Seeking Commitment
This article offers help for SMI advocates seeking involuntary treatment for loved ones and includes a sample letter that can be adapted for use in any state.
How do I best communicate the need for SMI treatment?
When individuals with severe mental illness (SMI) are in crisis, care partners (family or friends supporting the person with SMI) often find themselves searching for the right words to convince professionals that involuntary treatment is needed. Each state’s civil court system follows legal standards for involuntary treatment. By learning key words from state laws, a care partner can link those key words to the symptoms and behaviors they see in order to advocate for involuntary care.
What type of services are considered involuntary treatment?
Emergency evaluation: A psychiatric crisis in the community can lead to involuntary services if the person with SMI meets state criteria for an initial hold. This type of hold is an involuntary hospitalization for evaluation and, potentially, treatment for stabilization. Every state has its own laws and policies about who can petition for an emergency evaluation:
- Some states allow for a “citizen petition,” meaning any adult with knowledge of the circumstances can file paperwork with a local court to ask a judge to intervene and order that an evaluation be conducted. The purpose of such an evaluation is to confirm whether the person meets criteria for involuntary treatment, whether inpatient or outpatient. When using that option, care partners can incorporate key statutory vocabulary in their petition.
- In many states, only law enforcement or mental health providers can petition for court-ordered treatment. TAC’s downloadable Grading the States report includes a chart on page 38 that lists who can petition in which states. In those situations, care partners can share what they know, using key statutory words, with professionals responsible to petition.
Inpatient commitment: After doing an emergency evaluation, providers decide whether to file paperwork with the court for an involuntary hospitalization, often called a commitment. This process might be repeated if the state law allows for various time frames and/or extensions of the commitment period. A person cannot be held in a hospital setting on an involuntary basis if they are evaluated and determined not to meet those criteria. Providers, therefore, need as complete a picture as possible when making decisions about whether to petition for a patient’s court-ordered care.
Outpatient commitment: The same approach to advocacy applies in places where outpatient commitment is an option (often called assisted outpatient treatment — AOT). AOT is most commonly used as a step down from inpatient hospitalization. In some states, criteria for community-based involuntary treatment are lower than for an involuntary hospitalization, since it is a far less restrictive treatment setting. Key words can be adjusted accordingly.
When can care partners share information?
Care partners can share verbal or written information at each decision point about involuntary treatment. Never assume that information shared will automatically transfer or be reviewed. For example, you might share information with crisis responders who issue an initial hold. Plan to share that information again after your loved one arrives at the facility and again if your loved one is transferred.
Attempt to share written information through fax, as there are professional protocols for using and filing information received by fax. Always ask for the information to be reviewed, considered, and filed in the person’s medical record. Information shared by care partners does not violate HIPAA and does not require a release of information (ROI).
Pro tip: Make contact in multiple formats — verbal and written. For example, fax mental health history and then send an email and leave a voicemail requesting confirmation that the fax was received.
What should I share?
Care partners can prepare to share what they know by maintaining a timeline of symptoms, incidents, treatment, and medication. TAC provides an article and fillable form to help with development of a mental health history, which should be shared with each provider/agency every time someone is admitted into care or transferred from one program or facility to another.
Pro tip: When advocating for treatment, always share the updated mental health history with a letter of advocacy, which is a place to highlight your biggest concerns and clarify what you are asking for, such as a petition for commitment.
Who has the power to decide?
At any decision point, ask questions until you understand the authority of the person you are communicating with. For example, does their position require a concurring opinion from an additional party, such as another provider? If so, you may need to share information and concerns with more than one party.
Once you have determined that you are sharing information with the right professionals, consider what words they might be looking for — words that might come directly from state laws.
Where can I learn about state laws and services for involuntary treatment in my state?
TAC’s interactive map provides state-by-state information about treatment laws related to each possible involuntary treatment option and required criteria.
How do I know the right words to choose?
When describing a loved one’s need for treatment, you don’t need to cite specific statutes, but you can use language from state law to sculpt a full and honest depiction of the situation. One strategy is to copy and paste the statute from TAC’s interactive map into a word processing file. You can then highlight key words or trim away excess language.
Here’s an example of how to outline topics for an advocacy letter in Washington state, with language directly from statutes noted in boldface:
- Describe recent incidents that demonstrate repeated and escalating loss of cognitive or volitional control.
- Consider behaviors demonstrating that your loved one is unable to meet their essential needs for health or safety.
- Describe how past, similar, untreated symptoms have led to harm, substantial pain, or created a reasonable fear of harm to themselves or others.
The point is not to exaggerate but to connect what is currently happening to language that providers need to identify in order to pursue an involuntary treatment order. Knowing what standards must be met — and the language of those standards — can help you incorporate specific words into verbal or written advocacy statements.
As another example, Nevada grants authority for the hospitalization of someone in a “mental health crisis,” which is defined in statute as a person whose “capacity to exercise self-control, judgment and discretion … or to care for his or her personal needs is diminished, as a result of the mental illness, to the extent that the person presents a substantial likelihood of serious harm.” A care partner seeking involuntary care for a person in Nevada might highlight those words with timely and relevant details about a person’s behavior and symptoms, like this:
“My son is currently in crisis due to his inability to exercise self-control related to traffic. He has a fixed delusional belief that his body can pass through solid objects. He has stated his intention to walk into traffic in front of moving cars. He is substantially likely to be killed in a traffic accident if his psychosis is not adequately treated. During a similar psychotic episode last year, he was hospitalized for broken bones after being struck by a cargo van.”
Sample letter of advocacy
Here is a template to adapt using language from state law. You can find those laws by clicking on the state from TAC’s interactive map and then choosing “Treatment Laws” in the “Jump To” section or by scrolling down through state specific information.
Hello [name of provider],
I’m writing to provide key information about [name, birthdate ##/##/####], a person with severe mental illness [or specific diagnosis] in your care. I hope this information will help you understand the need for [emergency or ongoing court-ordered] treatment to prevent harm. I am [name’s mother, brother, friend, etc.], and I have been a primary care partner for [##] years. [If guardian, power of attorney, etc., include that here.] I have witnessed these concerning symptoms and behaviors:
- Symptom, symptom, symptom (i.e., extreme paranoia, catatonia, auditory and visual hallucinations)
- Behavior, behavior, behavior (i.e., talking to people who aren’t there, dismantling the home’s wiring to “remove bugs,” lighting fires inside the home)
- Suicide attempts or threats (be specific)
- Harm or threats of harm to others (be specific)
- Significant damage to the property of others, if included in statute
I have attached a mental health history for additional detail.
Similar symptoms and behaviors led to the current crisis. In particular, [briefly describe the most concerning recent behavior/symptom]. I’m deeply concerned that without adequate care and stabilization, [name] could be at immediate risk for [suicide, harming others, significant criminal activity, etc.]. My concern is rooted in history, as that is what happened last time a hospital [discharged or refused to admit him/her/them] in this stage of illness [include only if true].
[Describe any recent threats or acts of harm to self or others and offer to share any available evidence, such as a video, audio recording, screenshot, picture, note, etc.]
Add the following paragraph in any state that includes grave disability/psychiatric deterioration as a standard for involuntary treatment, and use language that matches the statutory language:
[Name’s] severe [grave disability/psychiatric deterioration] creates an ongoing, significant risk of harm because [he/she/they] cannot distinguish between reality and [his/her/their] delusions about [describe]. As a result, the ongoing [loss of volitional control, departure from safe behavior, wording from statute] creates a [clear and present, significant, wording from statute] risk. My realistic fear is that, if untreated, my loved one will most likely [what might reasonably happen, given the past?]
Add the following paragraph if the symptom of anosognosia is present:
This situation is additionally complicated because of [name’s] inability to recognize that they are ill and in need of treatment, a symptom known as anosognosia. This lack of insight, combined with significant symptoms of psychosis, have disabled [his/her/their] capacity for self-determination. I know this illness is not a choice, and I know my loved one wants help to find recovery but cannot make clear-headed medical decisions because of the nature and severity of this mental illness.
Please file the required paperwork to ensure that my loved one is [detained for evaluation, committed for up to a certain time, whatever this person has the power to do].
Please contact me with any questions. I can be reached by email and/or phone. Listening to my concerns does not violate HIPAA. I hope our communication can improve the outcome of this crisis.
Sincerely,
[Your name, with signature]
[email]
[phone number]
Seek legal help as needed
The information in this article is not intended to be taken as legal advice and TAC doesn’t provide legal advice on individual circumstances. TAC offers an article for those seeking legal resources.