What is the first thing the media and politicians ask after a mass or spree killing? Did the suspect “have a history of mental illness?” Then the Monday quarterbacking begins. Everyone has a right and an opinion; yet no one has a responsibility. Unless, you are a police officer or mental health professional - then anything you do or don’t do makes you liable.
Every hour of every day law enforcement officers detain and transfer mentally ill citizens to hospitals for an evaluation related to the need to procure involuntary treatment after the subjects present as a danger to themselves or others. As an officer, your fundamental duty is to serve and protect (and try to go home every night while not making national news). You frequently respond to a dispatch call and identify a citizen as having met the criteria for an involuntary psychiatric detention; you detain and transport them to a psychiatric hospital for evaluation. Some subjects are admitted to a locked behavioral health unit; some agree to voluntary treatment, many are discharged soon after your transport. You are frequently called to the same residence related to the same suicidal woman sometimes within the same day or the same week. The homeless schizophrenic screaming and jumping at cars, who was treated and released, has moved a block south and is repeating his MO; nothing has changed. Do you reattempt an involuntary hospitalization? Things have gotten worse, but you wonder why waste any more time or effort, hospital staff will just discharge him again, probably while you are eating dinner. There is a sense of severe frustration and futility. Has the mental health system failed again? Sure it has. Are there other factors that the hospital should consider about this character? Yes; but they may not have the resources or the support either. Is there a more effective way for you to write an involuntary hold? Probably. Is the whole system broken? I believe it is.
It is often a double bind situation. To protect the subject, the community, yourself and your department, you have a responsibility to take any individual who presents as a risk for harming themselves or others into a hospital for a psychiatric evaluation. If you fail to act, and something happens, you are liable. The psychiatrist and the hospital, on the other hand, cannot take someone’s civil liberties by an involuntary commitment without concrete probable cause that this person is a risk to self/others or they face liability. Most states also have provisions for the mentally ill client who is unable to meet their basic life needs for food, shelter and clothing.
Take a few minutes to educate yourself on how to present your involuntary commitment case to the emergency department‘s psychiatric staff. Your hold is the documentation they can use to support an involuntary detention as well as for the possible application for conservatorship. Think of writing the hold the same way you would write a crime report that you really want the DA to take action on. Think probable cause while you build your involuntary commitment case. PC includes a belief or strong suspicion that the mentally ill subject is a danger to self or others, and that this belief is related to specific and articulable facts. Quotations by the client should be used (“I can’t live another day in this kind of pain.” “The voice tells me that I need to kill my mother.”). Does the subject have access to weapons? Have they had numerous attempted suicides? Describe how you got the call and the situation once you arrived on scene. Describe the person’s behavior and appearance. Did the person attempt to assault you, someone else? Put all significant information in your hold. Take photographs of the living situation or self inflicted injuries and attach them to your hold as well. Bring a copy of the suicide note or a bizarre threatening letter to the hospital with you. Let the ED staff know that you can also provide them a copy of the 911-dispatch radio call. Check your state laws; per California laws, the law enforcement officer:
“shall consider available relevant information about the historical course of the person's mental disorder if the authorized person determines that the information has a reasonable bearing on the determination as to whether the person is a danger to others, or to himself or herself, or is gravely disabled as a result of the mental disorder.”
In other words, do use reliable third party documentation to support the psychiatric hold. Did the individual tell his/her doctor or therapist something that sent up a red flag? Did the statement indicate imminency? Use the reporting party’s information, their name and even their phone number in your hold. What are the family and neighbors saying? Was the subject chasing others, brandishing a weapon while making delusional statements? Quote them by name and relationship in your hold. If any party is misrepresenting the subject’s statements, behaviors or the situation to you or to the hospital, they can be held liable for any statements they know to be false; not you.
In general, most states have provisions for grave disability, although different terminology may be employed. Gravely disabled relates to a condition in which a person, as result of a mental illness (rather than a chosen life style or lack of funds) is unable to provide for his or her basic personal needs for food, clothing or shelter. Law enforcement officers writing involuntary psychiatric holds tend to grossly under-use these criterion. When a person meets the criteria for grave disability, they are usually kept by the psychiatric facility for a longer evaluation time, and more comprehensive dispositional plans are made prior to discharge. Whereas when the individual is no longer suicidal or homicidal and he/she must be released, the facility’s staff has to make sure that a treatment plan is in place for a gravely disabled mentally ill client to provide for his/her basic needs.
In order to support a finding of "grave disability," the person must presently be unable to provide for food, clothing and shelter due to a mental illness to the extent that the failure to do so results in physical danger or harm to the person. Mental retardation, developmental disabilities, alcoholism, drug abuse, or repeated antisocial behavior do not constitute grave disability criterion. Homelessness in and of itself does not constitute mental illness either. An involuntary commitment cannot be based on these reasons alone. If someone is gravely disabled for a longer period of time, they may be placed on a conservatorship.
The following are examples of states or conditions that have been upheld as evidence of grave disability. These examples go beyond the basic definition relating to food, clothing, and shelter. There is a variety of ways to articulate that a person is currently gravely disabled due to a mental illness. Use supplement pages to add anything that is pertinent and appropriative.
Need for food
- Cannot distinguish between food and non-food.
- Endangers health by gross negligence in needed diet and nutrition.
- Begging or stealing food.
- Eating out of refuse or garbage cans.
- Ordering meals at restaurants without having funds.
- Demonstrates excessive and consistent food preferences or aversions which endanger health. (Except for genuine religious reasons).
- Having spoiled food in refrigerator or no food for a lengthy period of time in the house.
Need for clothing
- Engaging in public nudity or "unthinking" exhibitionism.
- Engaging in bizarre style of dressing that does would be apt to lead to social difficulties.
- Wearing filthy or soiled clothes with lack of recognition of personal hygiene problem.
- Wearing disheveled clothes for prolonged period of time.
Need for shelter
- Leading a nomadic existence with an inability to establish stable community living, including living in the streets or other public places.
- Unable to locate housing and make the appropriate arrangements with an inability to ask for or accept assistance in doing so.
- Unable to manage his or her household in such a way as to avoid clear dangers to health.
- Presence in household of filthy conditions) fire hazards that the person cannot correct, vermin infestations, and lack of bathing and toilet facilities.
- Resists leaving residence even if evicted or the residence is sold.
- Hoarding nonsensical items while misplacing necessary items.
Financial incompetence
- Unable to earn an income and unable to avail himself of financial assistance from public or private agencies.
- Completely dependent on family or friends to provide financial assistance for basic personal needs.
- Has funds but no longer knows or understands the location and/or extent of them.
- Refusing to expend funds to the extent of endangering personal health and/or safety.
- Has no funds and does not see this as a problem.
- Grossly and inappropriately expends funds needed for basic personal needs.
- Have untrue beliefs as to having extensive money or property.
- Mismanages funds so that rent and utility bills remain unpaid.
- Inability or loss of ability to understand complex financial matters leaving the subject vulnerable to manipulation by unscrupulous individuals.
Incompetence in regard to health
- Unable or unwilling to follow medical instruction regarding treatment and self-care which are essential to health.
- Loss of weight or other evidence of malnutrition due to not eating or lack of proper food.
- Wanders away from residence and becomes lost frequently without recognition of the seriousness of the problem.
- Failure to adjust in the community.
- Involved in frequent confrontations with family members or neighbors involving abusive, threatening, or assaultive behavior.
- Engages frequently in disruptive, destructive acts in the home or neighborhood, possibly leading to threatened or actual eviction.
- Engages in bizarre or other behavior which may be self-endangering and/or a threat to others requiring police intervention.
Pamela Kulbarsh
Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.
