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Hayley: Hi everyone. My name is Hayley and this is Straight Talk With The Doc, a podcast that discusses addiction, mental health, and treatment. Today I’m here with our medical director, Dr. Bhatt. How are you doing today?
Dr. Bhatt: Doing well Hayley, how are you?
Hayley: I’m doing great, thank you. Dr. Bhatt, not only has your work focused on substance abuse treatment, but a huge part of that has also been dual diagnosis and psychiatry because the two really go hand in hand, correct?
Dr. Bhatt: Definitely. Many people, if not most, that we suffer with addiction, substance use disorders, often do have underlying or primary mental health conditions. Definitely we see that very often.
Hayley: I’m sure you’ve seen your fair share of cases of people struggling with very severe mental health disorders, who sometimes may not be capable of making the best decisions for themselves. That brings us to our topic today of involuntary commitment, also called civil commitment. There are a lot of rules surrounding this subject to protect a person’s autonomy, but most people probably don’t know all those guidelines. That’s where I want your help to explain it to me and our listeners. What does that mean? What is involuntary commitment?
Dr. Bhatt: A lot of times we see patients in the clinical setting that unfortunately, due to some underlying mental health condition, are unable to take care of themselves or could be dangerous to themselves or other persons. And due to their mental illness without treatment, can suffer from further deterioration or unfortunately, neglect or self-harm, or harm to others. And that’s when due to their inability to actually think rationally, make decisions that somebody who has the capacity to do so, a professional, law enforcement, or the courts often have to intervene. And have those people sent to receiving facilities where they can get a proper evaluation to determine what treatment is needed, if they have the ability to sign in involuntarily or ultimately, be further committed for further treatment.
Hayley: And who’s making this determination? Is that a judge or a psychiatrist?
Dr. Bhatt: It really depends on where this person is encountered. If I had to divide it, we have different types of civil commitment. Civil commitment really is just distinguishing the act of holding somebody, committing somebody, that’s not criminal in nature. That’s why it’s called a civil commitment. These laws exist in most of the states around the country. And we would like to distinguish why somebody might present a certain way either secondary to mental health disorder or substances of abuse. Often times, depending on the presentation, they could run into or be faced with law enforcement. And difference states can have different people involuntarily initiate an examination where they are sent to be further examined. Law enforcement can often do it, judges can often do it, depending on the state different professionals, physicians, social workers, psychologists, they often can be the ones initiating these examinations.
Hayley: In your career, how often do you see this? Is this common?
Dr. Bhatt: It really depends on the setting, again. In the public arena, we often do see people who, due to the nature of their mental health illness or substance use disorder, often not getting the proper care that they need and filtering down that social ladder so to speak. We do see more people who present to emergency rooms or hospitals that would warrant needing further commitment because they haven’t been taking care of themselves. Their state of mind is further deteriorated. In the private sector, we often don’t see this. These are people who often have been engaged in treatment, have additional monitoring, have tighter follow ups. And they often are caught earlier on before deteriorating to the level where they become incapacitated, where they can’t make those decisions, might become a danger to themselves or others, and are just getting treatment overall. When I was at the hospital base or working more of a public setting, I unfortunately saw more people that ended up getting civilly committed. Not so much on the private side.
Hayley: With the criteria in regard to the risk of harming oneself or others, is that criteria always necessary? Can someone still be committed even if they’re not determined to be dangerous?
Dr. Bhatt: You look at most of these laws that exist, again, through the entire country and states vary to a certain degree. But in general, we have to see some level of danger. Now, that interpretation can be difficult to tease out sometimes because it’s an often subjectively determined situation. But there should be some level of safety issue, danger to self or others, or some neglect that could be there. So, danger could occur just by the verge that somebody’s not treated properly and starts to self-neglect and starts to not take care of their basic minimum needs. That is a dangerous situation to the individual. Really it depends on the context of how it is, but dangerousness is often one of the main criteria that has to be there. It has to be secondary to a mental illness or some substance use illness that’s there. Just by itself, having somebody be dangerous, we have to distinguish if that dangerousness is coming from some sort of criminality anti-social behavior versus coming from a mental illness or a substance use disorder. That would distinguish then the nature of a civil commitment versus somebody getting arrested for their behaviors.
Hayley: Okay, that makes sense. I know it varies for different states. But one of the criteria I came across was that someone be unable to determine for themselves that treatment is necessary. Could you try to give an example of a situation like that?
Dr. Bhatt: Many times we have certain mental health conditions that due to their presentations and the symptomatology, they can’t often determine what’s real and what’s not. The reality testing is not intact. Psychotic disorders for example, unfortunately due to their nature of their illness, often they believe things that aren’t real. They see things that might not be there, they hear things that somebody else might not be able to hear. These are treatable conditions. And if you’re not receiving the proper medication, or you’re feeling paranoid about the meds that you’re being prescribed, and then you don’t take the medications or you decompensated in any way, well sometimes you might not have intact thinking of what’s good and what’s bad. What’s right for you and what’s not. Often you might not have the capacity to make those educated rational decisions to take care of oneself or determine if care is even needed. When we see that somebody’s in that situation where they can’t take care of themselves or maybe they do not have the capacity to make those decisions, and their behavior is dangerous because of that underlying mental health condition not being treated adequately, that can be criteria for involuntary committing somebody for their own well-being.
Dr. Bhatt: That becomes touchy. I think that it’s often hard to determine one or the other. Being that there are multiple types of individuals that can initiate an involuntary commitment, obviously a judge, a police officer, licensed health care professionals who have that training and knowledge to initiate and involuntary examination commitment. These things need evidence. You can’t speculate and involuntary commit people. You need to have evidence through your own examination and though data gathering. It’s important that those things are done and done properly in order to send somebody to get involuntarily committed. It is a two-stage process. Most states you can initiate sending somebody to get evaluated. You have a certain amount of time to make the determination if those people need to be further hospitalized and further treated. When it comes to substance abuse though, they should have separate categorization. But often due to the urgency or the eminent nature of people’s presentations, it’s often hard to tease out if their presentation is coming from a primary mental illness or primary intoxication. I painted that background because then it depends on what law needs to be initiated. Because in certain states there are separate laws that distinguish involuntary civil commitments from primary mental health conditions and those that are secondary presentations to substance use disorders. You have to ensure that you are civilly committing somebody under the right laws and secondary to the right illnesses.
Hayley: We’re in Florida and we have the Baker Act. Can you walk through what that is? Also, is there something else for drug and alcohol abuse?
Dr. Bhatt: The Baker Act is our mental health law in the state of Florida that speaks exactly to what we’re talking about. Involuntarily committing somebody for treatment to help stabilize them due to their underlying mental health condition. Again, there’s criteria there. Some just general guidelines are that somebody has to have a mental health condition. And due to their mental health condition is presenting in somewhat a danger to themselves or other persons. Or they can’t make the proper decision for themselves to seek help. They’ve refused voluntary help. And because of all of these conditions without certain treatment interventions, they will continue to deteriorate. That whole picture should definitely portray some level of urgency or eminency that these people are in harm or will cause harm. That’s generally the nature of the Baker Act. If that presentation is secondary to substance use, we have another law called the Marchman Act. It’s basically similar in the fact that due to a substance of abuse or an addiction, that if left untreated, further harm will occur to them or others in kind of the same set of criteria that I mentioned in general. The lengths of how long you can hold them until you’ve rendered that decision, if they should be discharged, if the person can be voluntarily admitted to the hospital for treatment, or if they’re going to need further legal commitment, those time frames differ. But in general the premise is the same.
Hayley: With the Marchman Act, can somebody be sent to rehab involuntarily?
Dr. Bhatt: Yeah, I think the goal is for either one of these things is it’s not punishment. It’s an endeavor to get these people treated. One thing I want to highlight here is that this is not a criminal commitment. These are people who, again, they have to have some underlying mental health or addictive illness. And to our understanding, due to that lack of treatment, having that presentation that’s dangerous. If it is a substance use disorder, yes, rehabilitation is often the target in order for them to get that treatment that they deserve. On rare occasions, certain states can impose assisted outpatient treatments. But that’s often when people have gone through the process multiple times, have been inpatient hospitalized, often have other resources available that a judge would order something like that. But rehab can be the ultimate target for somebody with substance use disorder to get their involuntary court ordered treatment.
Hayley: For somebody who is committed, is there a certain time frame that they are usually held? Also, is there a limit for how long you can hold somebody?
Dr. Bhatt: If, again, we’re talking about the state of Florida, with the Baker Act in terms of the mental health situation, the first step is you’re going to have an involuntary examination. If somebody determines that due to their mental health condition, like I said, a judge, police officer, a physician, social worker, it involuntarily enacts that paperwork. These people have to be transported by law enforcement. We can’t just put somebody in a car privately and take them to the hospital. That’s against the law. Law enforcement will take them to a Baker Act receiving facility. They have up until 72 hours at that Baker Act receiving facility to make a determination of one of three things. Either the person signs themselves involuntarily, they are discharged, or the provider or the person performing the examines determines that the person still needs further treatment. And that’s a second step process to further commit that individual for ongoing treatment. Now, for the Marchman Act, which is the over-arching law for substance use disorders, those people would be taken to a Marchman Act receiving facility. Often it could be a hospital or a detox or a crisis stabilization unit, and those people have up to 5 days to make these determinations similarly and make such examinations. The difference between the two is that often with the Marchman Act, it could be initiated by family by petitioning to the courts. But ultimately a court order has to take place for somebody to be set there. If they end up going to treatment after the examination or the judge determines they can go straight to treatment, then they can be held up to about 60 days. But, if it’s not in a locked facility with other stipulations, although, yes, it’s a court order, these people technically could leave. But there is that added pressure that if they do leave, that they could be facing criminal charges. Often you don’t see that, but that is the implied consequence.
Hayley: Oh wow, okay. I have a question about the Baker Act receiving facility. For those who are committed, are they held in a regular hospital or are there special psychiatric hospitals?
Dr. Bhatt: There’s a lot of history behind that. Years ago, we had a lot of state psychiatric facilities, state hospitals that were the end all place for patients who had chronic mental health conditions that really couldn’t take care of themselves and used specialized treatment. Over the last many decades, we’ve seen them diminish. There’s less state hospital beds and many private hospitals, public hospitals, started developing more psychiatrically focused inpatient facilities. We do see a lot of patients now who have, after they were baker acted, they’re determined to need further treatment. But they don’t have the capacity to make determinations for themselves or sign involuntarily. These people are often committed in psychiatric or behavioral health inpatient units that could be attached to private hospitals or public hospitals, or even free-standing behavioral health hospitals. That’s usually where most people end up getting treated, but they still could be sent to a state hospital and depending on the severity and the treatment course. Many people can stay anywhere from a few days to weeks, even up to months. But I think the goal is we don’t want people in hospitals for long periods of time if that could be avoided. That’s where we’ve seen the changes from people being sent to state hospitals to shorter term more acute hospitals stays.
Hayley: I want to talk a little bit more about this change. Can we talk about the history of civil commitment? How has it changed and why is that change necessary?
Dr. Bhatt: The history is civil commitment is there’s been recognition of mental illness for hundreds and thousands of years. We’ve documented this in history, depending on how you look at it and how much of a history buff you are. We’ve seen this even in ancient Greece and Roman times. When we fast forward in the 1800s and early 1900s, we see a lot of patients being treated, as a I mentioned before, in state hospitals. Often it was due to the fact that somebody identified them having a mental illness. A doctor or provider would end up initiating that commitment. That could be dangerous, though. And when I say the word dangerous, we want to recognize people: human’s rights and human being’s freedoms. We can’t just allow somebody’s testimony and a doctor’s simple opinion without gathering enough evidence and facts to send somebody into a long-term commitment where they can’t leave. There was a push, let’s say in the 50s, 60s, and 70s, in the 20th century where it was challenged. Many people were looking at our people being sent for commitment and our rights being violated. We saw a lot of laws change as a result. There were some cases that were highlighted. Due to those cases being highlighted, people became aware. “Wait a minute. We can’t just send these people and lock them up. We need more structured laws regarding that”. We saw a swing. We saw a change where we saw people getting less length commitments, reform with the laws. As a result, there were less state bets that were there. We deinstitutionalized as much as possible while trying to maintain as much freedom as possible and autonomy for people. I think that’s where that barometer for that degree of dangerousness came into play. Unless somebody’s showing some level of imminent danger or reasonable danger that’s there because of their untreated mental health condition, people have the right to make decisions and be untreated if they want it. That’s where this change started to occur. Now most people in the country are being treated outside of those systems either through outpatient treatments or acute hospital settings.
Hayley: Can a person who’s been committed be given medications involuntarily, even if they refuse to take it?
Dr. Bhatt: I’ve seen this and I’ve been the provider when I used to work in inpatient psychiatric units. It’s not easy to just give somebody a medication. If a person is presenting in an emergent way while in the hospital where their behaviors are so dangerous, there are the provisions where an emergency treatment order may be given. Again, I’m simplifying it for this conversation, but we don’t want to just inject somebody or give them medications against their will unless there’s good reason. But beyond those emergency situations to treat somebody who’s been committed, you need a court order in most cases. This is done after a trained physician, psychiatrist, gathers clinical evidence and often collateral information painting the picture of the patient’s mental health condition. Then putting it in context and submitting this to the court where a court order then is generated where ongoing medication can be provided. It’s kind of broken up in two, if I can say it like that. Emergency situations we can treat, but we can’t continue to treat it like that unless it’s an emergency. For the long-run, until somebody’s medications render effective, a court order is necessary.
Hayley: Are there different rules for committing a minor versus an adult?
Dr. Bhatt: Minors have different rules just by the fact that they’re minors. They don’t have the ability to make certain decisions for themselves. But minors can be Baker Acted and Marchman Acted. Again, I’m speaking to the laws here in Florida. In other states there are involuntary commitments that can occur for children who meet those same conditions, who are dangerous to themselves or others, or who suffer from neglect, or again the part where they can’t make decisions for themselves due just to the fact that they’re under the age of 18. But if they were seeking out voluntary or elective mental health treatment that can be done. Again, this is context of them having a mental illness and them not knowing what’s right for them, and being under the age of 18. These laws do apply in general; they’re similar.
Hayley: Would they need the guardian’s permission per say?
Dr. Bhatt: Yeah, initially if there’s a certain level of dangerousness that’s there, depending on who’s initiating this, the initiating of the involuntary examination, that can be done in the spur of the moment by those who are under the law capable of doing so. But yes, we want to involve the guardian. We want to involve the caregiver and inform them along the way. At the end of the day, somebody could be held, again, under the opuses of doing right by the person and looking out for their well-being. But I don’t think anybody wants their child to be held without their involvement. There is an obligation there to have the guardian, the caregiver, the parent, be involved when it’s appropriate and when the time is right. Usually the law stipulates that we want to lookout for the best interest of the person in front of us, and they’re doing life-saving or emergent measures. That should be the first step. Then informing the prequel should be after the fact. If there’s a delay in life-saving or emergent measures, then you’re risking somebody’s life. I think they would hope that the life-saving measure comes first.
Hayley: Okay. Dr. Bhatt, is there anything else on this topic that you think people should know?
Dr. Bhatt: I know that is if often an unspoken side of the door to treatment and often difficult to initiate. I know that the audience and the people who we’re targeting in this podcast probably have been in and out of treatment, or those who have not might not know that this exists. Addiction and mental health conditions are difficult illnesses to treat. Often times due to the nature of them, people aren’t often thinking in their right mind. These laws are there, these situations exist and in order to exactly do that. To help people get into treatment and receive treatment, where they would not do so for themselves and also when they put themselves in such a dangerous situation as a result of their untreated addiction or mental health condition. I would explore, if I was a family member, if you’ve really tried very hard and somebody you know, you’re losing them. Their behaviors are so dangerous that they are a significant danger to themselves or others due to their substance use or their mental health condition. They should look into their local state laws and investigate ways to help their loved ones get the treatment that they need. If it means to do it under an involuntary commitment that they really entertain it, because at the end of the day, it could ultimately save their life. That’s really the take home message here.
Hayley: Absolutely. Thank you for explaining that, Dr. Bhatt. The whole subject is definitely clearer to me and I hope to our listeners as well. You can catch more episodes at addictioncenter.com, SoundCloud, Spotify, and Apple Podcasts, and we hope to have you again for another episode of Straight Talk With The Doc.