Mental health commitment: A Retrospective Rant

[Jackpine Radical]

Do you know how &^%$* hard it is to get someone committed? And, if you do, do you know how long it takes the hospital to turn them loose again?

I have been doing commitment and protective placement evaluations for more than 25 years, and have seen a dramatic change over time. It used to be that the courts were willing to commit people who were reasonably deemed to be mentally ill and dangerous, and, once they were committed, they were placed in hospitals where they received both pharmacological and "talk" therapy as appropriate.

In the old days, the process typically went something like this:

A person would be displaying signs of serious mental illness, and family would become concerned for that person's safety or the safety of others. They would try to bring the person in for examination and, if the person refused, they would ask the police to intervene.

The family or the cops would bring the person in to the psych hospital (or ER, if it was that type of hospital) for a 72-hour detention. Nursing staff would do an immediate assessment, and within 72 hours the person would be seen by at least 1 psychiatrist or psychologist.

If the shrink thought the person posed a danger to themself or others, a probable cause hearing would be held in front of a judge and, if probable cause was found, a 2-week observation period would be initiated during which time 2 doctoral-level shrinks would conduct examinations and give written opinions.

If they were in agreement that the person still seemed to pose a risk, a commitment trial would be held, at which the psychologists/psychiatrists would testify. The examinee would have access to a defense attorney (generally a public defender), and could get an independent examination if they wanted, paid for by the Public Defender's Office. They had a right to a jury trial, but usually didn't exercise that right because juries are usually easier to scare into a decision to commit than judges are.

The first commitment would run for 6 months, at the end of which time the examinee would either be released or the evaluation and commitment process would be repeated. Subsequent commitments were for 1 year.

Commitments are actually to the county of responsibility, not to a hospital. The county can, for example, decide that an outpatient commitment would be most appropriate.

These days, though, the whole process usually plays out somewhat differently.

Theoretically, the same process remains in place, but it usually works very differently in practice.

The person of concern will be brought in to the hospital. The county will not want to pay for care and treatment (mostly because they lack the funds to do so). A doc will examine the person within 72 hours, prescribe a medication, and declare that the person is no longer a danger to themselves or others, and will order them released. End of story.

On those rare occasions where the commitment process runs its full course, the person committed will likely spend about a week in the hospital. There will be no treatment other than medications. The county will decide that a nice, cheap outpatient commitment will do just fine. And the individual will be back out on the street with a prescription in their hand, which they will likely as not immediately discard because “They’re making me take these pills to mess with my mind.”

And of course, the mentally ill person will soon run afoul of the law, get arrested about a dozen times in the next 5 years, and begin a new career as a "habitual criminal," finally coming to rest in prison.

Now you know why we have about 10% as many psych hospital beds as we did 2 or 3 decades ago.