The events necessary to trigger most treatment laws are among the most trying and stressful imaginable.
Although the language differs from state to state, many state laws, or interpretations of those laws, require someone to be in danger of physical harm to themself or others before being placed in treatment. Being forced to wait until someone is incapacitated by a severe mental illness and presents an imminent danger often leaves families and treatment providers waiting for an extreme crisis before they can act. As too many family members know, that is a situation full of worry and pressure.
When a crisis does arise, family members must react minute-by-minute to a deluge of circumstances. It is not a time for efficient thought or strategizing, which is why preparation is critical. Now is the time to do research, gather materials, and reach out to key people in case the situation deteriorates, even while working on other fronts to avoid a crisis.
Information is power. The more you know - about the law, the options, and the people you might work with in a crisis - the more effectively you will be able to navigate through the system if such a crisis occurs. To start, get the answers to some basic questions.
What is your state’s commitment law? Know your state’s standard for intervention and familiarize yourself with its provisions for commitments. The statutes for each state are in the Legal Resources section at . Your state/local mental health departments should also have materials summarizing the standards. In the 45 jurisdictions that allow direct petitioning for commitments, the clerk at the local court should have copies of the petition form. Gather printed copies of the criteria for emergency evaluation and civil commitment.
What is the local landscape for treatment? One place to start is with your local chapter of NAMI (the National Alliance for the Mentally Ill). NAMI is a support and advocacy organization for people with psychiatric disorders and their families. Local chapters have biweekly or monthly support meetings; leaders are usually willing to advise on the local treatment system and procedures. Find your chapter via the national hotline at 1-800-950-NAMI (6264).
Also call the courthouse and ask the clerk of the court about the procedures for filing an involuntary commitment petition in your county. Different jurisdictions have different procedures, so always call the county where your loved one lives, not the one where you live (if they are different).
Which screening facility or local emergency room performs emergency psychiatric evaluations? Find out which facility your loved one would likely be transported to in a crisis. Contact them and ask about the process when someone is brought in. What is involved in getting someone committed? And what, if any, resources do they have to help avert crises? (Few facilities have such programs, but it is worth asking.)
What is the process to initiate placement? The process to initiate placement of someone incapacitated by a psychiatric disorder varies from state to state. A law enforcement officer can take a person deemed to meet the state’s “pick-up” standard to a psychiatric facility for an evaluation, although a few states require that the officer first receive authorization from a judge or magistrate. In some states, physicians or other medical personnel can temporarily prohibit the release of a voluntary inpatient or call for an emergency evaluation without prior court approval.
Many states also allow other individuals to directly petition a court to order an evaluation, sometimes defined as “any person,” “interested persons,” family members, or designated mental health department employees.
What is the duration of evaluation? Regardless of the manner in which evaluations arise, almost every state limits duration. Providers must usually decide within 72 hours either that the person continues to meet the placement criteria (so pursue a formal commitment) or that they should be released.
Build a Care Kit
In a three-ring binder, file box, or other easily-transportable storage system, create a CARE kit (Critical Advocacy Resources for Emergencies). A CARE kit is a “ready-file” of materials that you can quickly share with treatment professionals in a crisis.
Psychiatric history summary. It is unlikely that treating professionals will have immediate access to, or time to review, the full medical records of someone brought in for an emergency evaluation. A one-page summary of psychiatric history can be very useful. (And may also be useful as evidence in commitment hearings.) Keep at least five copies of this important document in your CARE kit, so it can be easily and quickly shared with more than one person in a short span of time. Keep it current (update it regularly) and short (one page is best) but be sure it contains the most critical information, including the following.
Age at diagnosis
Town or city of residence
Current concerns (suicidal, homeless, missing, vulnerable, violent, abusing substances, other)
Psychiatrist’s name and number
Local service provider’s name and provider
Dates of previous hospitalizations and locations
Dates of previous arrests or jailings and charge(s)
Current medication name(s)
Past medication(s) that have helped
Past medication(s) that have not helped
Past history of symptomatic behaviors (e.g., running up huge debt, getting into car accidents, threatening family members, failing to care for basic needs)
Full name, contact numbers, and address for emergency contact person
Recent picture and description. Keep a recent picture of your loved one, a list of vital statistics (such as height, age, weight, hair color), and any pertinent physical medical conditions (such as allergies or diabetes). Ideally, keep these in a format that allows them to be easily faxed or e-mailed to police and mental health agencies. Leave space to add a description of clothing last worn in case that information is needed.
List of emergency numbers. Create, and periodically update, a list of emergency numbers.
Copies of important criteria. Print out a copy of your state’s criteria for emergency evaluations and for civil commitments (as mentioned in the “research” section). That way if anyone along the way contradicts or misunderstands the law, you have a copy of it in hand.
Petition forms. Get blank copies of involuntary commitment forms if your state permits this. Complete any nonincident-related information ahead of time. You may never have to use them, but at least you will have them ready.
Medical release (if applicable). If possible, have your loved one sign a
release that allows you access to his or her medical information. If you have such a document, keep a copy in your CARE kit.
Advance directive (if applicable). Advance directives are legal documents that allow individuals with mental illnesses to dictate aspects of their care in case they become incapacitated by illness. These documents might include the designation of a person to make treatment decisions should the subject become incapacitated. The specific details of these legal documents vary widely from state to state. Most advance directives are immediately revocable, which is a significant limitation on the effectiveness of these instruments as that can allow individuals to nullify their previous treatment decisions even when suffering from impaired judgment. If your loved one has such a directive, keep a copy in the CARE kit.
Alert your local mental health crisis unit. These outreach workers typically conduct on site evaluations and often are empowered to initiate commitments. They are also likely to be called by law enforcement to assist in crises involving an individual with a psychiatric disorder.
Reach out to your crisis unit. Ask to speak to or meet with the supervisor or director. In that short meeting, in person or via phone, ask for information about the process involved in a commitment, and what would happen to your loved one if he/she arrived at the unit for an involuntary commitment. Get the appropriate contact information for your CARE kit and ask if you can or should provide some information about your loved one for their files. And ask for a tour of the facilities.
If you think a crisis is imminent, alert the unit that you suspect that your family member is on the verge of meeting commitment criteria. Fax over or drop off a copy of your one-page history form for their records. If your state is one of the 42 that offers assisted outpatient treatment (AOT), ask about the steps needed to ensure that AOT can be used on discharge.
Alert your local law enforcement agency. Make your local law enforcement agency aware of the person’s condition in case officers are called to initiate an emergency evaluation or respond to a disturbance. Eliminating the element of surprise can help reduce the risk of a call escalating into a crisis.
Reach out to the crisis intervention team (CIT) coordinator, if your community has CIT, or to the commander for your precinct/district. Or ask for an officer who has expressed interest in or knows about mental health issues. It is also often helpful to talk to the 911 supervisor (reach them through the general office number of course, not via 911 itself).
The message to convey is that your loved one has a severe mental illness that might make encounters difficult. Explain specifically, if you can, what happens when the person is symptomatic or delusional - for instance, that he hears voices and cannot easily follow verbal instructions so he may appear to be disregarding officer orders. Or that she has delusions that police officers are aliens and may be unreasonably afraid and unable to comply with commands.
If there is a particular officer or sheriff’s deputy who patrols the area regularly, invite that officer and any local CIT officer to come by to meet your family member when they are well. This can help build some rapport and trust for all involved.
Finally, as with the mental health facility, do not wait for a full-blown crisis before calling law enforcement. If you anticipate an imminent crisis, alert them so they are not caught off guard.
Fighting for Treatment
Those who are the most severely ill often cannot get the services that they need. If you face obstacles advocating for needed services for someone you care about, you may want to try some of the following strategies.
What treatment options are available? A person seeking the best possible care for a person suffering from a severe mental illness must first research what treatment options are available. The best and most obvious place to turn is to the professionals presently managing the person’s care, but that is only the beginning of a thorough investigation. The leaders and staff of local NAMI affiliates will not only be familiar with service options, but may offer a better “real world” assessment of what is available than employees of mental health departments, hospitals, or private community providers. Another basic resource is state or local mental health administrators.
What are the eligibility criteria? Most specialized services (such as PACT or ACT teams) are reserved for specific populations. Those advocating for a particular service must also learn the eligibility criteria for these programs.
Does your loved one meet the criteria? Don’t assume the answer is “no.” Ask for written policies governing eligibility. Use the person’s treatment history (for example, repeat hospitalizations) to establish whether they are eligible for those services.
Never accept a first answer, and know what questions to ask. For example, does the community have intensive case managers, intensive family support services, and residential support services? Visit the local mental health center or mental health service providers and request a tour.
What are the financial incentives to treatment? There is often a financial disincentive for providers to serve those who are most acutely ill - they may require intensive and expensive treatment. One way to counteract this is to document what it costs not to provide those services. For a person who is repeatedly hospitalized, multiply the cost per day by the total number of days. A state or county mental health administrator may appreciate that providing the needed community services or additional inpatient days to more fully stabilize the person’s condition will be less expensive in the long run. Law enforcement may respond to the costs of repeated jailing someone.
Maintain detailed records
For long term use, there are materials in addition to those in your CARE kit that will be useful in dealing with caregivers and providers, whether in an outreach team, outpatient clinic, inpatient facility, or a jail or prison.
Fully documented medical history. Remember that patients have the right to request copies of their own medical records, which can be compiled and saved for future use. Any information/records that can be gathered along the way should be saved in a central file, including the names, addresses, and phone numbers of all previous or current treatment providers. The basic one-page summary is still important to maintain and share - the full history supports more indepth advocacy.
Informal incidences journal. Keep a journal that regularly documents the person’s illness, medications and reactions to or side effects of medications, and any significant/related symptoms or problems. Journal entries should concentrate on observable facts, and use action words. They should be descriptive (not “we had a fight” but “he picked up a heavy frying pan and waved it at my head”). Being able to provide specific dates and detailed descriptions of events is a substantial advantage for someone testifying in a treatment hearing or trying to convince a treating professional of the severity of a person’s illness.
Fight for the best care
Whether the person is in an inpatient facility or needs psychiatric care in the community, it can be frustratingly difficult to obtain appropriate mental health services from often unresponsive mental health care systems. However, a persistent family member or friend can secure action from these bureaucracies.
Be an advocate first. Building relationships with a service provider and letting them see how much you care about your loved one is vital and demonstrates your value as a member of the treatment team. But don’t get too cozy. It is more important to be an advocate than to be friends with service providers and mental health officials. Feel free to disagree with politeness and persistence when cooperation is not possible. It sometimes may even be necessary to go over someone’s head.
Don’t be stymied by medical privacy laws. Sometimes treatment providers raise concerns about breaching confidentiality as a reason not to talk to someone trying to help another person who is receiving or in need of treatment. Sometimes confidentiality is used inappropriately. Remember that listening is not against the law. Even if treatment providers cannot tell you about someone’s condition or treatment, no privacy law prohibits them from taking information concerning a patient’s condition and psychiatric history. In fact, some would argue that a mental health professional is negligent if they fail to gain as much information about the person’s condition as possible. If nothing else, you may establish a relationship that could at some point be invaluable. (Read a detailed overview of medical privacy laws and some tips on navigating them.)
Call the department of mental health. Call the county department of mental health and explain that you are having a “service delivery problem.” Keep a record of who you talk to at the county level, and try to get in writing whatever information they give you. Make sure you write down exactly what they say. Note the dates of conversations and any actions promised. If you are still not getting a satisfactory answer, follow the same steps with the state department of mental health.
Work your way to the top. Jails, hospitals, and treatment facilities have established chains of command. Work your way up the chain until you get results. For example, the chain of command in an inpatient setting may start with a social worker. From there, contact a nurse, psychologist, or psychiatrist. Next, ask for a treatment team leader or section chief. If those attempts fail, contact the hospital administrator. Every county and state has its own methods for handling grievances, so you need to find out what these procedures are.
Most organizations have oversight from a Board of Directors or Trustees. The identity of board members is a matter of public record. Write them a short letter documenting the problems and lack of responsiveness. The board has a fiduciary responsibility to ensure that the organization’s mission is met and will likely investigate and address your complaints. For publicly funded services, you can work your way up from the director of mental health services to the very top. We have seen well-documented cases get a Governor’s attention - and results.
Keep track of everything. Get the name of everyone you talk to, and their supervisor. Document each attempted contact or conversation by email or fax, which will also politely make it known that you are creating a paper trail that can later be reviewed by supervisors or even in court. If you have to, send a certified letter or even a telegram to the commissioner of mental health in your state highlighting your concerns, detailing your conversations with other county and state staff, and requesting an immediate response. (Once a common way to deliver urgent messages, telegrams are rarely used today because there are faster means of delivering messages. Because they are less common, they definitely get people’s attention.)
Hire an expert. If you can afford it, an expert can be a huge help. Different situations call for different experts. For instance, care providers may react more readily to second opinions from fellow treatment professionals while hospital and community service administers are often more responsive to contacts from attorneys. Getting help in a jail or correctional facility can be easier with the assistance of a correctional expert.
Get help from law enforcement. If the person you are trying to help has repeated contacts with law enforcement, you may be able to get a sheriff or police chief to intervene. Help them understand that getting treatment for your loved one is in everyone’s best interest - not only would appropriate treatment benefit the person, it could help avert a tragedy and remove the burden on local law enforcement created by the person’s symptomatic actions. A call from a sheriff or police chief can be very influential in prioritizing services for someone you care about.
Get the media interested. Television and newspaper reporters cannot cover every story they hear about. But if your situation is particularly egregious, heart wrenching, or representative of a systemic problem, your local media outlet might be interested. Find contact information on their website and focus on a reporter who is in your community, especially if they have covered mental illness or crime issues before. When you call, summarize your story in one sentence and keep your comments focused on one main issue (such as treatment, insight, or criminalization). Picture the headline that you want to see and make that your theme. (“Man jailed for tenth time in five years because the law can’t help him: Mother demands answers.”) If an article is printed that is useful to you, email, fax, and mail copies to those you are trying to influence. Don’t forget to send copies - with a personal note - to your legislator and governor.