Court Is In Session

iStock_000001647199_SmallGood morning.

I’ve had family members call me before and ask about how to handle a pretty common situation. Their daughter or mother or husband have stopped taking their psychiatric medication, or they are drinking heavily again, or they are responding to voices or other hallucinations to the detriment of their day to day functioning. What to do? How to help?

If the family member or other person so afflicted is willing and able to go voluntarily to their local physician, counselor or mental health system, that’s a good start. Oftentimes seeing someone, ironing out any issues with adherence to a pre-existing treatment plan or getting new prescriptions written rights the ship and nothing more is needed. That is the best case scenario.

If the person gets to the facility and a clinician feels that they are not able to help on an outpatient basis, they might recommend that family take the next step and proceed to the local emergency department for further evaluation. Now, if the patient is willing to do this, no problem. If not, mental health center clinicians or other providers have the option to fill out what is usually known as Part I of a commitment form, authorizing the involuntary transport of the person to the ED. There, the ED physician and possibly a psychiatrist or telepsychiatrist gets involved and the evaluation moves forward.

Another way this can happen is that the family or other concerned person may go to the local probate court and petition for an involuntary pickup order that will force the person to be transported to the ED for the evaluation. When faced with this possibility while working in the clinics, I would almost always want the family members themselves to do this, versus someone from the mental health center, as the family usually had a much more intimate knowledge of how the patient was functioning and if an involuntary admission was likely to be needed. Oddly, even if they were worried sick about their loved ones or in some cases even being abused by them, family members would be hesitant about doing this, fearing the wrath of the detained patient or having extreme feelings of guilt about “having him put away”. With gentle encouragement, they would usually go to the court and proceed.

South Carolina utilizes two models for civil commitment, a police powers model and a parens patriae model. Both require a commitment hearing in a probate court in the county where the person is located. The police powers model allows for immediate detention, as I referred to above.

Under the police powers model, a probate judge, after receiving an affidavit from a family member or another party concerned about a person’s welfare, may issue a detention order that allows police to pick up the alleged mentally ill person and take him to a local mental health center or emergency room for evaluation, as I outlined above. After evaluation, the person may be immediately detained in a psychiatric hospital if the certain criteria are met.

There is a written affidavit sworn by a witness (the family member alluded to above is ideal in my opinion) stating their concern that the person is mentally ill and that because of that, the person is likely to cause serious harm to himself or others if not immediately hospitalized; the specific type of serious harm thought probable (what is the person likely to do if not treated); and the factual basis for this belief (what has the petitioner actually seen the person do, such as taking out a gun, loading it, and making a threat to shoot himself).

Also, certification by a licensed physician may come into play here. This written statement by the doctor must say that the person is mentally ill and that because of his mental illness, he is likely to harm himself through neglect, inability to care for himself, personal injury, or otherwise, or to harm others if not immediately hospitalized. (We take care of our own, so to speak, if they cannot take good care of themselves) The certification must contain the grounds for the opinion.

Read more about this process in the state of South Carolina, and how probate court judges play a vital role in it, here.

So, we’ve looked at several ways that a person may end up in the local emergency department. I see patients in two dozen EDs around the state. Some are very good at handling mental health emergencies and evaluations. Some are not so good.

Next, we’ll  take a look inside, pulling back the curtain of the ED bay, opening the door of the holding room and feeling just what it is like to be held against one’s will in a hustling, bustling hospital ED.

I think it might surprise you.