How a person becomes involuntarily committed

May 30, 2013

Exactly one year has passed since an angry and unstable man killed four people at Seattle’s Café Racer and one more woman near downtown before shooting himself. Ian Stawicki was never diagnosed with a mental illness, but he exhibited many of the signs.

When someone is in a mental health crisis, who decides if the or she gets hospitalized involuntarily?

The job falls on state-certified “mental health professionals” empowered to determine whether someone gets held for 72 hours in a hospital.

Call screeners and their outreach work

The process starts with a phone call to the crisis hotline. In King County, if you dial the Crisis Clinic to report an urgent mental health situation, you’ll end up talking to a screener at the Department of Community and Human Services. The screener focuses on getting a detailed report of what’s happening, and learning as much of the person’s history as possible.

Screeners are typically social workers and counselors who get certified as designated mental health professionals (DMHPs). King County has a team of 29 professionals who work shifts around the clock. They received more than 8,000 calls last year, and sent an outreach team to investigate three-quarters of the calls.

Deb Clark, who has been an DMHP for nearly 12 years, is partnered with Racheal Stuth. In King County, all outreach is on a buddy system. Other counties operate differently, and some contract out the job.

On a recent day, I tagged along as they made their rounds.

'That’s his choice'

Their first call was to see a man who has become increasing disorganized in thinking processes, to the point of becoming psychotic, according to his case manager.

“He believes he was sent by God and is Jesus Christ,” says Clark, as she peruses his file.

The man, a Vietnam vet in his 60s, held down a job for at least 20 years, but has also been homeless and in and out of treatment for a long time. He’s currently in a cheap motel on Aurora Avenue. The mental health file, an inch thick, says he was once thrown in jail after smashing a window on a bus.

They spend time reading the file first, to learn the person's patterns, but also so they're not caught by surprise by someone with a violent past.

“We’re going out, and it’s just she and I evaluating the person. And our safety is paramount also,” says Clark.

When they arrive at the motel, Stuth parks the car out of view of the man’s room. A loud dog barks nearby.

The man stands in the open doorway as the women approach. He’s friendly, a small older man—not intimidating. In fact, he's pretty mellow. The place is a mess, and the man a woman’s scarf tied over his pants. 

After a 20-minute conversation, he agrees to visit his case worker.

“We’ll let Jeremy know you’ll probably be coming down,” Clark says.

The women decide he has symptoms of illness, but not enough to meet the legal hurdle for involuntary hospitalization.

“Would it be good for him to be on his meds? Absolutely. To live to a standard that you and I would want? Sure. But that’s his choice,” says Stuth.

He loses his choice if he’s a danger to himself, others or property, or if he can’t care for himself. Those lines are drawn in Washington's Involuntary Treatment Act.

'There's nothing I need help with’

Clark and Stuth call back to the office. The screener has another case for them, sending them straight to an apartment building just north of downtown Seattle for people transitioning off the streets. 

They read a few pages of the case history over the phone, as Clark takes notes.

“A paranoid-schiz,” she says. “She was detained once.”

The case workers at the housing facility have called because they’re alarmed about a woman, in her 60s, who seems to be deteriorating. She’s disappeared onto the streets for weeks at a time, and, now that she’s back, seems to be getting much worse.

“This patient is increasingly psychotic, and made a statement to kill someone. And nobody knows who that person is. I mean, we have a name, but we don’t know if he’s real,” Stuth says.

We later learn that the woman fears an infamous thief is stalking her.

Staff say the woman has lost 30 to 50 pounds in the past month or so. She’s also lost her front teeth, and reportedly has some medical conditions as well.

Stuth and Clark find her watching TV in the lounge.

Their standard introduction includes a disclaimer alerting the patient to the fact that they are King County mental health professionals—here to help, but with the power to require hospitalization. Just like in a police contact, they offer her the right to remain silent.

“You have the right not to speak to us if you don’t want to,” says Clark. “We hope that you do.”

“I don’t get this," says the woman. "Look, there's nothing I need help with.”

The woman has spiky gray hair and piercing eyes. Stuth asks her about some comments she might have made, threatening someone, which she denies. They ask a lot of questions about her health.  She says she doesn’t want any of her prescriptions, not even her heart medicine.

“I feel a lot of electricity in my body. That causes pain and I take aspirin. I get rest. I take walks,” she says.

“What about psychiatric medication?” Stuth asks.

“I don’t need any of that,” she says.

Let's do a NED

The interview focuses on her health and what she’s doing about it. Clark and Stuth keep it all matter-of-fact, but glance at each other. Later, they say the glance meant something specific–a “non-emergency detainment” which they call a “NED.”

“Without taking medications—and she has deteriorated—I don’t see how that’s going to be reversed without being in the hospital,” Clark says.

It turns out the woman actually had a heart attack in February, so those medications are crucial.

“What helps make a case here is that staff hasn’t seen her like this before,” Stuth says, adding they rely on the staff reports to know how much she has declined from her baseline.

If she posed an imminent danger, they could call an ambulance—and police, if necessary—and take her straight to an emergency room for 72 hours.

In this case, there is no imminent danger, but she is declining to the point where she’s losing the ability to care for herself. The law allows for a NED, if they take paperwork to a judge and he grants a court order to hospitalize the woman. That often takes an extra day, so they’ll meet the ambulance at the housing facility the next morning.

'You have to want to assist people'

Clark and Stuth say they’re looking for whatever it takes to stabilize an individual. Sometimes, it’s enough to come offer advice. Nearly half the time they visit, they end up committing the person. But it has to be within the laws that protect personal freedoms.

“You are here to serve people who have been disenfranchised,” says Shuth. “You have to want to assist people.” And, she says, every case is different. 

They also visit a lot of families who’ve never dealt with the mental health system before. Those can be harder cases to evaluate, because families aren’t keeping careful written records that courts prefer, documenting a decline or a pattern of behavior.  

However, a new state law taking effect next year allows these investigators to give more weight to family testimony about deteriorating behavior.

Still, calling government authorities for help can be a complicated choice for families who worry about alienating a son or a daughter.