Involuntary commitment

Throughout the years I worked in the Alabama and South Carolina mental health systems, one of my responsibilities was to serve as a Designated Examiner (DE) in the Probate Court. Both states reviewed my clinical qualifications and certified me to examine people and give testimony in the Probate Court as to whether they met the legal criteria to be involuntarily committed to a psychiatric hospital. This commitment process was established nationwide to safeguard the rights of mentally ill persons, insuring that they couldn’t be “railroaded” into involuntary treatment, without due process. With only a few exceptions that I’ve witnessed over the years, the system worked.

You’ve probably heard the term “certifiably mentally ill.” Well, I was a certified certifier.  In most (all?) states a person that someone has petitioned the court to assess for possible involuntary commitment has to be independently interviewed by two DEs, one of whom has to be an MD. The two criteria were that the person had a diagnosable mental illness (based on the judgment of the DEs) and that he presented a credible threat of harm to self or others. Both DEs had to agree that the criteria had been met, in order for the person they’d examined to be deprived of their liberty. That person couldn’t be hospitalized indefinitely, but had to be re-certified at specified intervals.

The commitment process went like this: someone – usually a family member or medical professional or  law enforcement officer – had to petition the court for a hearing. Both DEs independently interviewed the individual, wrote reports on their findings, and made a recommendation for or against involuntary commitment. If both DEs agreed that that the person met the criteria for commitment, a Probate Court hearing was held. The hearing was recorded so that there would be a transcript, and if the person didn’t have his own attorney present, they were represented by a court-appointed attorney. Sometimes the person agreed that he needed hospitalization and the hearing was just a formality; but if he disagreed, the lawyer made sure that his point-of-view was represented in testimony.

Once the voice recorder was turned on, the court was declared to be in session and both DEs were sworn in. After they read their reports and recommendations, the attorney could consult with her client and ask follow-up questions, or have the client speak for himself. After hearing all the testimony, the Probate Judge could either dismiss the petition or order the person to be involuntarily committed. If both DEs had recommended commitment, the judge almost always went along with their recommendations.

The deprivation of liberty is no small matter, and the Probate Court hearing is an important safeguard, to insure that the commitment laws aren’t abused. Many people with severe, chronic mental illnesses have gone through the process multiple times and accept that they’re going to spend some time in the hospital. A few physically resist and have to be sedated. Yet others resist treatment in  a variety of ways, once they get on their assigned ward.

I spent the last nine years of my career as a treatment team psychologist on a locked ward at South Carolina’s largest psychiatric hospital, and had to deal with every kind of resistance imaginable. Some patients reasoned incorrectly that their refusal to speak or answer questions in treatment team would somehow shorten their stay. I remember an instance when I recognized an intelligent young man ( I’ll call him John) who’d been assigned to the treatment team I served on during a previous commitment, years earlier. At his treatment team initial assessment he was surly, but at least minimally cooperative. I asked if he remembered me, and he said he did. “You’re the one who told me that it’s impossible not to communicate.” I’m pretty sure I smiled at him, recalling our first encounter.

It had been John’s first commitment, and he must have reasoned that giving the treatment team the Silent Treatment (or elective mutism, as we call it) would lead to an early discharge. We’d tried to get him to open up, but he’d refused to answer a single question. So I said something like this: “John, it’s impossible not to communicate, and even though you’re not speaking, you’re communicating right now. What you’re communicating is, ‘You can’t make me talk,’ and you’re absolutely right. We can’t. We know you don’t want to be here, but we can’t discharge you until we know what’s going on with you, and that you’re safe.

“Let me tell you one thing that everybody on this team has in common with you. None of us wants you to stay here even one day longer than you have to. We plan for discharge from Day One. The best thing you can do to shorten your stay is to let us know what you think is going on. Work with us and I promise we’ll get you back home as fast as we can.” My intervention worked and John started answering our questions.

Sometimes people are so angry about their commitment that they get violent, so all employees who have contact with patients are trained to work with other staff to take down combative patients without anyone coming to harm. However most patients on locked wards understand that violent acts would be evidence of the “harm to others” criterion of commitment, and try to control their tempers.



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