Questions on Institutionalization

This question is inspired, in part, by this thread as well a Pit thread that I’m not able to find right now.

How difficult is it to get someone committed to a mental health facility? Once in, how difficult is it to get out? Are there any recent, well-researched books on the topic?

Along those lines, what possessions is one normally allowed in a mental health facility? Would these extend to books and/or a word processor?


The Constitutional standard, set in the 1975 case of O’Connor v. Donaldson:

a State cannot constitutionally confine without more a nondangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.

So, the person must be proven dangerous or incapable of caring for themselves with the assistance that is available on an outpatient basis. This requires a hearing before a judge, where evidence is taken and the person against whom commitment is sought has a right to counsel (one will be appointed if they cannot afford, etc.). The particulars vary to some degree state by state.

ETA: a person believed to be a present danger to themselves or others may be involuntarily committed for 72 hours without a hearing for evaluation. If they are not found to be a present danger, in many states they will be released in 24 or 48 hours because of overcrowding, even if they are obviously mentally ill (ie, currently experiencing a manic, delusional, paranoid, etc. episode). During this time they cannot be forced to take medication either.

A friend of mine works part-time as a special justice for adult civil commitment hearings. I’ll try to look him up and ask some questions.

Here are some materials on the topic. (both links pdf)

I just recently did a post on this is a related thread. I’ll see if I can find it.

I found the thread but now recall I didn’t post the draft post because it was me being Captain Factoid instead of having sympathy. Wish I’d kept it though because this[ thread looks like a job for Captain Factoid!

Assuming that you yourself are not a psychiatrist, it may be difficult for you to set out to get someone committed to a mental health facility. There are many factors involved.

It does not follow from that that you (anybody) is therefore safe from being committed on an involuntary basis to a mental health facility.

The official criteria that are SUPPOSED to matter are among the factors involved, but are not the only factors that count, and can definitely be drowned out by other factors. In other words, people who are not remotely dangerous DO get committed involuntarily to mental facilities sometimes. (And similarly, dangerous people sometimes are NOT subjected to involuntary commitment even when their dangerousness is vividly apparent).

Are you confining this to the process of getting out through proper channels (being discharged) or are you including escapes?

This, too, can depend on a vast number of factors. Being

• an adult
• in a private bin
• with insurance that will not pay for you to stay there
• under the care of a doctor who has no compulsion to ‘break’ you or teach you a lesson etc
• with friends /relatives who support your release and who come to visit you

… works in your favor. In marked contrast, being

• a minor
• in a private bin
• with insurance that will continue to pay for you to stay there
• under the care of a doctor who considers you to be obstinate or ‘treatment-resistant’
• with family members who were instrumental in getting you in in the first place

… you may be in deep shit; whereas being

•an adult
• in a public facility
• who did not harm anyone and are not currently being disruptive in any marked fashion

… usually means they’ve got a better use for your bed and they’ll be wanting you out of there soon.

Thank you. One question on the above, as it is written in passive voice: who may do the 72-hour involuntary committing? Is it as simple as a cop picking someone up, assuming they’re having a psychotic break, and dropping them off at a facility? More to the point, say my wife’s a nurse and she gets mad at me. If she calls the cops and tells them I left the house and am suicidal, will they come pick me up and throw me in the happy home with trees and flowers and chirping birds for 72 hours?

Something like this did happen to some acquaintances of mine years ago. (My ex was friends with the nurse, not the dude.) I was quite astonished to hear that it went down like that. The nurse seemed nonplussed, like she could do it anytime given her position in the medical field. Kinda freaked me out.

Don’t know about books. As for how difficult it is to get one civilly committed:

I used to work as a civil attorney in a large county attorney’s office in Washington State. One thing all the civil attorneys had to do was handle involuntary civil commitments, a job we were each assigned in two-week rotations.

At least in Washington, a person who is mentally ill may find themselves commited as follows (and I think the procedure is generally the same throughout the U.S.): A concerned person, like a police officer or a family member brings the patient to the emergency room for examination based on concern about the patient’s mental state. The patient must be examined by a mental health professional within three hours. If the MHP believes the criteria for involuntary commitment are met, he or she may file a petition with the local court to have the person commited for no more than 72 hours. The grounds for commitment are (1) that the person presents a likelihood of serious harm (a/k/a “danger to self or others”) or (2) that the person is gravely disabled (a/k/a “cannot meet his/her ADLs [activities of daily living]”). All that is required for the initial 72-hour hold is the MHP’s petition and affidavit.

Within 72 hours, a due process hearing must be held to inquire as to whether the person may be further involuntarily held. This is required because the deprivation of personal liberty is considered a grave constitutional matter, and a court must determine whether or not it will be allowed. That’s where we would come in: The mental healh hearings always had an attorney for the State (the party seeking commitment, that was our role); a public defender; a judge; the mental health professional who committed the patient; usually the mental health professional who was treating the patient; and sometimes family members or other witnesses. These were real legal hearings, but they were conducted in the conference room at the facility where the patients were held (there were three in the County in which I worked), instead of in a court room. At this hearing, the parties would put on witnesses and enter evidence either for or against further involuntary commitment of the patient.

Because we lawyers were not MHPs, we deferred almost entirely to the MHPs. This means that if the MHP thought the patient was stabilized enough to be allowed back to the community, we dismissed the petition. We never tried to hold someone who the MHPs didn’t think needed to be held. This means that the very vast majorityof hearings at the 72-hour mark resulted in further involuntary commitment of the patient – because if there wasn’t pretty persuasive evidence of a need for further treatment, we didn’t hold the hearing at all.

At that hearing, the patient could be committed for up to an additonal 14 days. At the 14 day mark, another hearing had to be held to see if the patient could be/should be committed for up to an additonal 90 days. Those 14 day hearings were much bigger deals, because the potential commitment was three months. If a person was committed at that point, then they would recieve a new due process hearing every 3 months.

Where I worked, 72-hour holds and 14-day holds meant the patient was treated in the community – at the hospital or at one of two clinics set up for mental health treatment. If the patient was committed on a 90 day hold, which usually indicated a need for longer term treatment, the person would be committed to Western States Hospital – the state mental hospital.

Getting out is a matter of showing you are not a danger to self or others, or gravely disabled. Things that were looked at included (but aren’t limited to): being compliant with medication and therapy; eating and sleeping appropriately; absence of obvious acute mental health symptoms (like hallucinations, pressured speech, paranoia); and personal insight into the situation.

Generally the cases were very clear cut: the people who were involuntarily committed were, in a word, crazy. Clearly crazy. Very crazy. Lots could be stabilized within 72 hours and released; the vast majoirty could be stabilized and released within 14 days.

The most difficult situations were: (1) the agony of parents who did not want to admit that they could no longer take care of their mentally ill adult child. I would have to tell them, Look, if you tell the judge you can take care of him, the judge will release him back to your care. You have to tell the truth: that you can’t deal with this child, that you’re worried about him and scared of him. “But he’ll be so mad at me!” (2) Alzheimer’s patients without support systems, like family or resources. These people were clearly gravely disabled, but not technically “mentally ill”. It was very hard to get them appropriate placements (i.e., a dementia nursing home), but being on the mental wards wasn’t really the place for them either. (3) People who were having acute mental illness issues for the first time – who had decompensated more or less out of the blue. This is unfortunately common with schizophrenia in particular. These patients did not have existing mental health services in place, or a history of mental health treatment, and they frequently had families who were either completely devastated by the situation or who refused to accept the gravity of it.

It depends on the placement. Is the person acutely decompensated and a danger to self or others? Because then they are likely to be in the proverbial padded cell. Suicidal individuals (although they are rare) are put in a quilted one-piece smock, akin to a hospital gown but much heavier and that you cannot rip or tear, called a “turtle suit.” They may be allowed literally nothing else, not even a blanket.

Out on the ward? Sure there are books. And games and TV and craft supplies, all to help the patients pass the time. Word processors? No; never saw one of those, though perhaps bigger facilities have them.

Jodi, thank you so very much. This really makes things clear.

ETA: Re: what Hello Again said, “A person believed to be a present danger to themselves or others may be involuntarily committed for 72 hours without a hearing for evaluation. If they are not found to be a present danger, in many states they will be released in 24 or 48 hours because of overcrowding, even if they are obviously mentally ill (ie, currently experiencing a manic, delusional, paranoid, etc. episode).” We never, and I mean ever, released anyone who met the criteria (likelihood of serious harm or gravely disabled), for overcrowding or any other reason. It would be a HUGE liability issue to let a clearly mentally ill person back into the community, if the legal criteria were met. What if that person hurt himself or someone else? Overcrowding was an issue, and we often had to move people to other counties – sometimes hundreds of miles, which tended to piss their families off – but we never just let them go.

And they can be forced to take meds, they just can’t be forced to take psychiatric meds. But any med for a physical condition can be forced, though staff never like to force meds and will usually try to coerce or cajole the patient into taking them. Since cigarettes are not allowed in most facilities, a bribe of a smoke can get many patients to take their meds.

A reasonable attitude for the attorney for the state to take. Not a tolerable attitude for the public defender to adopt.

No, they didn’t, and quite rightly. But theirs was an almost insurmountable problem: These hearings were done very much on the fly (had to be done within 72 hours) and it’s not like the PD had money for an independent MHP, so usually the only MHP who was there was the one actually treating the guy. They could cross-examine the MHP of course, but there was rarely (never, IIRC) an opportunity to bring in someone else to independently evaluate the patient and perhaps disagree. Multiple evals was a feature of competency evaluations for criminal trials – but these weren’t criminal matters, they were civil commitments. So all they could do was try to undermine the MHP’s opinion. But of course the judges tended to defer to the MHP too. We prosecutors almost invariably won those hearings – I never lost one – and the PDs almost invariably lost. That had absolutely nothing to do with lawyerly skill and everything to do with the fact that if the system works correctly only those truly in need of commitment will be brought to hearing anyway.

There’s a recent book called Voluntary Madness in which the author checks herself into 4 mental institutions, each catering to different a socioeconomic group. The author is Norah Vincent, the same lady who wrote Self-Made Man, a book about her year spent disguised as a man; there was another thread about this that you can use to judge the author if you’d like.

She is a writer-journalist and there is some research in the book, but overall it read more like a memoir. It was informative with the occasional insight here and there, but it wasn’t designed to be a top-down scholastic look at the big picture. But certainly worth a read if you’re interested in the topic.

IRT to the difficulty of getting out, the book points out that it is sometimes, unfortunately, dependent on the patient’s level of education and access to outside resources such as lawyers and family/friends who can argue on their behalf. Though perhaps technically protected by the system, patients are sometimes encouraged to sign things that work to their detriment or simply not informed of their rights, etc. Also keep in mind that patients may be heavily drugged when signing these papers, making it that much more difficult to comprehend legal/medical documents that would be hard to decipher even under the best conditions.

Like I said, if they are not a present danger. My aunt, in Hawaii was recently released after a 48 hour hold, when she was in the midst of a manic episode, had absolutely no support system (no family member to be released to, no current MHP, and in fact no fixed address), and refused psychiatric meds, because she was not a danger to herself or others. I am told this is extremely common in Hawaii, and a full 72 hour hold is rare there.

In New York, I’m not exactly sure of the circumstances, but a person who wants to be released can go to a jury.

Did you ever come across a case where the patient (or their family) was able to arrange private counsel for a 72 hearing? Did they fare better or worse than the PD?

Well, the grounds are two-fold – gravely disabled or “danger to self or others” – but you’re right, if neither of those grounds hold, the person will be released. That’s frankly as it should be, because just having a mental illness, or being mentally ill, does not alone mean you are not entitled to the same rights and freedom everyone else is. If you can function with your mental illness you should, indeed must, be allowed to do so. It’s not a system to keep people from being homeless. That said, most patients must be able to articulate how they will meet their daily needs before they will be released: Where will you go? What will you do? How will you get your meds? It is IME extremely rare to just “street” a person who hasn’t at least managed to articulate answers to those types of questions. But of course I couldn’t say it never happens.

In Washington as well, at the 14 day hearing. No one asks for a jury at the 72-hour hearing because you can’t get a trial set up that fast, so doing so would effectively be waiving the 72 hour hearing because it would take much longer than that to get the matter on the trial calendar anyway, even if it’s expedited, which it would be.

Not that I recall. It would be extremely unusual for a person to be involuntarily committed over an involved family’s objections. I don’t think I ever had such a case. If the family can handle the person and wants to do so, they don’t have him or her committed. Usually, family involvement occurred because the family had unfortunately realized they could no longer keep the person safe, or be safe from them, in the midst of an acute mental illness episode. Frankly, if the family appeared and said they were ready and able to care for the person – meet their ADLs, make sure they took their meds, make sure they got to their appointments – commitment would be highly unlikely. The judges were always looking for the least-restrictive placement.

I really can’t overemphasize that we are talking about people who were seriously and in most cases obviously mentally ill or demented. The guy who thought his mother was poisoning his coffee. The girl who repeatedly and randomly took all her clothes off (including in the hearing). The old lady with no family, who was kicked out of her assisted living facility for repeatedly whacking people with her cane and who was could not meet her own ADLs. The guy who stayed up all night pacing and talking about the embodiment of genius, and who hadn’t slept, eaten, or, apparenntly, shut up, in four days when his family brought him in. The guy who tried to jump out of his window so the FBI couldn’t get him. The woman who wandered into traffic and couldn’t say who she was or how she got there.

Yeah, that’s the crux of the problem.

The judge is not being asked to rule on a medical issue and should not be considering the issue at hand to BE a medical issue. If the hearing is a rubber-stamp procedure in which “well gee if the psychiatrist thinks you need to be held against your will, I guess you do”, our rights are going unprotected. The psychiatrist is entitled to present an opinion, but the opinion is on dangerousness and should be backed by evidence. Psychiatrists are not very good predictors thereof if the patient has not performed an actual no-kidding dangerous act. If the judge sees no actual indication of dangerousness, the pyschiatrists opinion that the person’s state of mind is such that this person might act in a dangerous manner should not carry any weight. The whole premise of a hearing is the notion that the patient may not agree with the psychiatrist. If the psychiatrist does not think the patient should be held there would be no need for a hearing — just discharge the patient.

New York has Mental Hygiene Legal Services who are better than your typical attorney in most such matters.

I don’t understand what you’re saying. The judge is ruling as a matter of law whether the legal standard for civil involuntary commitment has been met. But of course the issue presented is a medical one, for which he relies on the testimony of competent and credible medical providers. Their testimony is evidence that he certainly can consider – has to consider in fact.

The hearing is NOT a rubber stamp procedure, any more than any proceeding that presents a question calling for medical expertise, and therefore meriting medical testimony and opinion, becomes therefore a “rubber stamp proceeding.” No one “rubber stamps” the psychiatrist’s opinion; he or she is subject to cross-examination and the judge evaluates the weight of the testimony.

It IS backed by evidence. I don’t know where you’re getting the idea the MHP is pulling an opinion out of his or her ass. They are the people who are treating the patient. They know the diagnosis, history, current condition, level of insight, compliance with treatment, etc.

Do you have a cite for this?

(1) You’re entitled to your opinion, of course, but you can hardly expect many people to agree with you that without an overt act of violence a pyschiatrist’s opinion is entitled to NO weight. (2) Your characterization of a mental disorder as a 'state of mind" indicates some degree of oversimplication, if not misunderstanding, of mental illness. (3) The legal standard is not merely dangerousness; it’s dangerousness or grave disabilty. (4) Your argument would seem to indicate that no action may be taken with regard to a person who, say, voices suicidal ideation – we must wait until he actually tries to kill himself. Fortunately, that’s not the law.

Yes, but the psychiatrist has a hopefully neutral viewpoint and expertise on mental illness. The patient has a severe case of the crazies and light insight into his or her condition or best interests.

And it would be great if there were a specifically mental health-oriented legal service in every location, but most places cannot afford it. And you act like the whole system is set up to simply strip the rights of free people and lock them up. In fact, in most of the cases I saw, the families or care-givers for severely decompensated persons considered themselves fortunate to have access to involuntary commitment proceedings, because they had no other way to keep their loved ones or clients safe, or keep others safe from them.