Full Answer Section

• • Who Can Pick Up After Release: This depends on the patient’s condition and disposition plan. If stable and capable, the adult patient can leave on their own. Often, arrangements are made with family members, friends, or designated support persons. If transferring to another facility or level of care, transport is arranged. If the patient remains gravely disabled but no further hold is pursued, social services may be involved in discharge planning.

• Child/Adolescent Emergency Hold (WIC 5585):

  • Who Can Initiate: Same categories as adults (peace officer, designated facility staff, mobile crisis, etc.).

  • Criteria: Similar criteria apply – as a result of a mental disorder, the minor must be a danger to self (DTS), danger to others (DTO), or gravely disabled (GD). Gravely disabled for a minor also includes being unable to use the elements of life essential to health, safety, and development provided by others.

  • Duration: Up to 72 hours for evaluation and treatment.

  • Who Can Release: Similar to adults, the treating psychiatrist or psychologist can release the minor before 72 hours if criteria are no longer met. Parent/legal guardian involvement is central to discharge planning.

  • Who Can Pick Up After Release: Typically, the minor must be released to their parent(s) or legal guardian(s). Exceptions might involve Child Protective Services (CPS) involvement or if the minor is legally emancipated.

2. Differences Among Commitment Types (California Example)

• Emergency Hospitalization for Evaluation/Psychiatric Hold (WIC 5150/5585): This is the initial, short-term (up to 72 hours) involuntary detention for emergency evaluation and crisis stabilization. The legal threshold is lower (“probable cause” to believe the criteria are met). It does not require a court order initially but mandates evaluation by mental health professionals. Its primary purpose is immediate safety and assessment.

• Inpatient Commitment (Certification for Further Treatment): If, after the 72-hour hold, the individual continues to meet criteria for DTS, DTO, or GD and requires further inpatient treatment involuntarily, specific legal “certification” processes must be followed.

  • 14-Day Certification (WIC 5250): Requires signatures from two authorized professionals certifying the ongoing need based on DTS, DTO, or GD. The patient has the right to a certification review hearing (an administrative hearing at the hospital) and a writ of habeas corpus (judicial review).

  • Additional Certifications: Depending on the criteria (e.g., continued DTO, GD), further periods of commitment may be sought (e.g., additional 14-day hold for suicidal patients, 30-day hold, 180-day post-certification for dangerousness, temporary/permanent LPS Conservatorship for Grave Disability). These involve increasing levels of legal review and patient rights protections.

• Outpatient Commitment (Assisted Outpatient Treatment – AOT / “Laura’s Law” – WIC 5345 et seq.): This is a court-ordered mandate for an individual with severe mental illness to participate in outpatient treatment programs while living in the community. It is intended for individuals with a history of poor treatment adherence resulting in hospitalizations, arrests, or violence. Criteria are specific (e.g., history of multiple hospitalizations/violence, unlikelihood of surviving safely without supervision, likelihood of benefiting from AOT, AOT being the least restrictive option). It requires a formal court process and monitoring of compliance.

3. Capacity vs. Competency

While often used interchangeably in casual conversation, these terms have distinct meanings in mental health and legal contexts:

• Capacity: This is a clinical determination regarding a patient’s ability to make specific decisions. It assesses whether the patient can:

  1. Understand relevant information about their condition and proposed treatment.

  2. Appreciate the situation and its likely consequences (including risks/benefits of acting or not acting).

  3. Reason or manipulate the information logically to compare options.

  4. Communicate a choice.
     Capacity is task-specific (e.g., capacity to consent to medication, capacity to manage finances) and can fluctuate with the patient’s mental state. Clinicians (doctors, psychologists) assess capacity.

• Competency: This is a legal determination made by a judge in a court of law. It refers to a person’s overall ability to understand and participate in legal proceedings (e.g., competency to stand trial) or to manage their own affairs (e.g., competency to make contracts or a will). While clinical assessments of capacity inform legal competency hearings, only a court can declare someone legally incompetent. A person is generally presumed competent unless adjudicated otherwise.

In essence: Capacity is clinical and decision-specific; Competency is legal and more global. A person might lack the capacity to make complex medical decisions during an acute psychotic episode but still be legally competent overall.

4. Legal and Ethical Issues: Patient Autonomy

• Topic: Patient Autonomy (The right of individuals to make their own decisions about their body and healthcare).

• Context: Treating Psychiatric Emergencies.

• Legal Issue: The primary legal issue surrounding patient autonomy during psychiatric emergencies is the lawful basis for overriding it. Involuntary holds and treatments are significant infringements on fundamental liberty rights and the right to bodily integrity. The legal issue is ensuring that the criteria defined by statute (e.g., WIC 5150 criteria in CA) are strictly met and documented, providing the legal justification for depriving the patient of their autonomy temporarily. If procedures are not followed, or criteria are not met, the hold/treatment can be deemed unlawful, potentially leading to litigation (e.g., false imprisonment, violation of civil rights). Laws provide specific due process protections (like hearings) to balance safety needs with patient rights.

• Ethical Issue: The core ethical issue is the conflict between the principle of Respect for Autonomy and the principles of Beneficence (acting in the patient’s best interest) and Non-Maleficence (doing no harm). When a patient is deemed a danger to self or others due to a mental disorder impairing their judgment, clinicians face an ethical dilemma. Respecting autonomy might lead to preventable harm (suicide, violence, severe self-neglect). However, overriding autonomy through involuntary treatment involves coercion and risks undermining trust and patient dignity. The ethical challenge lies in determining when the impairment is severe enough to justify overriding autonomy, ensuring the intervention is the least restrictive necessary, maximizing patient involvement as much as possible even during involuntary treatment, and acting transparently to preserve the therapeutic relationship despite the coercive nature of the intervention.