Involuntary Treatment Act, Part 3: Odds and Ends

ITA Part 3 is a brief discussion of the other bits of this odd job. The difficulty is much of these other pieces are invisible to those unaware of the detainment and commitment process. In the video below are examples to give everyday relevance. Again, the purpose of this series of posts is to present general information about a little-known area of MH.

The conceptual and thought process is private (within the ITA officer). And if you don’t know, you don’t know what questions to ask or information to share. The intent is to shed some light for those who are interested or affected by this unknown experience. Part 1 presents a conceptual overview of involuntary treatment. Part 2 presents an outline of the details of this process.

Disclaimer: This is general information and is not advice, consultation, recommendations or legal advice. Please contact local professionals in your community, crisis services, law enforcement or attorney if you need help, consultation or services.

Protecting the future past: Legal less restrictive examples. These are things to consider and often a discussion for and with those in the family and their care/support environment. Teenager and their future. The messy divorce with kids and money. And the past with an elderly or disabled family member.

Go Voluntarily: It has some significance. Presumption of recognition, insight and judgment. Physical, mental, sovereign unless declared otherwise.

Applications: Often have a waiver of confidentiality for records (including MH) concerning jobs, guns, insurance, commercial transportation, security clearance, etc. Or an occupation working that requires security clearance or some licensing or bonding. Example of commercial airline piolet, military, with children, fiduciary capacity.

And the quick way is for the person doing a background check is via health insurance/billing, to look for dates of hospitalization billing for medication.

Gun Control. Individuals who have been detained for a 120 hour evaluation and treatment because the person presents a likelihood of serious harm are prohibited from possessing firearms for six months after detention. And if a person is committed for 14 days and longer, their right to possess a firearm is suspended until restored by the superior court that ordered the commitment (RCW 9.41.047). RCW’s outline reporting civil MH commitments to the National Instant Criminal Background Check System (“NICS”) database.

Payment and finances: Be poor! Pay in cash. Got insurance, get pre-approved, know what exactly what is covered both inpatient, outpatient, medications (generic vs brand name) and treatments. Insurance is a denial, delay and defend. If detained involuntarily; and if you have resources, you will be billed. Demand an itemized invoice/bill. And if needed, immediately apply for any financial help and make sure you pay attention to response times and appeal processes.

About records: Anything you sign; things like treatment plans, treatment agreements, etc. Tell them to print out the report, plan, treatment agreement, etc. And you will then sign and date the paper copy and also you demand a photocopy of the document that includes their signature and date. KEEP and organize (by date and provider) a hard copy of all records: medications, records, insurance correspondence, bills, etc. Never give away your original records. Copy documents if needed.

The reason is that everything has moved to electronic medical records and coded billing processes (ICD-10); these are two different processes are coordinated. Second, they can be difficult to get later via “medical records.” Third is because making these simple demands also make the professional step up and be a professional. Fourth is that it offers some ability for advocacy and protection in the unfortunate event if something goes sideways.

If you have the ability, access and resources to have an advocate present, i.e., friend, family member that knows of the situation. For children not yet 13 and for teens from 13 to 18, it is often required or strongly encouraged to have a parent present. They can help advocate, understand and clarify what is happening during times and events that are stressful and overwhelming.

Legal Bits

Where to go? Emergency Medical Treatment and Labor Act (EMTALA). Under EMTALA, the “reverse-dumping” provision prevents hospitals from refusing patients who require specialized capabilities or facilities if the hospital has the capacity to treat them.

Statutes are the law (RCW’s), WAC’s (Washington Administrative Codes) are the guideline interpretations of the law concerning things such as licensing, contracts, auditing, community practices are the interpretation and implementation. Case law, i.e., is the clarifications via litigation.

Two independent evaluations to petition for a commitment hearing. MD/Psychiatrist and mental health professional (court liaison) are co-­petitioners and testify at 14, 90 and 180 Day Hearings. At the 90 and 180 hearings there is the option for jury trial RCW 71.05.310.

Clinical Formulation:

Clinical Formulation: Drugs & Alcohol, Delirium, Dementia, Developmental Disabilities, Elderly/Geriatric/Nursing Home/Assisted living. Is it an environment, stress and situational or even have some financial aspect? It’s about conversations and consults, if you don’t understand, ask for clarification. https://lovechangegrow.com/diagnosis-clinical-formulation-and-treatment/

Checklist for Geriatric/Dementia/Delirious/Severely head injured/DD Persons

1. Have Geri/DD Consultant or PCP recommendations been followed? If not, why?

• Have they have done current appropriate labs to rule out medical issues? Ex: CBC, Chemical profile, Thyroid Panel, UA, electrolytes, B12, medication levels, etc.
• Has PCP and/or Pharmacist reviewed medications for drug interactions and side­ effects?
• Has there been any med changes recently? Do they correlate with any behavioral changes?
• Is there any constipation, dehydration, GI distress, oxygen deficiency?
• Are chest x-­ray, EKG, CT, MRI etc., diagnostic procedures showed and what are the results?
• Has a complete pain assessment been completed and what are the recommendations?
• Has the person experienced any environmental or social changes recently…any losses?
• Are PRN meds being used as ordered? Are they effective? If so, could they be ordered as routine meds?

• Are behavior changes and issues documented thoroughly? Is it descriptive and detailed? Does it include duration, frequency, attempted interventions and their outcomes?
• What specifically de­-escalates the behaviors? Ex: staff, family attention or presence, removal from precipitating stimuli, changing the environment or milieu, e.g., lights, music, walks, etc.?
• Has the family been notified of the problem and involved in interventions or plans?
• Is there a consultative and/or training need for facility staff?
• Have the facility staff and/or family prepared to submit an affidavit/statement?

Statement/Affidavit Notes for Initial Detainment (Psychiatrist, Therapist, Physicians, RNs, Facility Staff).

• Relationship: What is the nature and extent of the professional relationship with the patient (frequency, duration, and course of treatment)?
• History: State the diagnostic impressions of the patient as to the nature and extent (severity of the signs and symptoms) of both the chronic and acute conditions. Include relevant history and pattern of decompensation, previous hospitalizations, and refractory responses to treatment.
• Current Psychiatric Status: State the recent past specific signs and symptoms of substantial deterioration; give specific observed signs and symptoms using mental status descriptors.

• Discuss the nature and extent of current concerns about the patient’s impaired ability and/or impaired motivation in engaging in the recommended and offered medically necessary least restrictive care.
• Discuss if relevant the client’s noncompliance and/or refractory treatment response.
• Current Imminent Dangerousness: State, if any; the specific observed behaviors, statements that present an increased likelihood of serious harm, what is the specific evidence of imminent dangerousness (do not use conclusion statements, e.g., “suicidal”…instead use direct quotes and/or describe the dangerous behavior)? Include history of assault, arson, etc.
• Recommended Treatment: State your professional opinion as to the necessary care that you recommend for future (continued) safe and effective mental health/physical health care, (e.g., treatment, medications, labs, other somatic therapies necessary to prevent the continued decompensation or an increase of dangerousness).
• Attempted Lesser Restrictive: State that the client has been advised of the above care recommendations and offered the above services, however, has not accepted; or that they state intentions of not engaging in recommended treatment; or denied the need for the services; or that they agree to engage in such care but there is evidence to question their intentions/ability to comply voluntarily with the recommended care. And discuss client’s history and patterns of noncompliance leading to decompensation resulting in hospitalization.

Notes for family member or concerned party’s statement of concern:

Note: Your statement is useful, because it is often the start of the complaint/concern in the referral phase of the ITA investigation. Your statement is passed along with the police report if law enforcement is involved. (see below about your phone number). Remember to give law enforcement your contact number for their report.

Your relationship; how long and under what circumstances. For example, a parent, sibling, landlord, friend, pastor, etc.

The specific nature and severity of your concerns that result in imminent risk for health or safety. Discuss what you have tried. And despite your best efforts and attempts; the behaviors, statements the individual has continued to be a concern and/or is escalating.

Note date, times and attempts and type of help that you have encouraged the client to seek help, evaluation or treatment.

Note the client’s refusal of the treatment or their inability to consent or understand the need for the treatment. Conclude with a statement of your opinion of the resulting endangerment. What are your fears/concerns will happen?

Print your name, sign, date, time and note place (town and state). Also make a copy for yourself to refer to during your testimony.

***You might not want to note your phone number on this statement. This is because your statement is discoverable (i.e., they get a copy of your statement to prepare for their defense at the subsequent MH hearing). But you will need to let the ITA officer know your best contact phone number. The ITA officer may want to contact you asap, if they have questions and to verify the veracity and creditability of your statement. The ITA officer, MH court liaisons and/or the prosecutor may ask if you would testify at the MH hearing.

Emergency Evaluation: Contents of an 8 Point Write-up by the ITA officer.

• Reason for Exam/Evaluation: Specific requests from referral; why they called; if ITA investigation or only a consult, what was the specific consultative question.
• Presenting Circumstance/Chief Complaint: Circumstances, precipitating factors, Statement of the problem/request. Vegetative sx’s: sleep appetite, energy; nature and severity of psychosocial stressors.
• Psychiatric History: Related to current problem/sx’s. Previous and current tx, hospitalizations, meds; hx of dangerous behavior, substance abuse, family psychiatric hx and significant medical conditions.
• Social History: Minimal, relative to the current situation. Living situation, employment, and significant historical stressors.
• Mental Status: See mental status notes
• Diagnostic Impression: Provisional, supported by above data; Axis I­-V.
• Clinical Formulation: Thoughts and impressions leading to the formulation of diagnosis, risk assessments and decisions. What needs to be done next, consultative and management direction.
• Disposition/Plan/Follow-­up: Be specific, what will happen next, who is responsible patient/family/supports, Referrals given or encouraged, available supports; if AMA discharge…note circumstances and reasons; cleared/consulted with referring EDMD or referring party.

Safety Management Plan that the Client will do for themselves: (if not detained)

• List of skills or activities to engage.
• List of natural supports (with phone #’s)…friends, family, groups, church.
• List a spectrum of escalating behaviors and the appropriate interventions.
• Appointments with appropriate CM, therapist, PCP etc.
• Crisis referral and numbers.

Mental Health Treatment, 3-prongs and Wellness https://lovechangegrow.com/what-is-mental-health/

Part 3, the odds and ends are things that are important to be aware of to help understand, advocate and navigate the crisis mental health system. Just note family, friends and care givers are the lifeline for these folks. You do 95+% of the work, have great insights and resources. If you have questions, need information and consults about what to do; ASK your local professional! Often times when doing this work, if family is present, I will spend 2-4x more time with family members providing information, education and how to navigate both the MH and crisis system.

Thanks and Blessings!

Tim