How not to get yourself hospitalized, or Just because you like Kraft Dinner doesn't mean you are mentally ill. · 3:35am Sep 28th, 2018
As part of my job as a crisis worker, one of the things I need to be able to do is assist in the process of placing people who are mentally ill and in crisis on a hold. Now... a lot of people probably start thinking of getting '5150'd' - to borrow from California's statutory code related mental health hospitalizations - but it's... really more complicated than that. A lot more complicated. So much so that, after visiting Ebon Quill, I ended up having to drive the entire diagonal length of Oregon to take an 8 hour training on it.
Which led me to ask a few folks if learning about it would be interesting/helpful, and they said yes. I'm... not 100% sure that it's helpful to know how someone gets hospitalized against their will - aka Civilly Committed, but they asked and it's on my brain and so here goes.
To start, I should probably clarify that most of what I am talking about pertains to Oregon. Each state has their own statutes and laws and regulations that oversee the civil commitment process. But, while each state may have slightly different ways, words, acronyms, etc. of going about things, they all follow pretty much the same general guideline: if we can avoid taking away someone's right to choose to go to the hospital for their mental illness, we will avoid it at all costs. This means that, even if I have to put someone on a director's hold and they refuse services, it is A HUGE PART OF MY JOB to try to work with them toward agreeing to treatment without taking away their right to consent to it. I would much rather get someone somewhere safe for a few days to help them work through what they are going through than take them to court to be committed for up to 180 days, and in some cases, longer.
But how does that process normally work? Well...
So You're Having A Bit of a Crisis
I tend to see people when they aren't exactly at their best. Most people don't really want to have a mental health crisis, and those that do usually have deeper issues going on than what a crisis intervention can fix. Looking at you, personality disorders More often than not, this is where the process of commitment stops. If I have someone who shows up at the ED with suicidal ideation/plan with intent to follow through, they usually are scared that they are going to hurt themselves. At that point, it's a matter of trying to find a good fit for them and where they are at: be that immediate follow up with their counselor if they see on, a stay at the respite centre we have in the county for a few days to get back together and on meds, or possibly inpatient hospitalization. If you are curious about what that process looks like as a client, Novel Idea has some very frank, insightful commentary on the matter that he has been open and willing to share.
That said, the rule we go by is 'least restrictive care possible'. We want someone to feel like they have some semblance of control over their lives in a really scary moment, and work with them to come up with a plan of care they can agree to and feel safe completing. If they can't contract for their own safety, or we are worried that they may be telling us they'll be safe while still planning on attempting to hurt themselves or someone else, that's when we start discussing a higher level of care, like a hospital. But throughout this process, I try my best to make sure that the client understands that this is their choice.
The same thing happens when we are dealing with someone who is acutely psychotic. I'd much rather wade through a conversation with someone whose reality doesn't... quite match our own to get them to be ok to going to the hospital than force them to go. Client choice is super important, and taking away that right to choose is something that is taken very, very seriously. Even if someone is telling me that they can't take their medicine because it is poison designed to destroy the God Machine.
That means that if I can't get them to agree to voluntarily go to a hospital, I will put them on what is called a Hold.
Now, there's a variety of them, and many of similar names, so for the sake of not boring people, I'll focus on what is called a Director's Custody Hold. This is the hold used when an individual with an alleged mental illness is being forced to stay in an emergency room while they are awaiting 1. transport to a suitable hospital that can treat them (because the two hospitals in my county lack mental health treatment facilities) and 2. a trial to determine whether or not civil commitment is necessary.
As part of this process leading up to a hold being placed, I will discuss options with the client. I'll let them know it is their right to refuse, but if they refuse treatment, they may be civilly committed and may go to court about it. I let them know it may mean that they will be hospitalized for longer than they would originally. Basically I do everything in my power to avoid starting the commitment process, not because it is easier, but because civil commitment has many lasting consequences for the person's life. It's a long, arduous process to get that decision reversed, and it can sometimes make your life hell afterwords due to the legal issues caused by being committed.
So we try to avoid it as best we can.
Just because you like mac and cheese and the investigator does not doesn't mean that you'll be committed
There are four major criteria that we use to determine if we need to start the commitment process if an individual refuses treatment:
1. A reasonable suspicion that the person will hurt themselves in the immediate future (sometimes defined as within hours to a week)
2. A reasonable suspicion that a person will hurt someone else in the immediate future (same legal definition)
3. A gross inability to care for self that will result in possible death or harm in the immediate future
4. two or more involuntary commitments in the past 3 years (Also known as expanded criteria) and you have a 'chronic psychotic disorder or mood disorder'
That means that if you don't meet any of the above, you likely won't be taken to court and thrown in a mental hospital.
I don't know how many times I've heard from people "I can't say that to my therapist, they'll commit me." Unless you want to hurt yourself, someone else, or are doing things that cause gross neglect of self that could cause medical harm in the immediate future, you aren't commitable. Your therapist won't commit you for liking weird porn. Your therapist won't commit you for liking Kraft Dinner with Hot Dogs for dinner every night. They may look at you funny, but while that isn't maybe healthy, it's also like, not the same as telling them that God told you to strip naked and walk out into the desert with no water. We get worried about command hallucinations. If God or The Buddha or Malcom Reynolds is telling you to do something that you feel compelled to do, that's a different talk. We don't get so worried about normal idiosyncrasies in human behaviour. Usually. But even then, if those idiosyncrasies don't fit those four above criteria, you're not likely going to get thrown into a mental hospital.
Also we really try to not throw people. That's... really mean, and it stopped being the 'right' thing to do in the 1980s. Which is hella unfortunate it took that long to treat someone with mental illness with some dignity. Luna, Celestia, and Cadence above...
Regardless, if someone places a Director's Custody Hold upon someone, basically it means that the local mental health agency has three days to investigate the claim that this person is mentally ill and incapable of making decisions for themselves. Sometimes this investigation turns up that they aren't, and the hold is dropped. Sometimes after 24 hours in the ED with nothing to do and some stern looking man staring at you angrily every time you try to leave changes people's minds and they decide maybe they do need help. But other times, it leads up to a court hearing.
That court hearing is interesting in the state of Oregon cause it doesn't necessarily have to take place in a courthouse. Sometimes it'll take place at someone's home - if they aren't in custody and are in the community, or in the hospital itself. My job as an investigator is to present the facts of the case to the judge, DA, and the client's attorney. Which means I have to have met with the client at least twice, and have written up the reasons why I am worried about them, what evidence I have to show that they are not of sound mind, and what recommendations I have for them. This is then also run by a commitment examiner, who is another, older, and theoretically wiser clinician who looks over my work and asks follow up questions. Lots of follow up questions.
Which gets back to the joke about Mac and Cheese. One of the hardest things to prove is gross impairment that could result in immediate harm to self due to mental defect. This tends to be extremely rare, and requires extreme cases like the thing above about God telling you to walk into the desert naked with no water. That will cause immediate harm if you're allowed to do that. Just because you are poor and can't afford more than Kraft Dinner and hotdogs doesn't mean that you are mentally ill. It means you are poor, and are doing the best you can with what resources you have/know how to make. In fact, one of the questions we ask as part of the mental status exam when going through a commitment investigation is 'how do you take care of yourself. Where do you get money and food?'
Someone who may not be commitable may give the answer of "I get $X from SSD/I and I get food stamps and know how to go to the food bank if I need to." Someone who is commitable would probably give an answer more along the lines of "I pray to Buddha for a pony and a toy rocket and toast from the Great Breadinator." While silly, the thing is that one person is organized enough to manage their basic needs, the other may not be, and depending on what their other symptoms are (say, that in the name of the Breadinator, they need to sacrifice 8 humans and were found running around waving a knife), we may be able to move forward with the commitment process.
Which, if they are running around with a knife threatening to sacrifice people to the breadinator, they represent a reasonable threat to the public, and thus also meet another criteria for commitment that isn't necessarily the gross inability to care for self.
So once again, just because you like mac and cheese doesn't mean you're commitable.
Alternatives to Commitment
Oregon has a somewhat unique system that provides many alternatives to the commitment process. The one that I try to use the most is getting someone hooked up with a therapist, or having an immediate appointment for them. This allows the client to access natural resources and gives us an opportunity to avoid having them go into another setting. Another would be what is called a 'sub-acute' facility like our Respite Centre. There you're able to stay for a few days to get your head together, and maybe meet with a psychiatrist if a med change or med start is needed.
But sometimes that doesn't work, and we need something more. The first step in the process is the filing of a Notice of Mental Illness. This means that we believe someone is mentally ill, and may not be able to consent to treatment or is actively dangerous to themselves or others and is refusing treatment. Once that is filed with the court, we have several options.
A 14-day Diversion is an alternative to commitment for individuals who don't want to lose their rights, but need that inpatient care. It is a time limited stay of up to but not supposed to be more than 14 calendar days in a hospital or Secure Residential Treatment Facility (SRTF) in order to help stabilize the mental illness. There is usually a warning attached to this that if they refuse to participate in treatment, it may result in the commitment process continuing to a court hearing.
If a hearing takes place, the Judge is the final word on what happens. She may dismiss the case entirely, citing not enough evidence. She may require a hospitalization and the full commitment, which is usually a 180 day commitment timeframe where the individual is placed in the hospital or followed by the court system to make sure they are continuing to maintain their treatment. She could also request and emergency guardianship. This sometimes happens with older people with mental illnesses and dementia. A guardian can be appointed on an emergency basis to assist and advocate for the client, BUT! They do not have the power to override the client's will. If the client does not want to be in a hospital, even if they need it, they can decline that even with a guardian, and will likely be brought back to court.
A less restrictive option is Conditional Release. If an individual looks like they have resources in the community that they can access, the judge may order a conditional release. That means that the person won't be hospitalized if they agree to follow through with outpatient treatment. This outcome is also contingent upon maintaining that follow through, or they could be brought back into court and reassessed.
So again, while this sounds scary, the idea is that we do everything in our power to avoid taking away your right to choose to get help. Up to and including warning you about the consequences of your choices should you refuse help at a certain level of care. And actively talking to you about your options, and discussing alternatives.
Now that my brain feels like mush from writing all of that, hopefully that clears up a few things.
At the very least you know that if you like mac and cheese, you can't be hospitalized for it.
Unless the mac and cheese is telling you to hurt yourself, someone else, or walk out into the desert naked with no water.
Dangit now I want mac and cheese...
I love mac and cheese.
In Michigan, at least, at the group homes where I work part-time, residents who are not court-committed generally cannot be held against their will. (I work with developmentally disabled adults.) That can be a problem when one of them decides to elope in the middle of the night, gets picked up by the police (who know him quite well) and then he decides that he doesn’t want to go back to the group home. We can’t make him, and the cops can’t force him, either, so he has to be convinced to come back of his own free will. Obviously, if the resident is court-committed, it’s a very different manner.
There’s another guy who every now and then decides that he just doesn’t want to deal with his roommates any more, and it’s part of his treatment plan that we drive him to the mission (if he asks; sometimes he just walks), and come by once a shift to ask him if he wants to come back home, and give him his meds.
4944784
Yeah, DD homes have their own criteria as well that I didn't want to go into cause it's... complicated. Usually, however, we try to stick to what is in their action plans and work with the group homes around that. Up to and including doing what you do with your guy who needs to go spend the night at the mission. Luckily DD services usually handles those cases, as they can be quite... complicated when you have someone who doesn't want to go home but doesn't technically have a court commitment to be there. The right to choose where you live is super important. It's just... sometimes hard when the person decides "Nope, I'm outie!" at 3am...
...What if I make my own mac & cheese from scratch instead of buying the boxed Kraft stuff? I still can't get committed for that, right?
Soo what inspired this?
Why must you use outre terms like "Kraft dinner?"
I'd consider it a feather in your cap if you'd just call it macaroni.
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"I say, do you see what I did there, dear fellow?
I don't really have any comments except that I caught all your Firefly references 🚀
Psychology is complicated and confusing, but I also find looking through other people's perspectives to be interesting. It sort of adds a little more wisdom to the 'melting pot' of mindsets that I pull from for contrast and comparison, and allows me to understand the current situation better.
But what about Marmite?
4945950
Mmm, that might actually be signs of suicidality right there. XD
4944794
Since I’m just residential staff, I don’t have to deal with all the minutiae, thankfully. I’m sure it’s quite complicated, overall. I’ll admit, we do do a fair bit of griping at the upper levels of management for resources we don’t get and things which we think are obvious that management just can’t seem to figure out. But I suppose that’s the same anywhere you go.
Also, it’s really frustrating sometimes to have to deal with the various levels of freedom we have to allow legally while at the same time doing what’s best for the individual. We’ve got one house where they used to keep the kitchen locked and now we can’t do that any more and of course one of the guys is raiding the fridge now, and there’s no solution to that, really. Tell him not to, but if he doesn’t there’s not much we can do about it.
Even though, you explained the process and anyone could find the description of this process if they looked it up, sometimes people act based on their fears and not facts.
Even if priests had this rigorous process before they could go to the police, people would still see the cases where a criminal told something to a priest and is now in jail. Many would stop talking to a priest even if they committed no crime.
What I'm saying is, sometimes a solution to a problem is even worse than the problem. Just because you have the option to commit someone, it might drive somebody away that you could otherwise help. What is your personal opinion; would more people trust mental health workers if they didn't find threatened?
4974036
Yeah, think so. For the most part I try to avoid commitment. I'd much rather try to help someone connect with outpatient resources than have them go to the hospital. I think people fear that try are worse off than they think they are, and I think that can drive fear. However, in a lot of cases where full commitment sticks, it's super necessary. With severely depressed people, I can usually do some motivational interviewing with them to weigh their options. But for the extremely rare case of someone who is violently psychotic (And I've only ever had to deal with one person like this in 6 years of practice) commitment was the best way to keep them and others safe.
4975042 I know what you're saying. There are always good intentions involved in the matter of commitment. However, on the outside observer, it's a yes or no question. Do these people have an option to take away my freedom? In your case, the answer is yes. Because of that option alone, a person might rather go talk to a priest who is less qualified to help in these matters but does not have the authority to take away somebody's freedom.
By committing those who need commitment, you save people. What I'm asking is, are you sure you're not losing people on the other end? People who could have been saved but did not seek help because they didn't like the loaded gun you have strapped to your belt (the option to commit a person).
I thought calming depression was a long and strenuous process. How do these interviews look like? I'm curious.