Users Guide to Mental Commitment

Tom O'Brien

This narrative was prepared for use by Guardianship Services of Seattle staff in educating people concerned about GSS clients.

From time to time a GSS client who has a mental illness experiences a deterioration in mental functioning. This generally is handled by adjusting treatment, which is almost always in the form of medications. When adjustments do not work or when the client refuses to cooperate with treatment, the client may begin behaving in ways that are disturbing to others, and very often becomes very distraught. It sometimes becomes necessary to impose therapeutic treatment that is unwanted by the client in order to resolve their distress or to protect others. Under our founding principles and laws, it is very difficult to impose unwanted medical treatment, including psychiatric treatment. This users guide is intended to set out how the laws governing mental commitment work.

For want of a better word, I refer to the person with a mental illness as "the patient".

CDMHP’S ARE THE PEOPLE TO CALL

Under the law each county maintains an office called the "County Designated Mental Health Professional" (CDMHP). It sounds like a person, but it is an office, and there are 27 CDMHP’s in King County. The CDMHP has the legal authority to detain someone for up to 3 days if there is sufficient cause.

To get the CDMHP  click here to look up the number Crisis Lines Statewide.

CALL WHEN THERE IS DANGER TO SELF OR OTHERS

The CDMHPs should be contacted whenever the patient does or seriously threatens property damage or violence to anyone else, or to harm himself, or is very disruptive. The basic rule is that histrionic behavior or threats that are not taken seriously at the time do not count. You should call every time the patient causes you to feel at actual risk for your self or your property. It is very important that you call immediately. The CDMHP's correctly reason that you must not have felt too threatened if you did nothing for a day or two. Behavior that is simply strange or unsettling will not result in action.

CALL WHEN A PERSON IS UNABLE TO MEET ESSENTIAL LIFE NEEDS

A person may be committed for being "gravely disabled" if he or she is so impaired that he or she is unable to get such essentials as food or shelter. This is a very restrictive criteria. A person who is capable of getting to a homeless shelter, for example, is not gravely disabled even though homeless. A person who is unable to care for him or herself, but does accept assistance is not gravely disabled if such assistance is available. Thus a person who is unable to find food or shelter, but who is cared for by a friend or relative is not gravely disabled.

BE PERSISTENT

Most importantly, you should call the CDMHP every time there is an incident; even, if needed, multiple times in a day. Persistence in this regard is very difficult and frustrating, but is very necessary. The way the process works in the real world, a person is seldom detained by the CDMHP the first or second time there is an incident. It is very easy to assume that the CDMHP will never do anything. This is not the case. In practice, most people who are detained have had a number of recent contacts with the CDMHP. Thus, you should not waste the CDMHP’s time with insubstantial reports, but you should make a report every time there is a serious incident.

ACCEPT THEIR SYSTEM

The CDMHP does keep careful track of referrals. All of their calls are logged into a central computer. It is very common that you will not talk consistently to the same person, but for the most part the workers are pretty skilled at identifying what is going on. If you know that there have been previous calls tell the person you speak with that there is an "open case". That is the term they use.

The way the commitment process works is frustrating and sometimes aggravating. It is natural to feel like taking your frustration out on the CDMHP’s, who may appear to be indifferent or irrational. These are people working in a very difficult system in which the best interests of very sick people are not the priority: legal rights are the priority. They are there every day and do not necessarily display the same emotion that may seem to a novice to be appropriate. It does no good to hector the CDMHP about how bad the system is or about his or her personal style. No matter how accurate such criticisms may be, they will probably not improve the patient’s situation. And, don’t forget that the CDMHP does not make the rules, our elected officials and their appointees do, which is to say: we do.

IN AN EMERGENCY, CALL THE POLICE

If the patient is in the process of harming himself, someone else or property; or has just done so and is on the scene call 911 first to deal with the immediate situation, and then also call the CDMHP's. Should the patient be taken away by police, be sure to point out that he has a mental illness and ask the police to contact the CDMHP. In some circumstances, the police will detain someone long enough for the CDMHP to make an assessment, or take the person to an emergency room to be evaluated by the CDMHP.

Usually when police take any action or a report they assign a "case number". Get the case number and write it down.

CALL ME

Please let me know each time you have contact with the authorities about a GSS client. Professionals who are familiar with the system are given somewhat preferred treatment, particularly when, as in the case of a guardian, the professional has resources available to provide support. My numbers are given at the top of page 1.

THE LAW

Washington has an Involuntary Treatment Act (ITA), RCW 71.05. Under the ITA a person is committable who is dangerous to self or others or is gravely disabled as a result of a mental condition can be required to accept mental health treatment. Dangerous means to cause or seriously threaten physical harm, or damage to the property of others. Gravely disabled means completely unable to acquire shelter or food or other absolute necessities; or imminently endangered by impaired judgement and lack of self control, like walking in traffic or causing cooking fires.

Under the ITA, a person who is dangerous or gravely disabled can be detained by the County Designated Mental Health Professional for up to three days. At the end of this time a hearing can be held at which the Prosecuting Attorney represents the county and at which the patient is entitled to an attorney. At this hearing, it must be shown to be more likely than not based on recent events that the patient is dangerous or gravely disabled. If the judge finds this to be the case the patient can be held in a hospital-like unit for 14 days. At the end of the 14 days, another hearing may be held at which the county must show beyond a reasonable doubt based on recent events that the patient is still dangerous or gravely disabled. If this is found to be so the patient can be committed for an additional 90 days in a mental hospital.

The law is purposely weighted in favor of a patient seeking to avoid involuntary treatment. At each stage, the attorney for the county must determine that there is sufficient evidence to justify seeking further involuntary treatment, based on the evidence and the law. It often occurs that the attorney chooses not to bring a case forward despite what seems like obvious evidence of danger or disability.

The time periods of 3 days or 14 days are often not strictly observed due to crowded court dockets or agreements to put off hearings. Facts that are to be shown must be reported by sworn testimony. Because of the way that cases are managed, the exact time of the hearing is hard to predict. The result can be considerable inconvenience to witnesses.

LOOPHOLES

Patients who are willing to accept treatment voluntarily are not subjected to involuntary proceedings. Sometimes patients who clearly meet the legal criteria to be committed are advised by counsel to enter the hospital as a voluntary patient. Sometimes, the patient stays in the hospital for a few days and then simply sings out of the hospital. If there have been no instances in which hospital staff have observed behavior justifying commitment, they will usually not interfere with the patient.

The ITA requires that if there are less restrictive alternatives to hospitalization, that this be done. As an alternative to being sent to a mental hospital, patients often agree to "less restrictive orders". These are court orders that create a probation type of arrangement under which the patient must do things like take medications as prescribed or reside in a particular place or participate in outpatient treatment or stay away from certain people. If the patient violates the requirements, they may be taken directly to the hospital. In practice, however, enforcement of the less restrictive order is often not aggressively done; and the patient is not taken in unless s/he causes a new incident.

It is well to keep in mind that these alternatives do often have the desired effect of getting people to accept treatment. The failure of such arrangements is taken into account in subsequent proceedings.

GUARDIANS

Many people, including many lawyers, assume that a court appointed guardian can have the ward "taken away" or "put in the hospital". In some states this is true, but in Washington, the law is very, very clear that a guardian may not ever cause a ward to be involuntarily detained except under the terms of the ITA. In this regard, the guardian has no special powers and is given little special treatment by the CDMHP’s.

A guardian does, however, have access to information that is ordinarily not provided. When a person has been mentally committed, everything is confidential, and family or friends are prevented from getting virtually any information. A guardian of the person ordinarily has authority to authorize disclosure of confidential information, and this includes information compiled by CHMHP’s or mental hospitals. A guardian need only transmit a copy of the letters of guardianship and a written request for information. This can be a tremendous aid to families and other professionals.

LANDLORDS

In some circumstances the behavior of a person with a mental disability affects people around him or her, and this can become a particular concern of the landlord. Problems can include property damage, unhygienic conditions, noise or other disturbances, altercations with neighbors and the like.

In a situation in which the landlord is calling family or a guardian asking for the patient to be removed, the fact is that the only mechanisms for this under Washington law are either the ITA or eviction.

Very often, landlords are willing to tolerate these problems out of concern for the well being of the patient. One hardly wants to belittle a kindness to a person with mental illness. However, there are occasions when the kindest thing a landlord can do is to evict. This situation arises when a person is very significantly impaired, but does not meet the ITA’s criteria. If a person’s thinking is so disorganized that he or she would be unable to obtain shelter, the criteria for grave disability may be met, with the result that the patient receives treatment. This should not be advocated unless the patient is legitimately in violation of the lease. If the landlord is tolerant, one should hesitate to suggest eviction.

Revised July 7, 2000

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