Involuntary Treatment Act: Part 2

The intent of the ITA (Involuntary Treatment Act, Washington State, RCW 71.05) posts is to present information about the process very few folks have access to. Part 1 presents a conceptual overview of involuntary treatment. Part 2 presents an outline of the details of the evaluation and detainment process. Part 3 presents some other factors to be aware of.

Disclaimer: This is only general information. It is not advice, consultation or recommendations. Please contact your local community professional, crisis services or law enforcement if you need help, consultation or services.

The link to Part 1 https://lovechangegrow.com/involuntary-treatment-act-part-1/

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Tim

ITA Evaluation and Detainment Process

NOTES:

4 Phases + Court Hearing of the Involuntary Detention Process and Commitment

1. Referral: Complaints and collection of concerns.
2. Investigation/Evaluation: Rights, active, interrogation, temporary custody.
3. Decision to Detain: Casual Nexus requires 5 pieces of evidence.
4. Disposition: Where, when and how logistical details. Availability, access, medical clearance, i.e., negotiation. Discussion of needs of the patient vs capacity and capability/resources of the psychiatric unit.
5. Judicial Process of Commitment (Hearing): See ITA Options below.

Diagnosis vs Mental Disorder? The diagnosis is the identification of the illness which is usually done by a psychologist (Ph.D.) or by a psychiatrist (M.D. ). Verses the “mental disorder” is descriptive; based on the signs and symptoms via the “Mental Status Exam.” Or another way to view this; diagnosis is a speculative conclusion based on the data. And the “mental disorder” is the data (signs and symptoms) that leads toward the speculative conclusion (diagnosis). This seems like splitting hairs, but it is an important distinction in court when testifying, being cross-examined and the creditability of a witness.

Mental Status Exam (MSE)

Identification: Name, age, race, sex, gender, marital status, employment, situation, referred by and the presenting problem.

Appearance: Posture, bearing, clothing, grooming, attitude, manner, degree of anxiety.

Behavior and Psychomotor Activity: Mannerisms, tics, gestures, twitches, stereotypic behavior, echopraxia, hyperactivity, agitation, combative, rigidity, flexibility, gait, ability, calm, relaxed, posturing, ritualized, catatonic, anxious, panic/vigilant, restless.

Attitude: Cooperative, friendly, attentive, interested, frank, seductive, defensive, hostile, irritable, ingratiating, evasive, guarded, giddy, playful, gamey, negotiating.

Speech: Rapid, slow, pressured, hesitant, latency, demonstrative, garrulous, unspontaneous, monotonous, loud, whispered, slurred, mumbled, stuttering, echolalia, mute, soft, poverty of speech, poverty of content.

Mood (climate): Statement, depth, intensity, duration/onset/acute/chronic/situation, and fluctuations, swings… depressed, anhedonia, dysthymic, WNL­, euthymic, euphoric, expansive, mania; grief/mourning, irritable,

ANXIETY: Apprehensive/anticipatory, free-floating/pervasive/unfocused, fear, agitation, tension, panic/overwhelmed, apathy, ambivalence.

Affect (weather): Range/ constricted, intensity/ blunted, appropriate, labile, flat, shallow… proud, angry, fearful, anxious, guilty, euphoric, expansive, grieving, anxious, tearful, calm, vigilant, embarrassed, ashamed

Perception: Perceptual distortion, hallucinations, type/sensory, depersonalization, derealization.

Thought Process: Overabundance/paucity, poverty, rapid/pressured, flight of ideas, ideas of reference, slow, hesitant, continuity/tangential, goal/circumstantial/rambling, blocking, perseveration, condensation, derailment, distractible, loosening associations, evasive, irrelevant, illogical, incoherent, incomprehensible, magical, concrete, abstract, clang association, neologisms, neurotic, psychotic, autistic reality testing, glossolalia speaking in tongues. Be aware of and eliminate conditions of Dementia or Delirium.

Thought Content: Preoccupations, obsessions, compulsions, phobias, delusions/type/grandiose, paranoid, bizarre, persecutory, noesis/chosen, ideas of reference, thought broadcasting, insertion, disorganized/concrete/abstract, overvalued, mood congruent/incongruent delusions, ruminating

Sensorium and Cognition:

Consciousness/alert, fluctuations, attention/focus/sustain/shift, disoriented, clouded, stupor, delirium, coma, twilight w/ hallucination, dreamlike state, somnolence.

Orientation/date, time, place, situation, names/roles

Attention/distractible, selective, preoccupied, avoidant, hypervigilant.

Concentration and Cognition/performance of task (math/spelling)… anxiety, mood, consciousness

Memory/immediate, recent, remote, amnesia, confabulation, hypermnesia/exaggerated retention and recall, eidetic images/ visual memories

Information and Intelligence/abstract, concrete, fund, similarities, education/vocation/socioeconomic

Conative: Goal directed, purposeful, impulsive, motivations, wishes, drives, instincts, cravings, compulsion, ritualistic/anxiety reducing

Judgment: Safety, consequences, influences, resources, critical, automatic, impaired/diminished

Insight: Awareness/understanding of illness, responsibility… acknowledge/adaptive/coping, denial, blame, evasive, intellectual/emotional, access to resources/refusal of TX resources.

Lethality: Gravely disabled, suicidal: compulsive, ritualistic/anxiety reducing, magical, tension­stress relief, grounding, hx, plan, intent, homicidal, ideation, intent, hx, plan,

Drug/ETOH type… intox/abuse/hx, type, frequency, first/last use, Delirium/sensorium, visual hallucinations, intox/withdrawal

Also consider if appropriate: Mini Status Exam, Alcohol Intoxication/detox/withdraw scale, opiate withdraw scale, pain assessment.

Clinical: (Link to https://lovechangegrow.com/diagnosis-clinical-formulation-and-treatment/)

What is the clinical/psychiatric presentation?

The clinical formulation: Why is this happening?

Match the appropriate clinical/psychiatric intervention meet the need to stabilize and ensure the client’s health and safety.

Clinical Treatment and Rationale:

The clinical/medical problem (i.e., organic, neurological, substance intoxication/abuse, personality disordered, behavioral, environmental, family, criminal, placement/containment, etc.) and is it best treated in an inpatient psychiatric unit? 

• Clinically appropriate treatment,
• Necessary and least restrictive treatment. Either outpatient or inpatient AND voluntarily or involuntarily. In relation to the concept of “legal less restrictive.”
• And is in the above treatment in the best interest of the client.

(Who is the client? The individual, family, community?).

***Causal Nexus: 5 Pieces of Evidence are Required for Emergency Detainment***

1. Complaint: Clear line of evidence via collateral reports/affidavits, e.g., police reasonable fear for danger to others, Medics/physicians, i.e., medical life threatening, affidavits of mental disorder and resulting dangerousness

Reasonable Cause for law enforcement/ITA officer for temporary detention pending an ITA evaluation vs. Probable Cause for a ITA officer to detain for 120 hours.

Custody Authorizations—reasonable attempts at face to face, rights/time frames, and unlawful imprisonment.

2 Mental Illness: MSE…signs and symptoms describing a “mental disorder…substantial adverse effects on an individual’s cognitive or volitional functions”

3 Dangerousness: “as a result of a mental disorder.” There are 5 clauses/conditions.

Likelihood of serious harm: Evidenced by threats or attempts or behavior;

• i) danger to self; self-harm, suicidal, or via grave disability.
• ii) danger to others; Active/assaultive behaviors. And/or current threats of physical danger to specifically identified others and a history of one or more violent acts.
• iii) danger to other’s property; damage has occurred.
• Grave disability: (passive/neglectful, i.e., a condition or state). Can be either Non-imminent/not-immediate but concerning and reasonably predictable. Versus imminent; immediate acute condition or state).
  • Danger of serious physical harm resulting from their failure to provide (or they refuse offered treatment) essential human needs of health or safety. (***Sometimes there is the event that a party withdraws support that had ensured the client’s health and safety. Thus a discussion and documentation of why the the withdrawal of support has happened. Often there are issues of capability, capacity, duty, relationship and occasionally in the context of negligence or abandonment that then creates/results the grave disability condition for the client.)
  • Manifest severe deterioration in routine functioning evidenced by repeated and escalating loss of cognitive and volitional control over actions and is not receiving essential care essential for health or safety.

4 Imminence

• Time frames 24­/48 hours: Past, i.e., reports/statements or recent behavior vs. Future­, i.e., threats, intent, plans & means and perhaps past behaviors.
• Probability: Likelihood = 51+%; Light vs Heavy cases. Preponderance = 70%; Clear, Cogent, and Convincing 85%.

5 Lessor Restrictive

In the sense of legal liabilities; not physical containment or restriction. But to avoid increased legal liabilities for the client.

Criminal law take precedence over civil MH law.

Based on the patient’s behavior of having been offered and refused, unable to consent or agree; or there is “poor faith voluntary,” i.e., recent failed less restrictive alternatives.

Legal Issues

• RCW’s 71.05­ Adult, 71.34­ Minor, 10.77­ Criminal, 70.96­ Drug and alcohol (was rolled into the adult MH law of RCW.71.05).
• Presumption of Voluntary Status verses evidence of “poor faith” or unable to consent.
• Client’s in/ability, or “poor faith” verses MH Provider’s good faith attempts to offer/provide services.
• Legal Lesser Restrictive….legal liabilities for the client.
• Police welfare checks vs. Police’s “reasonable cause” vs ITA officer’s “custody Authorization” vs concepts of “unlawful, detainment/imprisonment.”
• Petitions are a request for a hearing vs Orders are the results of hearings.

Evidence

• Opinion and Speculation
• Hearsay and Conclusions
• Observable Behavior and Client’s Statements
• Collaborative Evidence, e.g., Police Reports, Medic Reports, Labs and etc. and “clear line of evidence”
• Evidence (recent overt/observed acts, statements and self-­admissions)
• Danger to Others; “reasonable fear,” who and how was that demonstrated; did they make a police report and are they willing to testify?
• Affidavits (sworn statements), discovery and willing to testify?
• Weight of Evidence:
• Likelihood @ 51% used retrospectively at Probable Cause
• Preponderance @ 60­-70% used at the 14 Day Hearing
• Clear, cogent, and convincing @ 70-­85% used at the 90/180 Day
• ***use Mental Status Exam descriptors of behaviors and client’s statements

ITA Options per RCW 71.05

Summons, Affidavits of complaint, with required or demonstrated attempts face-to-face evaluation, reviewed by prosecutor and petition/request of a Judicial Review that results with an Order for a person to appear for evaluation by an ITA officer.

—Non Emergent Order; face-to-face contact, No Imminence…No Emergency Custody, with Judicial Review ordering an:

Outpatient… for evaluation by an outpatient psychiatrist. Or Inpatient evaluation at an inpatient psych unit.

—Initial Emergency Detainment 120 hour Emergency Custody Probable Cause Hearing; due process & likelihood 51%.

—14 Day Petition Hearings; 2 parts of the hearing. The reasonable cause for the initial detainment. The 2^nd part is the need for commitment based on preponderance 70%.

There are four basic options: 1) Released. Or 2) agrees to Sign in Voluntary. 3) 14 Day More Restrictive Order for treatment at the inpatient unit. Or 4) agrees to a 90/180 Less Restrictive Order for outpatient treatment.

—90 or 180 Day Hearings; Court Order; clear, cogent, convincing 85%. MRO; Inpatient treatment unit. LRO Outpatient treatment at where and who provides Tx?

—Detention for Revocation outpatient vs inpatient treatment.

• May (violation/deterioration) verses Shall (increased likelihood of harm).
• Outpatient…Noncustodial notice & service of Revocation, i.e., to be see the outpatient treatment team.
• Emergency Custody in as inpatient for up to 5 Days. Then a revocation hearing occurs, where a there is a modification of the order (LRO) with release from the hospital. Or the client is ordered (MRO) to inpatient hospitalization for up to the remainder of the order.

—Revocation Hearing; evidentiary phase and dispositional phase MRO Inpatient or LRO; Outpatient and/or LRO Modification Additional 90 or 180 Day Court Order Extensions

***Court Orders reflect the where the client is, i.e., in (MRO) inpatient vs. out (LRO) outpatient.