do anything. In fact we also learned the family filed a missing person report and the police was able to track the patient in a different state, but she is unwilling to return home. Law enforcement has stated they cannot do anything and HIPPA protects the patient's medical records. Essentially this decision has destroyed this family with several small children who are still depended on their mother. I looked up a recent law called Laura's Law which some regions have adopted to force certain outpt population to take meds on very strict guidelines (evidently most do not meet the criteria so there's no plausible way to force anyone with serious psych disorders to take meds at home).

Essentially, the law seems to not take any actions for any preventable measures. It's only until something drastic takes place (like pt exhibiting harmful behavior publicly, etc) before any intervention is made. In this case, the pt is a ticking time bomb and it's only a matter of time before any damage is done. In the meantime the family and primarily the children suffer the most. Perhaps I'm not seeing something, but is there any solution to bring the mother back other than the wait and see approach? I'm curious to hear how other psychiatrists feel about these laws that attempt to protect the patient, but may end up doing more harm than good.

EDIT:
Update- So the husband was able to track her down based on credit card activities. He also took his son (he's most attached to his mother) in hopes that she would return. Despite trying to reason with her and the child crying for his mom, she stated that God told her that they are divorced and that she needs to help who are possessed. Essentially she has become an exorcist by divine help. What's more interesting she is with another female who's basically her disciple and they are both exorcists. Finally the husband had enough and called the police explaining the situation to the officers. In the meantime, the mother started to get agitated and the husband was holding her so she wouldn't run away again. After the police arrived, they basically escorted the two females away and told the husband they can't do anything until she is a danger to herself or others. What a country we live in!

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[birchswing]

Hmm . . . my first thought is whether the husband could go to a family court. Do they get involved in non-divorce cases? My second thought is that he can file for divorce and if she wants custody she'll be forced into maintaining some sort of treatment. My third thought is whether police are allowed to keep a watchful eye on someone they have a reason to believe is suspicious. Cars get pulled over for suspicious behavior. Police cruise certain neighborhoods based on levels of violence. Can the same be done for an individual known to pose harm to herself? Not saying arrest her or anything like that, but to keep an eye on someone? Or even walk up and ask if she's OK. As far as I know police are allowed to ask questions. If she doesn't seem to be well enough to function during questions, presumably she could be brought in?

This is a situation that is repeated by many, if not the exact same scenario. I've heard of parents being told to lie about their children threatening to kill themselves when there's no other option.

I'm not a psychiatrist or a lawyer or a police officer or a fireman or an Indian chief.

 

[nitemagi]

There are limited options for you, especially since she's out of state. Overall there is not a preventive measure, but the courts in california will often decide in a conservatorship if someone has required repeated hospitalizations for GD. In cali that's as good as you get.

Each state falls somewhere different on the spectrum of individual rights vs. state's rights. California errs much more on the side of the individual.
Other states, like Illinois, have a hold qualifier for if someone is likely in the immediate future to meet criteria for a hold is good enough (though reportedly under exercised criteria).

So no, there's nothing that can be done. You need a legislator willing to change the law, and police willing to enforce it.

On the upside, HIPAA actually doesn't prevent communication. Doctors can talk to another doctor without written permission for the purpose of collaboration of care.
http://www.hhs.gov/ocr/privacy/hipaa/faq/privacy_rule_general_topics/193.html

 

[psych md jd]

The 5150 statute was an attempt by the California Legislature to balance a person's liberty interests versus the government's duty to protect / promote the health, safety, and welfare of its citizens. The 4th, 5th, and 14th amendments of the Constitution come into play. I would say this situation is more of a legal question than a philosophical one. Different states, and for that matter, different countries use different criteria for involuntary detention due to mental illness. The United States has for the most part adopted the dangerousness standard, whereas many European countries have adopted the need for treatment standard.

Regardless, I don't think that the 5150 statute, under the facts presented, allows the long arm of California law to reach out beyond its borders and make the wife return. This would be a violation of state sovereignty. Additionally, the criteria for a 5150 involuntary detention requires imminent danger to self or others. How can that be determined when the wife is not even in the state? Psychiatrists are not precogs.

The standard of proof at the 5150 level is preponderance of the evidence. That something may happen is pure speculation.

The third basis of the 5150 is the lack of the ability to provide for food, clothing, or shelter. But again, speculation is not sufficient.

From my experience, Department 95, the mental health court in Los Angeles has some pretty knowledgeable judges and attorneys. If the standard is not met by the facts or evidence, the hold will be broken. In other counties without a dedicated court YMMV.

OP, my advice is to consult with the forensics fellow or attending.

 

[shan564]

I'm not sure about the interstate issue, but if somebody is actively psychotic and running away from demons, you can probably find a reason why she's a risk of harm to self/others if you ask the husband enough questions. She doesn't have to be physically violent or suicidal - if she's that paranoid, she probably won't be able to make basic self-care decisions, which is a risk of harm to self. Before she left the house, I'll bet she said something at some point to suggest that she's at risk of doing something that puts her own safety at risk... for instance, if she's wandering the streets trying to tell people that they're possessed, somebody will eventually punch her in the face (or worse). Also, if she's wandering the streets without a clear destination, she probably won't be able to do basic things required to maintain health (i.e. maintain nutrition, avoid getting hit by a car, maintain adequate hygiene to avoid getting an infection, etc.). I'm not sure about California, but that's enough to commit somebody in Missouri.

 

[Ceke2002]

I'm not sure about the interstate issue, but if somebody is actively psychotic and running away from demons, you can probably find a reason why she's a risk of harm to self/others if you ask the husband enough questions. She doesn't have to be physically violent or suicidal - if she's that paranoid, she probably won't be able to make basic self-care decisions, which is a risk of harm to self. Before she left the house, I'll bet she said something at some point to suggest that she's at risk of doing something that puts her own safety at risk... for instance, if she's wandering the streets trying to tell people that they're possessed, somebody will eventually punch her in the face (or worse). Also, if she's wandering the streets without a clear destination, she probably won't be able to do basic things required to maintain health (i.e. maintain nutrition, avoid getting hit by a car, maintain adequate hygiene to avoid getting an infection, etc.). I'm not sure about California, but that's enough to commit somebody in Missouri.

I was actually thinking the same thing, what is the actual standard for 'risk of harm to self or others' and could that be applied in this situation. I had a friend in the UK who was placed under a section even though she'd made no direct threats towards herself or others, simply because she was in a manic enough state that her behaviour alone was putting her at risk (walking 20 odd miles, or kilometres I can never remember which, in the middle of an English winter wearing nothing but a windcheater and her underwear, hence risk to self of hypothermia, and then staggering around the next county/city's streets yelling incoherently, which obviously put her at risk of someone deciding to take matters into their own hands in order to get her to stop disturbing the peace). Then again it depends on why this other patient left home and what condition she was in when she actually did, maybe she just needed to get away for a while and wants some time to herself - I doubt it, but the other side of the argument of course is that just because someone is mentally ill doesn't mean they shouldn't be given the right to decide where they go and who or where they live with. Difficult situation, but it sounds like she at least needs to be assessed for her own safety.

 

[heyjack70]

If she's not in California, California laws will almost definitely not apply. If anyone wants to get her help she likely needs to placed on a hold in whatever state she's in and forced into treatment that way. Hopefully she will stabilize there and realize what she's done and then want to return home to California.

 

[smalltownpsych]

Families of the seriously mentally ill suffer greatly. Helping them to understand mental illness and cope with a difficult situation and accept the realities of it. Often the family dynamic of fear and desire for control makes the situation worse. Actually, that describes our cultures attitude toward serious mental illness pretty well, unfortunately.

 

[splik]

So in the state of California, there are obvious strict guidelines for a 5150, but an adult with history of mental health disorders leaving home voluntarily isn't one of them.

do you think it should be?

actually I believe california law does allow one to take into consideration of historical behaviors for civil commitment. So for example if a person becomes violent or self-mutilates whenever they become manic, that can be used as grounds for a 5150 when a patient becomes manic even if they are not mutilating themselves at the time.

Here are the relevant passages:

(a) When determining if probable cause exists to take a person into custody, or cause a person to be taken into custody, pursuant to Section 5150, any person who is authorized to take that person, or cause that person to be taken, into custody pursuant to that section shall consider available relevant information about the historical course of the person’s mental disorder if the authorized person determines that the information has a reasonable bearing on the determination as to whether the person is a danger to others, or to himself or herself, or is gravely disabled as a result of the mental disorder.

(b) For purposes of this section, “information about the historical course of the person’s mental disorder” includes evidence presented by the person who has provided or is providing mental health or related support services to the person subject to a determination described in subdivision (a), evidence presented by one or more members of the family of that person, and evidence presented by the person subject to a determination described in subdivision (a) or anyone designated by that person.

 

[OldPsychDoc]

I'm not sure how Cali would handle this, or how long it would take, but often the threat of loss of parental rights can be leverage that serves as an impetus to change. Don't know if Dad/Hubby is at the point of petitioning for this or not.

 

[flight24]

I'm not sure how Cali would handle this, or how long it would take, but often the threat of loss of parental rights can be leverage that serves as an impetus to change. Don't know if Dad/Hubby is at the point of petitioning for this or not.

Unfortunately according to the father it looks when she is in this state of mind, she does not particularly care for her children either. So going to court will probably not matter if she is willing to give full custody to the father. I'm wondering how long a person stays in this manic/psychosis state without intervention before they start thinking more rationally. I guess the best and only option here is to simply wait until she willingly comes back if that ever happens.

 

[flight24]

The 5150 statute was an attempt by the California Legislature to balance a person's liberty interests versus the government's duty to protect / promote the health, safety, and welfare of its citizens. The 4th, 5th, and 14th amendments of the Constitution come into play. I would say this situation is more of a legal question than a philosophical one. Different states, and for that matter, different countries use different criteria for involuntary detention due to mental illness. The United States has for the most part adopted the dangerousness standard, whereas many European countries have adopted the need for treatment standard.

Regardless, I don't think that the 5150 statute, under the facts presented, allows the long arm of California law to reach out beyond its borders and make the wife return. This would be a violation of state sovereignty. Additionally, the criteria for a 5150 involuntary detention requires imminent danger to self or others. How can that be determined when the wife is not even in the state? Psychiatrists are not precogs.

The standard of proof at the 5150 level is preponderance of the evidence. That something may happen is pure speculation.

The third basis of the 5150 is the lack of the ability to provide for food, clothing, or shelter. But again, speculation is not sufficient.

From my experience, Department 95, the mental health court in Los Angeles has some pretty knowledgeable judges and attorneys. If the standard is not met by the facts or evidence, the hold will be broken. In other counties without a dedicated court YMMV.

OP, my advice is to consult with the forensics fellow or attending.

Hmm. Thanks for the insights. It looks like the best hope for them is to provide proof that she cannot provide food, shelter etc for herself. But that may only help if she ever decides to come back to Cali.

 

[hamstergang]

But that may only help if she ever decides to come back to Cali.

Not so. She's in some state right now. That state has some law concerning involuntary psych admissions/psych holds. Why does her family need to wait for her to return before taking action?

 

[psych md jd]

What action do you suggest the family undertake?

 

[hamstergang]

What action do you suggest the family undertake?

If they're concerned about her ability to care for herself or for her being an imminent risk to herself, they can call the local (local to where the patient is) police/psych center. Depending on the state, they may or may not be able to do anything about it. I know that if someone called over here in NJ to report a family member like this, we would have people go to where the patient is and see what's up. It wouldn't matter where the family calls from.

 

[psych md jd]

The police have tracked her to another state, but what if she has since gone somewhere else?

A PET team can be sent or police can be sent for a welfare check to a location, but if the person's current location is unknown then what?

Since the police "found" her she is no longer a missing person.

Further, even if she is put on a hold in another state, her family may not necessarily know about it.

 

[heyjack70]

I think hamster is saying that if the family knows where she is in the other state, they can attempt to contact local police and see if she can be put on a hold where she is located.

 

[birchswing]

This might be an odd question, but if you can just call the police do a welfare check on someone due to their inability to take care of themselves, could you do that for any homeless person who seems to be asking for/needing help? And would they get any type of help as a result (I fear they would just be told to scram)? I say it's an odd question as I imagine if you actually did this the police would be very rather quizzical about you calling, but if the measure is whether a person can take care of themselves or not and a person can't feed themselves adequately or find adequate shelter, I wonder if that qualifies. I know is a non-psych question, but the conversation piqued my interest in that direction.

So I guess to essentialize the question: Is there a difference between someone who can't feed themselves due to lack of being able to find resources/not having resources versus someone who can't feed themselves due to a mental issue in the eyes of the law? You could presumably commit someone with anorexia nervosa out of paternalistic interest; does the same reasoning hold true for helping the poor? And I don't mean in a sense of what actually happens (obviously many hungry people are ignored), but in the more technical sense.

 

[nitemagi]

So I guess to essentialize the question: Is there a difference between someone who can't feed themselves due to lack of being able to find resources/not having resources versus someone who can't feed themselves due to a mental issue in the eyes of the law? You could presumably commit someone with anorexia nervosa out of paternalistic interest; does the same reasoning hold true for helping the poor? And I don't mean in a sense of what actually happens (obviously many hungry people are ignored), but in the more technical sense.

In california, the 5150 statute spells out Grave Disability as inability to manage food, shelter, or clothing due to a mental illness.

 

[smalltownpsych]

There are major flaws with how we conceptualize and treat mental illness in this country with involuntary commitment being a big part of the problem. If our treatment of the SMI involved increasing motivation to access treatment as opposed to an all or none forced approach, we would have better outcomes. If I hear "they just need to take their meds" one more time from some burnt out case worker, I might have to be commited. The most effective person at our local community mental health center was the cook who provided the daily lunch, talked to the patients as human beings, and provided opportunity to socialize. He left, they stopped providing lunch and we have hospitalized at least ten clients because of this. I could come up with more examples every day.

 

[nitemagi]

There are major flaws with how we conceptualize and treat mental illness in this country with involuntary commitment being a big part of the problem. If our treatment of the SMI involved increasing motivation to access treatment as opposed to an all or none forced approach, we would have better outcomes. If I hear "they just need to take their meds" one more time from some burnt out case worker, I might have to be commited. The most effective person at our local community mental health center was the cook who provided the daily lunch, talked to the patients as human beings, and provided opportunity to socialize. He left, they stopped providing lunch and we have hospitalized at least ten clients because of this. I could come up with more examples every day.

Yes and no. I agree that having the involuntary commitment option leads to relying on force far too often. Just like the police, use of force as a default doesn't always help the situation. And yet sometimes it is necessary. The whole difficulty with some serious mental illness is that it impairs someone's judgment inability to look at reality rationally. While food is an incentive for some, for the person who is worried about microchips planted in his brain, it might not matter.

 

[Shikima]

There are major flaws with how we conceptualize and treat mental illness in this country with involuntary commitment being a big part of the problem. If our treatment of the SMI involved increasing motivation to access treatment as opposed to an all or none forced approach, we would have better outcomes. If I hear "they just need to take their meds" one more time from some burnt out case worker, I might have to be commited. The most effective person at our local community mental health center was the cook who provided the daily lunch, talked to the patients as human beings, and provided opportunity to socialize. He left, they stopped providing lunch and we have hospitalized at least ten clients because of this. I could come up with more examples every day.

I think you've hit upon something more sinister - the burnout process.

 

[flight24]

If they're concerned about her ability to care for herself or for her being an imminent risk to herself, they can call the local (local to where the patient is) police/psych center. Depending on the state, they may or may not be able to do anything about it. I know that if someone called over here in NJ to report a family member like this, we would have people go to where the patient is and see what's up. It wouldn't matter where the family calls from.

Just posed an update in my original post. I will paste it here in case you didn't see it:

So the husband was able to track her down based on credit card activities. He also took his son (he's most attached to his mother) in hopes that she would return. Despite trying to reason with her and the child crying for his mom, she stated that God told her that they are divorced and that she needs to help who are possessed. Essentially she has become an exorcist by divine help. What's more interesting she is with another female who's basically her disciple and they are both exorcists. Finally the husband had enough and called the police explaining the situation to the officers. In the meantime, the mother started to get agitated and the husband was holding her so she wouldn't run away again. After the police arrived, they basically escorted the two females away and told the husband they can't do anything until she is a danger to herself or others. What a country we live in!

Looks like legally at least via the police there's nothing to be done (at least in Minnesota). Maybe NJ law is different and more proactive in these types of situations. Not sure if there are any other route other than to simply wait and see. The police basically told them that if she's running around crazy in public, then they will take her to a psych unit. Even then they don't have to report it to the family.

 

[smalltownpsych]

Yes and no. I agree that having the involuntary commitment option leads to relying on force far too often. Just like the police, use of force as a default doesn't always help the situation. And yet sometimes it is necessary. The whole difficulty with some serious mental illness is that it impairs someone's judgment inability to look at reality rationally. While food is an incentive for some, for the person who is worried about microchips planted in his brain, it might not matter.

I completely agree that force is sometimes necessary and have testified in involuntary commitment proceedings to that effect. The using it as a default is part of the problem and also not making our community mental health treatment meet the needs of our patients which makes it more attractive and useful for them. I have seen some good examples of how the SMI patients can be helped and getting the right medication is only part of the picture. Patients with schizophrenia often need a lot more than "just take your meds" and all too often that is the only thing they are hearing. Just adjusting to having a serious mental illness is a huge pill to swallow, pun intended.

 

[psych md jd]

What a country we live in!

Would you rather the US be like Germany in the 1930's? China or Russia today?

In many parts of the world the treatment for mental illness is being chained to heavy farm equipment.

 

[MLT2MT2DO]

In any other state she would be deemed as a danger to self or others.

In California she's probably considered high functioning.

 

[smalltownpsych]

Just posed an update in my original post. I will paste it here in case you didn't see it:

So the husband was able to track her down based on credit card activities. He also took his son (he's most attached to his mother) in hopes that she would return. Despite trying to reason with her and the child crying for his mom, she stated that God told her that they are divorced and that she needs to help who are possessed. Essentially she has become an exorcist by divine help. What's more interesting she is with another female who's basically her disciple and they are both exorcists. Finally the husband had enough and called the police explaining the situation to the officers. In the meantime, the mother started to get agitated and the husband was holding her so she wouldn't run away again. After the police arrived, they basically escorted the two females away and told the husband they can't do anything until she is a danger to herself or others. What a country we live in!

Looks like legally at least via the police there's nothing to be done (at least in Minnesota). Maybe NJ law is different and more proactive in these types of situations. Not sure if there are any other route other than to simply wait and see. The police basically told them that if she's running around crazy in public, then they will take her to a psych unit. Even then they don't have to report it to the family.

Also, just because the police won't act doesn't mean that there is no recourse. Many states have provisions by which family members can petition for involuntary commitment so the husband would have to seek legal guidance for the state in which she is residing. There are also various types of guardianships that families can pursue, but again the state line issue complicates things.

 

[flight24]

Would you rather the US be like Germany in the 1930's? China or Russia today?

In many parts of the world the treatment for mental illness is being chained to heavy farm equipment.

Haha just frustrated with the all the logistics. Clearly, she's not well and needs help. But unfortunately the laws prevent her from getting proper treatment.

 

[flight24]

Also, just because the police won't act doesn't mean that there is no recourse. Many states have provisions by which family members can petition for involuntary commitment so the husband would have to seek legal guidance for the state in which she is residing. There are also various types of guardianships that families can pursue, but again the state line issue complicates things.

Hmm interesting. When you say various types of guardianships that family can purse, do you any links or sources where one might be able to educate oneself regarding these provisions?

 

[psych md jd]

Haha just frustrated with the all the logistics. Clearly, she's not well and needs help. But unfortunately the laws prevent her from getting proper treatment.

Or, maybe the laws are protecting her (and our) privacy rights--the right to be left alone, and her liberty interests.

The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants -Thomas Jefferson

 

[Armadillos]

Thread brings up interesting point, how tough is it for psychiatrists to adjust to the transition from training in one state to practice in another when it comes to this sort of thing? I know I've gotten used to what a involuntary pt looks like in my state and its probably a pretty low standard. Obviously it's the standard mental illness + risk imminent harm caused by the illness, but practically seems pretty much anyone who is acutely psychotic or manic will have their involuntary admission held up by court even if they haven't actually done anything dangerous yet. Seems like there is the thought that being manic for example is inherently an imminent danger. I imagine other states would be much much stricter.

 

[OldPsychDoc]

Thread brings up interesting point, how tough is it for psychiatrists to adjust to the transition from training in one state to practice in another when it comes to this sort of thing? I know I've gotten used to what a involuntary pt looks like in my state and its probably a pretty low standard. Obviously it's the standard mental illness + risk imminent harm caused by the illness, but practically seems pretty much anyone who is acutely psychotic or manic will have their involuntary admission held up by court even if they haven't actually done anything dangerous yet. Seems like there is the thought that being manic for example is inherently an imminent danger. I imagine other states would be much much stricter.

You will find differences, to be sure, but they're fairly easily adjusted to.
I just grafted a good social worker to my left shoulder for the first six months or so.

 

[psych md jd]

Thread brings up interesting point, how tough is it for psychiatrists to adjust to the transition from training in one state to practice in another when it comes to this sort of thing? I know I've gotten used to what a involuntary pt looks like in my state and its probably a pretty low standard. Obviously it's the standard mental illness + risk imminent harm caused by the illness, but practically seems pretty much anyone who is acutely psychotic or manic will have their involuntary admission held up by court even if they haven't actually done anything dangerous yet. Seems like there is the thought that being manic for example is inherently an imminent danger. I imagine other states would be much much stricter.

http://www.treatmentadvocacycenter....itment_Criteria_and_Initiation_Procedures.pdf

I would go directly to the source. Go to the codebooks and actually read the statute. Then read the legislative intent and history, and read the floor debate, if available. Then read the Shepardized case law. Then you will know what your state requires and the meaning of "clear," "serious," "substantial," "immediate," or "imminent" in the statute in your state. [Out of curiosity, has anybody else besides me done this as an intern?]

Four years later I heard this very advice in fellowship with regard to insanity statutes.

Relying on someone else to tell you what the statute says is like playing the game "Telephone." Invariably, biases, prejudices, distortions, mis-truths, and half- truths get handed down that way and solidify with time.

 

[Armadillos]

http://www.treatmentadvocacycenter....itment_Criteria_and_Initiation_Procedures.pdf

I would go directly to the source. Go to the codebooks and actually read the statute. Then read the legislative intent and history, and read the floor debate, if available. Then read the Shepardized case law. Then you will know what your state requires and the meaning of "clear," "serious," "substantial," "immediate," or "imminent" in the statute in your state. [Out of curiosity, has anybody else besides me done this as an intern?]

Four years later I hear this very advice in fellowship with regard to insanity statutes.

Relying on someone else to tell you what the statute says is like playing the game "Telephone." Invariably, biases, prejudices, distortions, mis-truths, and half- truths get handed down that way and solidify with time.

I've read the laws in my state, but have not gone farther than that. I'm crossing my fingers that if I in good faith attempt to follow the law to the best of my understanding as a physician, that I don't have to have a lawyers understanding to avoid getting in trouble.

 

[psych md jd]

I knew I was going into forensics before residency so I wanted to be prepared.

You may not need to have a lawyer's understanding of the laws, but if you are called to testify, the PD, DA, and Judge will. I didn't want to be the odd man out.

When venturing into an unknown arena, best to know the rules of the game.

If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle― Sun Tzu, The Art of War

 

[flight24]

Or, maybe the laws are protecting her (and our) privacy rights--the right to be left alone, and her liberty interests.

The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants -Thomas Jefferson

I definitely understand the other side of the coin, but this is one of those situations when the law should be more flexible (or at least needs some sort of amendments) not so black and white. I think most would agree in this case that it's better to intervene earlier than to wait until more damage is done both from a financial and psychological perspective particularly because she is a mother to several young children who are all devastated to be away from their mother for this long (and for the indefinite future).

Another hypothetical situation that I can think of is when a schizophrenic adolescent suddenly hits the age of 18 and bam all of a sudden he is an adult. If he were to run away from home, then nothing could be done by his parents who cared for him all of his life. This is a great example: http://www.silive.com/news/index.ssf/2014/05/mentel_illness_and_missing_adu.html

 

[nitemagi]

I definitely understand the other side of the coin, but this is one of those situations when the law should be more flexible (or at least needs some sort of amendments) not so black and white. I think most would agree in this case that it's better to intervene earlier than to wait until more damage is done both from a financial and psychological perspective particularly because she is a mother to several young children who are all devastated to be away from their mother for this long (and for the indefinite future).

Another hypothetical situation that I can think of is when a schizophrenic adolescent suddenly hits the age of 18 and bam all of a sudden he is an adult. If he were to run away from home, then nothing could be done by his parents who cared for him all of his life. This is a great example: http://www.silive.com/news/index.ssf/2014/05/mentel_illness_and_missing_adu.html

Yep. But presence of a mental illness doesn't automatically preclude someone from having rights and choice. Someone must demonstrate the impairment (a burden of proof that goes beyond carrying a diagnosis). Otherwise who's to say the family isn't abusive and worth running away from. Thinking a schizophrenic can't make choices for themselves is simplistic and forgets that they are people. And people in this country are allowed to screw up. A lot. We don't take away their rights for making bad choices (though some could argue we should). The illness must be severe enough to impair their judgment, and that's not a persistent state.

A comparison I would make is capacity vs. competency. Capacity is the ability to make a single choice, at that moment (a snapshot). Someone could lack capacity one minute, then have it again another minute (such as in delirium). Competency (incompetent) is a ruling (by a judge) that someone lacks the global ability to make decisions. It's a ruling that lasts and someone is appointed as a surrogate decision maker.

With Schizophrenia you might have a temporary impairment but that must be proven. Showing permanent impairment is a much taller order, and goes far beyond carrying a diagnosis.

 

[smalltownpsych]

Hmm interesting. When you say various types of guardianships that family can purse, do you any links or sources where one might be able to educate oneself regarding these provisions?

I tell families in this situation to contact an attorney with knowledge of family law. Each state has is own laws and protocols and if we start making legal recommendations or advice it can get past our competency pretty quickly. Some social workers are knowledgeable of the system and can also be helpful through the process. The hard part is that the system is overstressed throughout the nation so lots of people just want to kick the can down the road and not really help. So not only do you have to deal with the psychological ramifications of serious mental illness and its effect on the family, you also have to fight the system. No wonder people get burned out by it all.

 

[whopper]

This won't solve the problem but when doing outpatient treatment, if I get a patient with a disorder where they must absolutely be on meds or lose their ability to function in society and the patient is married, I usually ask the patient to bring in the spouse so we can plan ahead in case something bad happens.

Such things include being able to share records with the other spouse, if the spouse notices problems with the patient they are allowed to call me and I can discuss the issue with them, and recommendations that they consider legal planning such as power-of-attorney.

Of course there is risk with this. The spouse of the patient could use this information to sabotage the patient if their marriage has problems and they're not on the same page with how to deal with the mental illness.

 

[michaelrack]

As others have said, it all depends on the state laws (and perhaps the interpretation of those laws by the COUNTY judge) where the patient is located.. Another thing to keep in mind is that it often takes a while (1+ weeks) to arrange a committment hearing. In MS, patients are held under an order of retention either in jail, a crisis center, or psych hosp until their hearing (they are more likely to be held in a psych hospital if they have insurance or $). In the psych hospital, treatment often starts while waiting for the hearing (the order of retention allows for standard medical treatment); so the patient may benefit even if not committed.

 

[Ceke2002]

Yep. But presence of a mental illness doesn't automatically preclude someone from having rights and choice. Someone must demonstrate the impairment (a burden of proof that goes beyond carrying a diagnosis). Otherwise who's to say the family isn't abusive and worth running away from. Thinking a schizophrenic can't make choices for themselves is simplistic and forgets that they are people. And people in this country are allowed to screw up. A lot. We don't take away their rights for making bad choices (though some could argue we should). The illness must be severe enough to impair their judgment, and that's not a persistent state.

A comparison I would make is capacity vs. competency. Capacity is the ability to make a single choice, at that moment (a snapshot). Someone could lack capacity one minute, then have it again another minute (such as in delirium). Competency (incompetent) is a ruling (by a judge) that someone lacks the global ability to make decisions. It's a ruling that lasts and someone is appointed as a surrogate decision maker.

With Schizophrenia you might have a temporary impairment but that must be proven. Showing permanent impairment is a much taller order, and goes far beyond carrying a diagnosis.

Great post, and thank you for mentioning the bolded part as well (I wanted to bring that point up in my previous post, but didn't wish to inadvertently cast aspersions on the family in OP's case). I've been in a similar situation with an abusive ex attempting to utilise the police and mental health system to try and force me to return to him after I'd attempted to leave for the second to last time (long story short I did end up returning just long enough to get myself back on the methadone program at the time and to start looking for proper alternative accommodation - I knew what his cycles of abuse were like by that point, so I also knew I'd be safe going back...for a while at least). Thankfully the laws in my state don't preclude someone from making a decision for themselves by mere virtue of the fact that they may be diagnosed with a mental illness, or else I may have been forced back into a situation before I was sure it was safe to return. And my ex was very good at playing the concerned, doting partner, who really just wanted me back where he could make sure I was safe, and take care of me (and attempt to dislocate my shoulder, and kick me across the room when it suited him) - had it not been for the letter of the law regarding capacity and competency in mental health cases I'm sure he could have convinced some unsuspecting officer of the law or courts to have me returned to his 'care'. IMHO any mental health capacity/competency type laws should be in place not just to protect the patient from being a risk to themselves or others, but to also protect the patient from any risk that might be posed to them from others as well - which includes giving the patient the right to leave a situation that is potentially unsafe for them to be in.