WHAT TO DO IN A PSYCHIATRIC CRISIS IN INDIANA

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1 WHAT TO DO IN A PSYCHIATRIC CRISIS IN INDIANA NAMI Indiana P.O. Box Indianapolis, Indiana

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3 TABLE of CONTENTS Preface ii Introduction Planning Ahead How Do I Prepare for a Mental Health Crisis? Who to Call in an Emergency How Do I Get Help Quickly? Hospitals and Emergency Departments Legal Basis for Detentions & Involuntary Commitment Detentions Immediate Detention Emergency Detention Physician/Judicial Hold Commitments Some Common Questions Concerning Commitment Proceedings Social Security: IMPORTANT! Juveniles What You Can Do to Facilitate the Process Keeping a Mental Health History Alternatives to Involuntary Commitment Glossary Community Mental Health Centers in Indiana Resources Acknowledgements i

4 PREFACE When a person is in a psychiatric crisis, it is imperative to be able to get him or her into treatment as quickly as possible. This can present a very significant challenge that we hope this booklet will help you meet successfully. In the booklet itself, we will describe the general parameters of what to do to get help in a psychiatric crisis. However, as you are probably aware, there are 25 Community Mental Health Centers (CMHCs) serving 92 counties in Indiana. Each of these CMHCs has its unique set procedures, and we have found, when a CMHC serves more than one county (and most of them do), there can be county-to-county variations in these procedures. We very much appreciate the cooperation of our CMHCs in providing this information to us. It would be hopeless to describe these variations in this booklet and keep it at a reasonable size. Instead, the detailed information for each county will be listed on the NAMI Indiana web site (www.namiindiana.org). In the event that you do not have access to the Internet, this information can be obtained by calling the NAMI Indiana Help Line ( or, in Indianapolis, ). We sincerely hope that this booklet will help you in dealing effectively with a psychiatric crisis. We realize, however, that it will have shortcomings; some in the first edition have been corrected in this second edition. We heartily welcome any suggestions you have for its improvement. Send your suggestion to NAMI Indiana, P.O. Box 22697, Indianapolis, Indiana 46222, or by to Joe Vanable This booklet is the brainchild of Abby Flynn, who, up to the point of her hospitalization for heart valve replacement surgery, chaired the committee that produced it. Her drive, her focus, and her indomitable spirit provided the wherewithal that made this booklet a reality. Sadly, Abby did not survive this difficult surgery, and so she was deprived of the pleasure of seeing it actually produced in final form. We dedicate this booklet to Abby s memory; it is one of many examples of the good things that have resulted from her very active and fruitful life with NAMI Indiana. If you read through this NAMI Indiana booklet and visit the accompanying web site and you still do not find the answer to your question, you are not alone. Of the 92 counties, few give identical services to people with mental illnesses. Feel free to contact the Community Mental Health Center(s) serving your county for further clarification. Contact information will be found at each of their web sites. This is the very reason why NAMI Indiana Affiliates have been formed and continue to be active in advocating for services. They persevere, they persevere, they persevere; they never give up in working with the Community Mental Health Centers to improve the services to our loved ones. This is your opportunity to bring your question to light. Gather your NAMI Indiana neighbors together and work with your Community Mental Health Center for your loved one's services. It works! NAMI Indiana Crisis Booklet Committee Indianapolis, January 2011 ii

5 INTRODUCTION Mental Illnesses are biological brain disorders that, untreated, can disrupt a person's thinking, feelings, mood, or ability to relate to others in his or her daily functioning. Most people with serious mental illnesses live successfully in their communities as long as they have access to appropriate support and treatment. Sometimes people stop taking their medications or their medications stop working. In addition, some individuals with mental illness have anosognosia, meaning that they are unaware of their mental illness, and so do not believe they have a mental illness. They do not acknowledge their symptoms or have insight into their illness and thus do not think they need treatment. All of these things can result in people with mental illnesses not being able to care for themselves or becoming a danger to themselves or to others. In these situations, it may become necessary to have a court order to get the person into treatment. The process of obtaining a court order is called the Civil Commitment process. It has two main purposes: To treat persons with mental illnesses when they are unable or unwilling to seek treatment voluntarily. To protect the person with mental illness and others from harm due to the illness The Civil Commitment process involves the legal system and can be confusing or intimidating for individuals with mental illness and their families. Civil commitment can be a very emotionally difficult path to take and is viewed as a last resort, when nothing else has worked. Recent discoveries have shown that mental illness is very treatable with medications and other therapies. At times, however, the medications may not work well enough or people with mental illness may refuse to take their medications or see their doctor or therapist. When this happens, persons may become isolated, and lose their job or even their housing. In some situations, such persons may lead a life that involves homelessness, jail or prison. Sometimes commitment is the only way to get a loved one back to functioning better. This booklet is designed to help individuals and families understand the Civil Commitment process. First, this booklet provides suggestions for handling mental health emergencies before the commitment process begins. Then, it outlines the steps involved in the Civil Commitment process. Next, it explains what happens if a person with mental illness is committed and discusses alternatives to involuntary commitment. Finally, contact information for Indiana s Community Mental Health Centers and additional resources are provided at the end of this booklet. Throughout the booklet, people who have committed loved ones provide advice and comments about the Civil Commitment process. It is not an easy process; families need to understand the process and be strong advocates for treatment, in order to gain access to it for their loved one. While initially my son was upset with the family over his commitment, in the end he was thankful. He now lives in an apartment with community supports and is working. Without the commitment I don't want to think about where he would have ended up. CL When deciding what is best for your loved one who has mental illness, the reality is that you have only one choice. Hopes and dreams will have to wait until hopefully a better day. ET 1

6 PLANNING AHEAD Discuss with the person with mental illness the preparation of a Psychiatric Advance Directive (PAD; discussed on p. 14) and the option of signing a Power of Attorney and/or Appointment of a Health Care Representative. Everyone should plan ahead by signing a Power of Attorney and appointing a Health Care Representative. Anyone can suffer a medical crisis and be unable temporarily to handle his or her own affairs. Power of Attorney and Health Care Representatives can only be appointed when a person is well enough to make his or her own decisions. A Power of Attorney or Health Care Representative can only be used when a person is unable due to illness or detention to make his or her own decisions. This type of planning can help avoid court-ordered intervention or loss of housing or property or benefits if the person becomes unable to act for himor herself. These forms are simple to fill out and available on line, from your attorney, or from many hospitals or organizations for the aged or disabled. At the end of this booklet, you will find listed all of Indiana s Community Mental Health Centers, with addresses, phone numbers and web sites. NAMI Indiana also provides county-specific information on What to do in a Psychiatric Crisis on its web site, which may be found on the Internet at or you can call , and ask that a copy of your county s Mental Health Crisis Information to be mailed to you. HOW DO I PREPARE FOR A MENTAL HEALTH CRISIS? A mental health or behavioral emergency often triggers the concern of family members or friends who may then consider Civil Commitment for the person with mental illness. Knowing how to handle these emergencies requires preparation. Having information about emergency rooms and the mental health examiners who handle emergencies will better prepare you for helping a person with mental illness in managing his mental health crisis. To be well prepared for a crisis, collect and keep in an accessible place the following: 1. The name, address, and phone number of the last known psychiatrist of the person with mental illness. (Regardless of any release of information, this information is helpful for emergency responders.) 2. The name, address, and phone number of the last known therapist or case manager of the person with mental illness. 3. A list of current medications or last known medications. 4. A list of any previous medications that resulted in serious side effects. 5. The diagnosis of the person with mental illness, if known. 6. Any medical diagnosis or condition such as diabetes, high blood pressure, seizure disorder or any other ongoing medical condition. 7. Information on the client s use or abuse of alcohol, prescribed medications or illegal drugs. Be as realistic as possible as this information is important in an emergency. 8. A list of the approximate dates and facility names of any previous hospitalizations. 9. Emergency numbers for the Community Mental Health Center or emergency-coordinating agency in the County in which your loved one resides. 2

7 WHO TO CALL IN AN EMERGENCY Assess the situation of the person with mental illness. If he or she is not in immediate danger, call his or her psychiatrist, clinic nurse, therapist or case manager. If the hospital in your loved one s area has a psychiatric service, many will also have a crisis or assessment center. These centers also can provide assistance and advice. Or you may call your local Community Mental Health Center or CMHC. Every CMHC has emergency services to advise, direct or assist in an emergency, urgent situation or continuing decline of the person s condition. Remember: If your loved one does not live in your community, you must be making all these inquiries and arrangements for facilities in the county in which your loved one resides. If your loved one is in another state, contact that state's NAMI (via the nami.org web site; click on Find Your Local NAMI) for information about that state's CMHCs and their contact information. Some police departments will do what is generally known as a well-being check. This may be appropriate if you have little information about the current condition of the person with mental illness, but you have good reason to be concerned. (For example, if you are used to seeing or talking with the person frequently or at certain times and you cannot reach him or her, or if the person has just called you and said something which causes you concern.) In such an instance, you can call your local police department number to see if an officer can check on the well being of a person with mental illness. If you think the person with mental illness needs emergency medical or psychiatric attention, drive him or her to the nearest emergency room if you can do this safely. If it is not safe to drive the person or s/he refuses, call 911 for an emergency response. If your community has a Police Department Crisis Intervention Team (CIT), ask for a CIT officer. These officers have received advanced training in responding to persons with mental illness who are in a crisis. Keep the phone numbers for all of these resources where you can find them in a hurry. Every community has a least two places to call: The Community Mental Health Center, even if it is located in a different city, and the local Police or Sheriff Department. HOW DO I GET HELP QUICKLY? If you are worried that the person with mental illness is in crisis or is nearing a crisis, there are ways that you can seek help. Before choosing which option to pursue, assess the situation. Consider whether the person is in danger of self-harm, or harming others or property, or if s/he is unable to manage daily living. Consider whether you need emergency assistance, guidance or support. "Need support? Call your local NAMI and arrange to visit them. Membership is made up of families and friends of persons with serious mental illness, as well as those who have mental illness, themselves. They will become your best friends and be the best source of information to help you and your mentally ill relative navigate the system of care and available resources. JN Depending upon the situation, choose one of the following options: 1. If you do not believe the person is in immediate danger, call the person s psychiatrist, therapist, or case manager who is familiar with the person s history. This professional can help assess the situation and provide 3

8 advice for further action. The professional may be able to obtain an appointment or may be able to admit the person to the hospital. If you cannot reach someone and the situation is worsening, do not continue to wait for a return call. Take another action, such as: 2. Call the Emergency Services Department of the Community Mental Health Center that serves the county where the patient lives. 3. If you think the person with mental illness needs emergency medical or psychiatric attention, drive him or her to the nearest emergency room, but only if you can do so safely. 4. If you do not think that you can do this safely, call 911 Emergency Services. Ask for the Crisis Intervention Team or CIT member if your community has this service, or your local hospital emergency services. 5. If you want advice, support and to have someone assess the situation, contact the Emergency Services Department of your local Community Mental Health Center. Information on how to contact Community Mental Health Centers is listed in the back of this booklet. If the situation is life threatening or if serious property damage is taking place, call the police for assistance. When you call the police, tell them your loved one is experiencing a mental health crisis, and explain the nature of the emergency. If you have a Crisis Intervention Team in your area, ask for a CIT officer. Telling the police that it is a crisis involving a person with mental illness increases the chance that an officer trained in working with persons with mental illnesses will be dispatched. You can also call the police if you need help transporting the person to the hospital during a crisis. It is important to note that depending upon the police officer involved and other contingencies, s/he may take your loved one to jail instead of to the emergency room. Be clear about what you want to have happen. When giving out information about a person in a mental health crisis, always be very specific about the behaviors you are observing. Instead of saying, my son is behaving strangely you might say, my son hasn t slept in three days, he hasn t eaten anything substantive in over 5 days, and he believes that the FBI is transmitting messages through his fillings. Report any active psychotic behavior, and/or changes in behaviors (such as not leaving the house, not taking showers), threats to other people, increase in manic behaviors, or increase in agitation (pacing, irritability). You need to describe what is going on right now, not what happened a year ago. Finally, in a crisis situation, when in doubt, go out. Do not put yourself in harm s way. HOSPITALS and EMERGENCY DEPARTMENTS Every hospital and emergency department has its own set of guidelines for responding to a mental health crisis. Some hospitals have markedly improved their preparedness and ability to handle mental health or behavioral crises. While one may not be located near you, knowing what the best hospitals do in these situations will help you know what to ask for. You may want to talk ahead of time to the psychiatrist, other mental health professionals or other families about which hospitals in your area have the best reputation for dealing effectively with a mental health crisis. At the emergency room, immediately inform the hospital staff that your loved one is in a mental health crisis. Alerting the hospital staff to the nature of the crisis can speed up the response of trained mental health professionals. The staff will then know to use mental health evaluation forms and to follow the correct assessment and admission protocols. Clearly state how the person is in danger and describe the behaviors. 4

9 Find out if a separate emergency room is available for individuals experiencing a mental health crisis. A room separate from the standard, often chaotic, emergency room provides a less stressful setting where the person in crisis can wait. Some hospitals have these and people report that it makes a difference. Doctors and other examiners at the hospital should make an honest effort to obtain information from the person who brings a potential patient to any treatment facility. Be prepared to provide the following information about the person in crisis to the medical examiner: Psychiatric history Prepare an abbreviated history NOW and have it available for crisis situations when they occur. If you are just beginning this process, keep a continuing diary of the person s psychiatric history. You can find a downloadable form on the NAMI Indiana web site that can help you do this. Past behaviors and treatment including a current list of medications and dosages. List your knowledge and direct observations of the recent behavior that caused concern. It can be helpful to write down your observations leading up to and during the crisis be brief and concrete. You must provide detailed information on how s/he is incapable of self-care, any suicide threats, threats to property or others, new behaviors, etc. List current mental health providers and insurance information about the person. If you wish to give information about your loved one, contact the Emergency Room. Do not wait for them to call you. It is a good idea to compile this information before an emergency occurs. (And make extra copies; you ll probably need several.) Write it down and keep it easily accessible so that you are not pressed to remember the information during a crisis. Departing the hospital after visiting our son, a gentleman I shared the elevator with stated in despair, I cannot believe that my wife is in a locked down ward. Many of us have also experienced this despair, but what we must remember is that in this period of despair, this hospital is a place of hope that being there can lead to the appropriate treatment and recovery. MK Be prepared for a long wait in the emergency room. NAMI has heard that individuals with mental illness and their families have waited eight or more hours before being helped. It is important to note that bringing someone to an emergency room does not necessarily lead to an admission into the psychiatric unit. Don t be surprised if the emergency room physician asks you to assess how dangerous the individual is to him or herself or others and asks if you would be able to take the person home. Be prepared to hold your ground if you really believe the individual needs to be hospitalized. Don t take someone home if you believe you cannot reasonably keep him or her or others safe. Because of HIPAA restrictions, as a rule, doctors and other hospital personnel do not share information about an adult patient with the family, unless s/ he gives permission to do so. However, you can still provide information to them that may help them assess the situation and provide better treatment. You might also try asking broad questions such as If I had a relative with schizophrenia, what medications would be recommended if X medication wasn t working? If you have Power of Attorney, however, HIPAA restrictions do not apply. 5

10 LEGAL BASIS FOR DETENTIONS and INVOLUNTARY COMMITMENTS A person cannot be detained or committed for treatment against his or her will unless the individual meets certain legal standards. A detention or involuntary commitment is only authorized if: The person (1) suffers from a mental illness; and, (2) due to the mental illness is dangerous and/or gravely disabled. Mental illness is defined by statute as a psychiatric disorder that: 1. substantially disturbs an individual s thinking, feeling, or behavior; and, 2. impairs the individual s ability to function. The term includes mental retardation, alcoholism and addiction to narcotics or other dangerous drugs. Dangerous is defined as a condition in which an individual, as a result of mental illness, presents a substantial risk that the individual will harm him- or herself or others. Gravely disabled is defined to mean a condition in which an individual, as a result of mental illness is in danger of coming to harm because the individual: 1. is unable to provide for his/her food, clothing, shelter or other essential human needs; or, 2. has a substantial impairment or obvious deterioration of his or her judgment, reasoning or behavior that results in the individual s inability to function independently. Dealing with a psychiatric crisis is a daunting task that can be very, very discouraging. In dealing with the challenges of such a crisis, it is important to remember this: severe mental illness is treatable, more treatable than cardiovascular disease. The key here is to have access to treatment. Your effort in achieving this access for your loved one has the potential of providing rich dividends! JV Detentions Indiana statute provides for three types of detentions. One type of detention is the immediate detention (commonly referred to as the 24-hour detention). The other type of detention is an emergency detention (commonly referred to as the 72-hour detention). The primary purpose of the these two types of detentions is to permit law enforcement officials or emergency medical personnel to take an individual who is experiencing a mental health crisis into custody for transportation to a local health care or psychiatric facility for assessment and emergency treatment. The third type of detention is a physician/judicial hold. If your son or daughter is in trouble with the law, and you feel the court should know about his/her mental illness as it pertains to the case, it is appropriate and beneficial to write a letter about his/her mental illness and how it affected his/her judgment in the case before the court. However, you must send three copies. One to the Judge, and Cc: copies to the Public Defender and the Prosecuting Attorney. With the information you have provided, they all three know the facts, and they can feel free to discuss them with one another to arrive at a consensus about how to prosecute the case. I was advised to do this by our CMHC s counselor, and it worked! My son's misdemeanor was dropped and not prosecuted. PP 6

11 The statute grants immunity from liability for individuals who participate in obtaining detention or commitment of a mentally ill person, so long as the individual does not act with malice, bad faith or negligence. Immediate Detention (24 hour detention) The immediate detention (24 hour detention) can be utilized by a law enforcement officer who has reasonable grounds to believe that the person in crisis is mentally ill, dangerous and in immediate need of hospitalization and treatment. The officer is authorized to take the person into custody for the purpose of transporting the person to a local health care or psychiatric facility In those cities or counties that have a CIT Program, the CIT officers use the 24 hour detention. The CIT officers are trained to conduct a field assessment to determine if an immediate detention is necessary. Typically, the CIT officer will assess whether the situation can be handled without a detention. However, if the decision is made to exercise an immediate detention, the person is transported to an appropriate medical or psychiatric facility for the purpose of a psychiatric assessment. The psychiatric assessment must take place within 24 hours from the time the individual is admitted into the facility. Depending on the assessment, the assessor may release the person or decide to seek an emergency detention (72 hour) or a commitment. Emergency Detention (72 hour detention) An emergency detention can be initiated by a law enforcement officer, emergency medical personnel, family, friends or anybody who believes that the individual is (1) mentally ill and (2) either dangerous or gravely disabled and (3) in need of immediate restraint. In order to obtain an emergency detention, a petition must be signed by the party seeking the emergency detention. The petition must include a medical statement from a physician that is based on either a personal examination of the individual or on information provided to the physician by a third party that indicates that the individual may be mentally ill and is dangerous and/or gravely disabled. If you are in a situation where you believe something dangerous is about to happen to you, to others or to the person with mental illness, call the police department or the local crisis intervention unit immediately. For your sake, and for the sake of your loved one as well, it is imperative that you not put yourself in harm s way. Sometimes a person with mental illness creates such a risk of injury that s/ he must be held in custody before a petition for commitment can be filed. In these cases, an emergency hold can be placed to temporarily confine the person in a secure facility. Emergency holds last for 24 hours (not including weekends and holidays). An emergency hold does not necessarily result in starting the commitment process. It only serves as a way to assess the individual to determine if commitment is necessary. Once the petition has been prepared, the petition is submitted to a court. This may be done in writing or orally. The court must approve the petition and the approval may be in writing or orally. Once the court approves the petition, a law enforcement officer is authorized to take the individual into custody and to transport the individual to a health care or psychiatric facility. The length of the detention is not to exceed 72 hours, commencing from the time the court issues the order approving the detention; however, by statute, the 72 hours excludes Saturdays, Sundays and legal holidays. 7

12 During the detention, the individual is examined and assessed. If the physician determines that there is no probable cause to believe that the individual is mentally ill and either dangerous or gravely disabled and in need of continuing care and treatment, the individual is discharged from the facility. If the examining physician believes that probable cause does exist for continuing involuntary detention, a report is filed with the court requesting an involuntary commitment prior to the expiration of the 72-hour period. Within 24 hours of receiving the report, a hearing on the petition for involuntary commitment must be scheduled to take place no later than 2 days from the date of the receipt of the report. The statute provides for the hearing to take place in two stages if the court chooses to conduct the hearings in such a manner. If conducted in two stages, the first stage is the scheduling of a preliminary hearing to determine if there is probable cause to proceed with the involuntary commitment. If the court conducts a preliminary hearing and determines that there is probable cause to proceed with a hearing on the Petition for Involuntary Commitment, a final hearing must be scheduled within 10 days of the date of the preliminary hearing. Some courts conduct just one hearing and eliminate the need for both a preliminary and final hearing. Physician/Judicial Hold A physician/judicial hold occurs when a person, having voluntarily agreed to receive treatment in an in-patient setting, now desires to terminate the treatment and leave the facility. The person must give written notice of his or her desire to be released. The physician has 24 hours to make a decision as to whether to release the patient. If the physician has reason to believe that the patient is mentally ill and is dangerous and/or gravely disabled and in need of continuing care and treatment, the physician has 5 days to file a written report to the court in the county in which the patient is hospitalized, or is a resident, and request a commitment hearing. The court will issue an order of judicial hold. The judicial hold requires that the patient remain in the facility until the hearing, which must occur within 2 days of the court receiving the physician s report. The hearing may be either a preliminary hearing or a final hearing. If a preliminary hearing is conducted, the final hearing must occur within 10 days of the preliminary hearing. Commitments There are two types of involuntary civil commitments. A temporary commitment is a commitment that is a period of time not to exceed 90 days. A regular commitment is a commitment for an indefinite period of time, subject to mandatory annual review. An involuntary commitment authorizes the care provider to provide treatment in a setting that the caretaker determines to be the least restrictive given the existing psychiatric condition of the mentally ill person. The care may be in-patient care in a local facility or at one of the state operated mental health facilities. The care may consist of out-patient treatment with the person living in a sub-acute facility, a group home, or the person s private residence. For a temporary commitment, a petition is filed with a court in the county in which the patient resides or where the patient is located. 8

13 An involuntary civil commitment proceeding is typically initiated by the filing of a petition. The petitioner is the person seeking the commitment and the respondent is the person that the petitioner is seeking to have committed. The petitioner must be at least 18 years of age. The petitioner is often a member of the staff of a treatment facility where the respondent is being treated, but the petitioner can also be a family member, friend or someone in the community. However, we recommend that whenever possible, family members NOT be petitioners. The petitioner does not always have to complete and file the petition on his own. The person who prepares the actual petition may vary from county to county. Treatment facilities may prepare their own petitions. In hospitals, a social worker usually represents the hospital at the commitment hearing. The petition must include a physician s written statement whereby the physician states that the physician has examined the respondent within the past 30 days and that the physician believes that the respondent is mentally ill and either dangerous or gravely disabled and in need of custody care or treatment in an appropriate facility. The most important thing a family member can do to help with this is to provide a documented mental health history of the person in crisis. This, plus an understanding of Indiana law, will be the keys for you to find and receive the services needed for your loved one. A form to help you do this can be downloaded from the NAMI Indiana web site (www.namiindiana. org) (This web site also contains specific information about managing a psychiatric crisis in the county in which it is occurring.) Having this information written down will make it easier for you to remember events later on, especially if you testify in court during commitment proceedings. Without notes, it might be hard for you to remember details about who was there, what everyone said and what happened. You need to be able to state why a commitment is necessary. Tell the team about alternatives that have been tried and why the person needs treatment. Upon receipt of the petition, the Court has 3 days to enter an order setting a hearing date on the petition. The hearing must occur within 14 days from the date of the order setting a hearing date, unless the petition is being filed at the conclusion of an emergency detention, in which case the hearing must occur within 2 days after receiving the report from the physician. (See the section on emergency detentions on page 7.) Notice of the hearing must be given to the petitioner and the respondent. If the respondent is being treated in a facility, notice must be given to the facility. At the hearing, testimony is offered by the petitioner and by a physician. Perhaps other witnesses may have to be called to provide the evidence necessary for the court to determine whether the respondent meets the statutory criteria of suffering from a mental illness and being dangerous and/or gravely disabled. Generally, you can only testify about things that you have seen or heard directly, not what you learned through talking to other people. Be sure to dress appropriately for court, respond directly to the questions asked and follow the directions of the judge. There must be clear and convincing evidence that the respondent meets the statutory criteria. If the court determines that there is clear and convincing 9

14 evidence that the respondent meets the statutory criteria, the court enters an order of involuntary commitment. The court will commit the respondent to the care of an appropriate treatment facility. If the court determines that there is no clear and convincing evidence that the respondent meets the statutory criteria, the person is ordered released from any facility in which the individual may be a patient and the petition is dismissed. Sometimes it is difficult for family members of the mentally ill individual to accept a court s decision that the evidence offered does not clearly convince the court that the individual is mentally ill and dangerous and/or gravely disabled. Oftentimes it is not difficult to prove that the individual suffers from a mental illness; however, it is more difficult to prove that the mentally ill respondent is dangerous and/or gravely disabled. In the event that the court determines that the statutory criteria were not met, family members should not be discouraged from pursuing petitions for commitment in the future if there is a change in the factual circumstances of the mentally ill individual. A temporary commitment may be extended for one additional period not to exceed an additional 90 days. A petition for extension of a temporary commitment must be filed and the hearing conducted prior to the expiration of the original temporary commitment. If any additional petition is filed after two temporary commitments, the additional petition must be for a regular commitment. If a court orders a regular commitment, the court must schedule a date for the filing of a report to court (known as a periodic report) which has to be at least annually, since such a commitment is indefinite in length. The care provider must file the periodic report if it believes that the statutory criteria still exist for the commitment. If the court issues an order continuing the commitment, the respondent has the right to request a review hearing at which the care provider must present evidence that the statutory criteria still exist for the commitment. An involuntary commitment may be terminated at any time by the care provider if the care provider believes that the statutory criteria needed for the commitment no longer exist. Some Common Questions Concerning Commitment Proceedings Who can attend court proceedings? In Indiana, hearings on involuntary civil commitments are confidential and not open to the public. Typically the individuals who would be able to attend the hearing are the petitioner, any witnesses necessary to prove the petition, the physician, and court personnel. Members of the family who are not the petitioner or appearing as witnesses may attend only if the respondent consents to the presence of the family members in the courtroom. You can contact the clerk of the court to determine when and where the hearing will be conducted. Can you communicate with the respondent prior to or after the hearing? If the hearing occurs in the court and the respondent is an in-patient, the respondent will typically be brought to the courtroom by law enforcement officers, usually sheriff s deputies. The law enforcement officer is in charge of supervising and monitoring the patient. It is up to the officer in charge and the court as to whether they will permit family 10

15 members to sit with and/or communicate with the respondent before or after the hearing. It is important for family members to be supportive of the respondent through this process and while attending hearings. In most instances, communicating with the individual is a gesture that most respondents probably appreciate. It is valuable for preserving the relationship. If the person with the mental illness is being held in a facility during the commitment process, family members may contact the treatment facility to arrange a visit. Be slow and methodical in what you say. Be accurate and honest. It helps to bring in what you want to say in writing. MG The system seems designed to not work very well. Don t let frustration stop you. Be persistent. Be assertive and even aggressive if necessary. Always be respectful and speak with authority. Don t assume anything and always get everything in writing. EE "When I was newly into caring for my mentally ill son, I was not prepared for the court hearing. I did not present my concerns forcefully enough - about him not eating and no food in his house. When it was the psychiatrist's turn to speak, he said, No comment" so the judge had to let my son go. Be prepared when you go to court. Write down everything that causes you concern, and fight for the mental health treatment that will help your loved one, even if it involves commitment. My son was so sick that he admitted himself to the same facility three days later. PP What are the rights of the respondent? A respondent must be given advance notice of a commitment hearing and be present at the hearing and testify unless the respondent is disruptive or it is determined that it would be injurious to the respondent s mental health to participate in the hearing. The respondent is entitled to receive a copy of the petition. A respondent is entitled to representation by an attorney. The attorney may be a private attorney; however, most courts provide or appoint a public defender to represent a respondent in commitment proceedings. Who pays for commitment? Just because you act as the petitioner does not mean you have to pay for the person s treatment. Treatment costs may be paid by: private insurance, government programs, the individual with mental illness, or, in rare instances, the county. Although you should talk to the hospital staff or the county case manager about your specific situation to determine the cost and payment of care, here are a few general guidelines to keep in mind: Generally, who pays depends on where the care is given and what programs people are eligible for. If the patient is covered by a private insurer, the insurer is billed. If the person is between the ages of 18 and 65 and has no insurance, the person is ultimately responsible for the cost of treatment. In these cases, the person is usually committed to a state facility and the facility will bill the person and his or her spouse or guardian on the basis of his or her ability to pay. If the person is unable or unwilling to pay for the treatment, the state can apply to be payee of the person s Social Security or VA benefits, file liens against real estate owned by the patient or his or her spouse, file claims in his or her guardianship, or file claims on his or her estate after death. 11

16 The public defender must represent the wishes of the person who is being committed. This may seem very frustrating since your loved one s wishes may not coincide with his or her best interests. DH Social Security: IMPORTANT! Very often, a person with severe and persistent mental illness is unable to work and must depend on financial assistance from Social Security. Gaining access to this support can take time, and so it is crucial that you contact Social Security immediately after you get a diagnosis for your loved one. Call (or use the web site Do this to establish your intent to file an application, even if you don t actually file an application during this call. This will establish your protective filing date. Social Security pays disability benefits through two programs the Social Security Disability program (SSDI) and the Supplemental Security Income program (SSI). After it has been determined that your loved one who has a mental illness can no longer work, you can call Social Security to schedule an appointment to file the actual application or go online and file the claim. Juveniles Indiana provides that a juvenile court may commit a child to a child-care institution. A child care institution is defined as an institution operating under a license issued by the state of Indiana that provides for the delivery of mental services appropriate to a juvenile and complies with various rules adopted by the Division of Family and Children Services. If the commitment or placement of the child to a facility other than a child-care institution is necessary, commitment proceedings may still take place but would by done by the court that would normally have jurisdiction of civil commitments. Oftentimes a commitment is not necessary because the parent or guardian is in the position to give consent for the placement of the child into a hospital or mental health treatment center. What You Can Do to Facilitate This Process Contact NAMI Indiana, your local Community Mental Health Center, or Mental Health America (formerly known as the Mental Health Association) to assist family members or friends in the process. The petition for commitment needs to be supported by the report of a licensed physician or psychiatrist who has examined the person with mental illness within 30 days of the filing of the petition. The examiner must provide a written statement describing the person s diagnosis and behavior and stating that the person needs to be committed. This is called the support statement and becomes part of the petition. 12

17 Keeping a Mental Health History Here are some examples of questions you should be able to answer about the person with mental illness; constructing a Mental Health History will make it possible for you to do this. Refer to the NAMI Indiana web site (www.namiindiana.org) for a downloadable form that can help with this. It is worth pointing out that being prepared with this information can also be invaluable in applying for Social Security Disability benefits. Background information: Name, age, current location/address, social security number, and names of family members. Behavior: Has s/he made verbal or physical threats? Is s/he verbally or physically abusive? Has s/he mentioned suicidal thoughts or plans? Has s/he attempted suicide? Has s/he he acted irrationally? Diagnosis/Symptoms: What is his or her diagnosis? Why do you believe s/he has a mental illness? What signs and symptoms do you see? Medical care providers: Does s/he have a therapist, psychiatrist or other doctors? Who are they and how can they be reached? Mental health treatment history: Has s/he been hospitalized or received outpatient care? If so, when (year and month) and where? Medications: What medications have been prescribed? Does s/he take the medication as prescribed? Did they help? Did they have severe side effects? What medications was s/he on in the past? Never give up hope. Know your rights. Keep records of your loved one s behavior. Work with the system and make the system work for you. EE We need to advocate and support pharmaceutical companies that risk a lot to seek new and more effective medications to help our loved-ones have a better chance at effective recovery from these biological brainbased disorders that we call mental illnesses. JL Overall health: Does s/he have health problems in addition to his or her mental illness? What are they? Alcohol and other drug use: Does s/he use alcohol or other drugs? Has s/he admitted to alcohol or other drug use? Which drugs does s/he use? How much and where does s/he get them? How does s/he pay for them? Have you seen the person high or intoxicated? Weapons: Does s/he have access to a gun or other weapon? 13

18 Police record, court involvement, accidents: Has s/he ever been arrested, spent time in jail or prison? List dates and charges. Self-care: Does s/he shower, change clothes, and wash clothes? Does s/he do dishes and keep the house/apartment clean? Diet: Is the person eating? Has s/he lost or gained weight? If so, how much and over how much time? Sleep: Is the person able to sleep? If not, how many days have there been with out sleep? Housing: Where is s/he living? How long has s/he lived there? Is it a stable living environment? Employment history: Currently employed? When did s/he last work? How has his or her illness affected his or her ability to work? Financial information: Does s/he pay rent and other bills? Does s/he have insurance? It is OK if you can t answer all of these questions. It would be difficult to provide information on all of these categories. In some counties, if the family member is living in the community or in your home, and you are the petitioner, you should not be surprised if you are asked to arrange for an examiner to assess the individual and prepare a statement for the court. You can talk to the person s family doctor or psychiatrist. ALTERNATIVES to INVOLUNTARY COMMITMENT There are basically two alternatives to involuntary commitment to a psychiatric treatment facility to manage a psychiatric crisis: (1) Voluntary admission; and (2) Managing the psychiatric problem on an outpatient basis. Both alternatives require cooperation from the person in crisis, which may be problematic. The chances for cooperation can be increased by having a Psychiatric Advance Directive (PAD). This is a document that is prepared in advance by a person with serious mental illness (SMI) during a period of lucidity, in which instructions for preferred modes of treatment in cases of psychiatric emergencies are specified, and power of attorney is granted to a trusted individual, authorizing him or her to make medical decisions on behalf of the person with SMI when he/she is not of sound mind. Although these Psychiatric Advance Directives can be rescinded, they do increase the chances for cooperation by the person who is in crisis. Another approach, particularly if there is enough time available, is to benefit from the second half of the book by Xavier Amador, I Am Not Sick; I Don t Need Help. There, Amador outlines a specific series of steps that can be used to persuade a person who has mental illness to cooperate with devising and carrying through with a treatment plan. 14

19 GLOSSARY Listed below are acronyms and terms that might need some clarification: 24/7 24 hours a day, 7 days a week; usually used in reference to the time of availability of services of some kind. 24 Hour Hold See ID, Immediate Detention (page 16). 72 Hour Hold See ED, Emergency Detention (below). ACT Assertive Community Treatment is a team approach that provides care for persons with mental illness on a 24/7 basis, with the care brought to the person s residence, rather than requiring the person to come to a mental health facility. Usually restricted to treating the most severely ill, who are least likely to be able to keep appointments. Anosognosia The condition in which a person with severe mental illness (SMI), as a part of that illness, is unaware of his or her condition. It is exhibited in approximately half of all persons with SMI. This condition makes it especially problematic to get help for such persons. The book by Xavier Amador, I m Not Sick; I Don t Need Help, is especially helpful in dealing effectively with this condition. CIT Crisis Intervention Team, a selected subset of emergency responders (usually police) who volunteer to have targeted training in dealing effectively with persons who are in a mental health crisis. This training involves learning about mental illness, and techniques of de-escalating crisis situations. A crucial part of a successful CIT program is to gain cooperation with the local mental health facility that includes its agreeing to deal promptly with persons in psychiatric crisis who are brought in to them, allowing the CIT officer to return to duty with a minimum of delay. In calling 911 in a psychiatric emergency, one should always ask that a CIT officer be sent to deal with it. If it turns out that your community does not have a CIT program, work diligently to see to it that one is established as soon as possible. CMHC Community Mental Health Center ED Emergency Detention, or 72-hour hold, can be put in effect when a petitioner (who can be family, friend, or emergency responder, but most often is a psychiatric worker at the institution to which the person in crisis has been brought via a 24-hour hold) judges that the person in crisis cannot be dealt with adequately in 24 hours. To put this in effect requires a petition that must be approved by a judge. EDO Emergency Detention Order, which is what a judge issues to authorize an Emergency Detention (72-hour hold). ER Emergency Room, a section of a hospital that is set up to deal with crisis situations. No one can be denied treatment by emergency room personnel, regardless of whether or not the patient is able to pay for the services rendered. It is also the most expensive form of medical care, but often the only option that is immediately available. 15

20 Hearing on Order to Treat A hearing by a judge of arguments by (usually) a mental health facility to administer psychotropic medications to a person with mental illness who does not wish to take them. This is distinct from a commitment hearing, but can occur in the same session in which a commitment hearing is being conducted. HIPAA The acronym for the Health Insurance Portability and Accountability Act of 1996 which, in addition to specifying conditions with regard to insurance portability, puts restrictions on what can be revealed by a health provider to persons other than the person being treated by the provider. These restrictions can be a significant problem in managing the treatment of a person with mental illness (or any other illness), and a great source of frustration to family members and friends trying to improve that treatment. One very important fact to keep in mind: HIPAA does not restrict what a family member or friend can tell a health provider, and so HIPAA restrictions do not apply in instances in which this information is being offered. ID Immediate Detention, or 24-hour hold, can be ordered by an emergency responder (usually a police officer) who believes that the person in crisis is a danger to self or others, or is gravely disabled. This process does not require the involvement of a judge. IDO Immediate Detention Order, which is what an emergency responder issues to authorize a 24-hour hold. A judge is not needed in this process. Imminent Risk of Harm Situation in which there is an immediate danger of self-harm being done, or harm to someone else, usually by a person with mental illness who is in crisis. In Indiana, imminent is not a part of the requirement for justifying involuntary hospitalization. In-Service Training On-the-job training designed to provide knowledge and skills useful to improve performance of that job, or to extend the range of activities associated with that job. CIT training is an excellent example of this, as well as NAMI s Provider Education Program for mental health providers. MHC Mental Health Center MHP Mental Health Provider MICA Mentally Ill/Chronically Addicted (dual diagnosis). Approximately half of the population of persons with severe mental illness also have a problem with substance abuse. In treatment, it is crucial to treat both problems in parallel. PAD See Psychiatric Advance Directive (page 17) PCP Personal Care or Primary Care Physician (family doctor) Petitioner The person who files a petition with the court is called the petitioner. Any interested person may file a petition for commitment. The petition tells the court the reasons the person with mental illness should be committed. The family should do everything possible to make sure that the petitioner is a professional such as a doctor, because the person with mental illness is often angry at whoever initiates the process. Petitions are often filed by hospitals or treatment facilities but family members and people in the community may file them, too. 16

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