Commitment Process: When a Person Is a Danger to Self or Others
The Importance of Mental Health
In the United States, approximately one in four adults suffers from a mental disorder (National Institute of Mental Health, 2004). These numbers may be greatly out of date. According to John Grohol, Psy.D., as many as 75 million people, or one in three adults, suffer from mental disorders. This figure includes diseases such as alcoholism and drug addiction.
As the number of mentally ill people grows, it is evident that in our society not everyone receives the necessary care. Treatment can range from outpatient clinic care, in which a patient meets a qualified therapist, or inpatient care in a 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 its effectiveness. A therapist (psychologist, social worker, or nurse) will meet with the patient for a session in which cognitive therapy, group therapy, or other variations of therapy are used. The therapist will have expertise, and advanced education, in the specialty of psychological disorders and mental health.
These therapy modalities are used to support the client’s problem-solving ability and bring them 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 an insurance case manager has assigned a designated number of sessions.
However, what happens if a person cannot afford to see a clinician and their 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 they need?
When therapy is not enough to help a person with a mental health disorder, hospitalization may be the best process to protect all parties.
What is the process of hospitalizing someone with a mental illness? The broad terms of inpatient involuntary commitment is that the person is deemed to be 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 that they need it. Although they may protest being hospitalized, they must follow the decision of a 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 detailed. The affidavit will also state the name and address of the person who has requested the involuntary commitment.
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 is considered to be 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.
Upon 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 emergency room staff will alert a physician that a psychiatric evaluation is warranted. Criteria for that request include psychotic behavior or patient threats of suicide or homicide. In these cases. the patient may be given the choice to be transported to the unit as a voluntary patient, if the patient agrees to sign himself in for treatment, or to be transported 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 involuntary commitment form, especially in cases of suicidal or homicidal threats.
Mental Illness and the Law
In the United States, mental health laws are designed to protect people from getting lost in the system, forgotten, or lose access to treatment. Nonetheless, these laws are still abused through loopholes and the process can be manipulated to suit certain parties.
Laws that were erected to protect the mentally ill are sometimes misused to hospitalize people whose behavior is eccentric. In some cases, family members may abuse the law to commit a relative so that the relative will lose control of disputed family property.
The Florida Mental Health Act of 1971 (also referred to as the Baker Act, after state Representative Maxine Baker, who advocated for the mentally ill) was created in response to numerous cases in which family members committed elderly relatives and took over their estates. This form of commitment in state mental facilities is identified as a form of elder abuse.
Any person, regardless of age, who has been detained through an involuntary commitment process has the right to a hearing before a judge within a set amount of time. Usually the hearing window is the first 10 days of admission. The patient has the right to be present and appeal the commitment individually or with counsel representation. If the person is unable to afford counsel, they have the right to court-appointed representation.
During the hearing, the judge will listen to testimony and review documentation presented by the psychiatrist, the first examiner, or other staff with evidence of the patient’s condition. The judge will then listen to the patient. Questions may be asked and the circumstances leading to the lock-up will be reviewed. If there is insufficient evidence that the criteria for commitment is met, the judge will release the patient. The judge may also extend the treatment by a certain number of days—usually ten to fourteen. A follow-up court date will be set to ensure that the patient is not stuck endlessly in a locked facility.
Mental health laws vary from state to state, but each state has an obligation to follow the process through the legal system. In 1975, the U.S. Supreme Court ruled in O’Connor v. Donaldson that it is unlawful to hold a person against their will without a timely evaluation and that they must be released if there is no evidence to substantiate the need for continued hospitalization.
An Example of the Legal System at Work in an Involuntary Commitment Case
As a psychiatric nurse, I’ve been present at commitment hearings on occasion. I have seen how hearings can protect patients from being held unfairly by people who do not have the best interest of the patient at heart. When I was a student nurse in 1983, I watched as several cases were presented in a Detroit courtroom. My instructor asked for our decisions on the cases prior to hearing which way the judges ruled.
One case stands out in my memory. An elderly African-American woman had been committed by her daughter. The older woman was skinny and animated. She looked disheveled in her crumpled clothes. A 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, barricaded the door, and threatened anyone who approached the house with a baseball bat. 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. She countered the allegations and insisted that her daughter was attempting to take guardianship of her finances. Regarding the eccentric hat: It was cold at night in her house and it kept her head warm. She locked and barricaded her doors because she lived in a bad neighborhood and was afraid at night. She explained that she kept the baseball bat as protection from “any fool who would come knocking on a door in the middle of the night."
The judge ruled her competent and dismissed the case.
It is important that we all protect and care for our own mental health. When it comes to loved ones, particularly the vulnerable, we must be vigilant about discerning when they may be struggling with real mental health issues, or simply living in a manner we do not understand.
The law protects our independence and self-determination. Imagine how grateful you would be for these laws if you felt you were being unfairly committed to a psychiatric hospital!
I hope you have found this article helpful as you investigate the facts about the commitment process.