States with the Most and Least Onerous Commitment Procedures

[Mad Jack]

I'm curious about how challenging commitment procedures are in different states. I enjoy inpatient psychiatry, but have found that the commitment procedures in my current state of practice are so dreadful that they seriously detract from my ability to help patients. How are the proceedings in other states? I'm thinking about long-term areas in which to practice, as inpatient is my setting of choice, and I would like to know which states will allow me to help patients most effectively. Here's my take on two states, in particular:

Pennsylvania: Hearings are county-based and are either collaborative or conetentious depending on the county in question. Meds over objection requires two psychiatrists to agree on an involuntarily admitted patient. Overall, procedures are fairly simple and generally painless. Hearings are usually less than 30 minutes. Goal of hearing is to do what is in the best interest of the patient. 8.5/10, often painless, works toward best interests of the patient and community.

Massachusetts: Hearings require a contentious process through the court system, with very aggressive representation of clients, resulting in sometimes 2+ hour commitment hearings. Medications over objection require a separate hearing, usually held after the first, and are also contentious, with each medication and dose specifically having to be approved. Standard for commitment is extremely high (beyond a reasonable doubt). 1/10, the worst commitment laws I've seen, making it hard for patients to get help, draws patients and families into very stressful proceedings, and is quite challenging from a provider perspective to actually get patients treatment.

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[comp1]

Oh I LOVE this discussion. California is also somewhat county dependent on the setup (but here's mine). Initial hearings, called certification hearings before a county social worker or lawyer, are generally non-contentious and formalities unless the commitment is grossly inappropriate. The patient has the chance to appeal the finding of a certification in a writ of habeus corpus to a superior court judge. These can get contentious as everyone is lawyered up, but even complex ones where ultimately the judge finds for the patient often only take 30 minutes or less. The public defender can also decline to bring the case before a judge if they have no case at all. Involuntary medication administration is a parallel process to the writ hearing, but still less than 30 minutes. ECT has a similar process, but I have very rarely used it and in my recollection, it is much more contentious. ECT is statistically not done often in California relative to other states due to a supply that leads to a demand problem. Now this is all for acute hospitalization. If you are looking for a longer term conservatorship, then you're completely at the mercy of the county unless the patient is very wealthy. Counties are going to have different bars for when they are willing to conserve a patient based on their resources and the patient's. In general, the bar is the county's willingness, not a judge's. The patient has the option for a jury trial for conservatorship, but this is rarely exercised and it often functions more like a writ. However, the county has to be the one to bring forward the conservatorship (if the doctor asks), so if they say no, it's over and the patient re-enters the revolving door. Of course they may still go into that door once conserved because of the horrific lack of long term beds.

 

[Sushirolls]

I believe WA and NJ are the 2 states that don't allow doctors to commit people but require a 3rd party government contracted person, usually with a community mental health agency that goes around and does evaluations to determine if people meet criteria or not for the initial 72 hour type holds.

 

[birchswing]

Oh I LOVE this discussion. California is also somewhat county dependent on the setup (but here's mine). Initial hearings, called certification hearings before a county social worker or lawyer, are generally non-contentious and formalities unless the commitment is grossly inappropriate. The patient has the chance to appeal the finding of a certification in a writ of habeus corpus to a superior court judge. These can get contentious as everyone is lawyered up, but even complex ones where ultimately the judge finds for the patient often only take 30 minutes or less. The public defender can also decline to bring the case before a judge if they have no case at all. Involuntary medication administration is a parallel process to the writ hearing, but still less than 30 minutes. ECT has a similar process, but I have very rarely used it and in my recollection, it is much more contentious. ECT is statistically not done often in California relative to other states due to a supply that leads to a demand problem. Now this is all for acute hospitalization. If you are looking for a longer term conservatorship, then you're completely at the mercy of the county unless the patient is very wealthy. Counties are going to have different bars for when they are willing to conserve a patient based on their resources and the patient's. In general, the bar is the county's willingness, not a judge's. The patient has the option for a jury trial for conservatorship, but this is rarely exercised and it often functions more like a writ. However, the county has to be the one to bring forward the conservatorship (if the doctor asks), so if they say no, it's over and the patient re-enters the revolving door. Of course they may still go into that door once conserved because of the horrific lack of long term beds.

Do you have thoughts on this new initiative on the March ballot making it easier to force hospitalization and supposedly increasing resources?

I just moved to CA and had planned not to vote on this initiative since I don't understand the particulars of it well. My gut feeling is that it's needling the poor and mentally ill in a way the rich wouldn't be, but I'm a political dilettante of this state. I only have gut instincts so far, which is that the progressives here are not quite the same as progressives of Virginia. And I haven't found my political footing yet (among many other footings I have to find with this move).

 

[allantois]

Anyone can baker act anyone for anything in FL (ofc it's an exaggeration)..

 

[psych_0]

Anyone can baker act anyone for anything in FL (ofc it's an exaggeration)..

During my rotations in Florida, someone could come in as a Baker Act on a Tuesday morning and be started on involuntary ECT 3 days later on a Friday. The system works really well for that sort of patient population, IMO. Meds over objection can be done on day 1 of admission, even before a patient has gone to court. Before court they have a healthcare proxy that can consent to any and everything except ECT (so back-up IM meds, long acting Sustenna, etc). After court, they now have a guardian advocate (only applies to their time in the hospital, then it goes away) who can consent to everything, including ECT (if you specifically asked for that in court). In court you can request the patient be hospitalized 1 week, 2 weeks, 4 week or sent to the state hospital (essentially an indefinite hospitalization until they go to state hospital). Each court hearing usually takes 3-10 min. If patient doesn't show up to court, it commonly ends <3 min. If they show up and the public defender is feeling argumentative, it can go on for up to 15 min.

The Baker Act itself is also widely abused by family and police. So many patients said, "Police told me I could either come here or go to jail because me and [insert whoever here] were arguing." In my experience, 40-50% of them should've been taken to jail. Easy admissions for whoever is doing the admission. Usually a same day discharge easy peasy 90792.

 

[mcatqueen]

Anyone can baker act anyone for anything in FL (ofc it's an exaggeration)..

Florida does have Florida Man tho....

 

[comp1]

So Prop 1 in March in California is fine. I wish it was a bit more focused. It lumps in housing and CEQA reform with mental health funding. I don't think it actually changes involuntary commitment law, just funding. The changes to involuntary commitment already happened on 1/1, allowing you to commit someone for substance use disorders, unwillingness to use resources (as opposed to inability) and allowing hearsay testimony in mental health hearings. Most counties have not implemented the substance abuse allowances yet since they obviously need funding to do so and have until 2026. In general, I think a big important part of Prop 1 will be how the money is actually distributed. If we want to actually tackle chronic homelessness, the kind that the general population sees and that businesses get on the news and complain about, as opposed to more common, but also more technical homelessness like couch surfing, the vast majority of the money needs to go to long term locked facilities. I'm not entirely sure if the government has the stomach for that. I hope they do, but I'm not sure. There's going to be a lot of push to direct most of that money to low income housing, which is great, but doesn't actually tackle what I would describe as visible homelessness.

 

[Merovinge]

So Prop 1 in March in California is fine. I wish it was a bit more focused. It lumps in housing and CEQA reform with mental health funding. I don't think it actually changes involuntary commitment law, just funding. The changes to involuntary commitment already happened on 1/1, allowing you to commit someone for substance use disorders, unwillingness to use resources (as opposed to inability) and allowing hearsay testimony in mental health hearings. Most counties have not implemented the substance abuse allowances yet since they obviously need funding to do so and have until 2026. In general, I think a big important part of Prop 1 will be how the money is actually distributed. If we want to actually tackle chronic homelessness, the kind that the general population sees and that businesses get on the news and complain about, as opposed to more common, but also more technical homelessness like couch surfing, the vast majority of the money needs to go to long term locked facilities. I'm not entirely sure if the government has the stomach for that. I hope they do, but I'm not sure. There's going to be a lot of push to direct most of that money to low income housing, which is great, but doesn't actually tackle what I would describe as visible homelessness.

Can you expand more on how you would handle this situation? Are you suggesting a sweep through skid row and put into long-term locked facilities where mental health and addiction are identified and treated on an involuntary basis?

 

[comp1]

I would handle the situation with a great deal more long term locked treatment than is available now. I haven't heard anyone propose "sweeps" and I wouldn't support that. We all have no shortage of demand arriving daily now. There are already many times more patients brought to our EDs under current mechanisms than we would be able to fund the care of under Prop1 even if it all went to long term locked treatment.

 

[Stagg737]

I did part of my residency in Missouri and it's incredibly easy to place someone on a 96-hour hold. Any adult can file for a hold by filling out paperwork and getting it signed by a judge. If a MH professional submits the paperwork it's basically rubber stamped by a judge, no hearings. 96 hours is on business days only too, so file after Monday and it's actually at least a 6 day hold since weekends don't count. I never heard of a file in our city being filed by a psychiatrist or MH hospital that wasn't immediately approved by a judge.

If you want to hold someone longer than that, you have to submit paperwork for a continued hold before the 96-hour hold expires which is then heard in court as to whether it gets upheld or now. Subsequent holds are for 21, 90, then 120 days. Those are typically granted, though I have seen a couple cases where the patient got "good enough" in that first week of treatment that the judge let them walk and 1 instance where a judge released a patient because a resident got on the stand and said they didn't think they needed to be held. Once in the hospital, you legally can force meds, but none of the inpatient docs I worked with would do that unless they needed a longer hold and it was upheld by a judge. Most patients would be agreeable once they met with a lawyer who would tell them the process and what they needed to do to get out, which almost always involved complying with meds.

With all the problems Missouri had, it was definitely easier being an inpatient doc there as I could hold anyone who actually needed it easily. It is a format that could easily be abused, but if you're a good doc it was a dream.


Where I'm currently at it's more complicated but still not too bad. If I file paperwork for a hold then the patient is interviewed by a state screener (I've only seen SW doing this) as to whether they are accepted to the state hospital or not. If they decline then the invol is sometimes just dropped. I have had a couple instances where a patient clearly needed inpatient admission and was declined by the screener prompting me to have to make various calls to either get a new screener or talk directly with the DA to get them to intervene. In this state, initial holds are for 72 hours and if the hold is filed and screener agrees, then it goes in front of a judge.

 

[Styrene]

NY, the way it goes at my current institution, all patients admitted under 2PC, so two physicians certifying the necessity of admission by signing the form. This gives 60 days involuntary commitment after which a court hearing is required for further retention. If the patient submits a 72-hour letter before that initial 60 days is up, then a hearing is required sooner.

Treatment over objection is a separate court hearing, and that usually takes about 1-2 weeks start to finish until granted in straightforward cases.

Patients meet with the mental hygiene legal service prior to all retention and TOO hearings and at any other time if requested.

The retention/treatment is approved in the vast majority of cases from our institution.

 

[Mad Jack]

Florida does have Florida Man tho....

Have to react quickly when Florida Man is on the loose

 

[whopper]

I believe WA and NJ are the 2 states that don't allow doctors to commit people but require a 3rd party government contracted person, usually with a community mental health agency that goes around and does evaluations to determine if people meet criteria or not for the initial 72 hour type holds.

I don't know about WA but NJ allowed a 3rd person non-MD, DO, nurse or psychologist to act as a evaluator for a hold.

As for the Baker Act, I've heard FL's laws are one of the worst with commitments, in fact so bad that sometimes patients who should've been involuntarily held were misled into staying in the hospital under false pretenses so the hospital staff didn't have to do the involuntary commitment procedure. It's one of the landmark cases for the forensic board exam.

(Anyone remember the case?)

 

[aim-agm]

I don't know about WA but NJ allowed a 3rd person non-MD, DO, nurse or psychologist to act as a evaluator for a hold.

As for the Baker Act, I've heard FL's laws are one of the worst with commitments, in fact so bad that sometimes patients who should've been involuntarily held were misled into staying in the hospital under false pretenses so the hospital staff didn't have to do the involuntary commitment procedure. It's one of the landmark cases for the forensic board exam.

(Anyone remember the case?)

Zinermon v. Burch (1990)

 

[hamstergang]

I believe WA and NJ are the 2 states that don't allow doctors to commit people but require a 3rd party government contracted person, usually with a community mental health agency that goes around and does evaluations to determine if people meet criteria or not for the initial 72 hour type holds.

While it's true that in NJ we do have people who are called screeners that are basically social workers who make the initial determination as to whether a patient should be involuntary committed (and then within 24 hours the physician writes their document, and then within 72 hours another physician does as well -- this second one is generally on the inpatient unit), you can bypass the screener entirely and just have 2 physicians agree on the commitment. This is very rarely done but very legally allowed.

 

[aim-agm]

One important distinction is between commitment and evaluation.

In NY it is relatively trivial to commit someone you are evaluating in the ED, particularly if there is an emergency. But getting that person to the ED or hospital to be evaluated in the first place is basically impossible unless there is an emergency or they are on court ordered treatment (or conditional discharge). If someone isn't going to die (or get seriously injured) in basically the next couple of days, you have to get someone whom the state allows to apply for involuntary admission (which is almost never going to be you) and another psychiatrist, find the patient, get them to let you evaluate them, and then submit that to a psychiatric unit which then (if they accept the application) can ask the police to pick the person up.