Background:
Unfortunately, there are times when an individual becomes so ill that dangerous situations are created. Often, those who become this ill are the very people who are most likely to refuse to receive treatment. In these scenarios, it is common that the only way to help that person is to force treatment upon them. This is a harsh and intrusive remedy, but one of our laws allow us to pursue if the person's illness meets a certain threshold. This article is to explain the requirements which must be met to implement involuntary treatment.
In Arizona there are four grounds for involuntary commitment: gravely disabled, danger to others, danger to self, and persistently and acutely disabled. For an involuntary evaluation to be commenced, the proposed patient must both fall into one of these four categories, and be unwilling or unable to undergo a voluntary evaluation. The purpose of this article is to give the reader an understanding of the four standards and what they might look like.
Gravely Disabled (GD):
Gravely disabled means that a person is so very ill that she is unable to meet her own basic physical needs. Basic physical needs are food, clothing and shelter. While it is always tragic when involuntary treatment must be implemented, Gravely Disabled is the most heart wrenching of all. It means a mental illness has overcome a person to the extent that the person cannot function at the most basic level.
An example of GD is a person whose voices tell them that food is poisoned and therefore will not eat. Or one whose thoughts are disorganized enough that taking a shower or using a toilet is impossible. Or depression so deep that going to the grocery store for food or going to necessary doctor's appointments are unattainable t
asks. The examples could go on forever, but the bottom line is GD means that mental illness prevents one from performing life's most basic tasks.
If the court finds that someone is gravely disabled, it can order that person to up to 365 days of inpatient or outpatient treatment, or any combination of the two. The court order may also be extended by renewal, instead of going through the entire COE/COT process again.
Danger to Others (DTO):
This standard means that as a result of the person's mental disorder, judgment is so impaired that he or she is unable to understand the need for treatment, his or her continued behavior can reasonably be expected to result in serious physical harm.
Now, there are two clarifying points here. First, the behavior does not mean there needs to be recent dangerous conduct. Many mental health practitioners will proclaim that there needs to be some threat made, or dangerous act conducted. This is not the case. The standard means that the behavior exhibited would lead a competent medical professional to expect serious physical harm is likely to result. To clarify my point, let's say that a severely mentally ill son has attacked his father with a knife three times in the past. Before each attach the son followed the same pattern. A week before the attacks, the son started to talk incessantly about his father's employment with the F.B.I. The day before the attacks he glared at his father and followed him around the house. If analyzed in a vacuum, there is nothing particularly dangerous about these actions. There is no overt threat or dangerous act. But putting all the facts together, a medical professional would reasonably expect serious physical harm to result and thus this behavior is DTO.
Second, while the statute does not include the word imminent, the danger must be imminent. This is backed up by language at other places in the involuntary commitment statutes and by the case law. So if there is a strong belief that harm is to come, but it is likely to be months down the road, the person is not DTO.
Common examples of DTO behavior is a person who has been very sick, acting oddly, and then makes a threat like, “I'm going to hurt/kill you.” Or, there are families who have been physically attacked by a loved one many times in the past. And every time an attack comes, the mentally ill person starts to do X or Y. This is DTO type behavior.
Or it may be something non-oral like a gesture, or something physical like pushing a family member against the wall. This can be a wide variety of behaviors but the thing to remember when filling out the application is that it must be a behavior or series of behaviors - it can't be circumstantial.
Danger to Self(DTS):
The danger to self statute is fairly simple. It says danger to self is:
“behavior that as a result of a mental disorder constitutes a danger of inflicting serious physical harm on oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individuals previous acts, it is substantially supportive of an expectation that the threat will be carried out, and that without hospitalization the behavior will result in serious physical harm or serious illness to the person.” A.R.S. 36501
Most basically, this means the person has made a threat, inflicted an injury, or started preparations for self-harm. This could be in a statement made orally to a friend or family member. It could also be written down in a note or on a Facebook post. Or is could be a series of behaviors that paint a picture of danger. It could also be some act like buying materials to carry out a previously spoken plan (buying rope after talking about hanging oneself), swallowing pills, or walking into traffic. The act simply needs to be supportive of the expectation that the person will carry out the act, and without hospitalization the behavior will result in serious physical harm or serious illness to the person.
Persistently or Acutely Disabled:
The persistently or acutely disabled standard sets Arizona apart from many other states. Most states allow involuntary commitment only if the person is a danger to self or others. Arizona however, recognizes, that mental and emotional harm can be just as grave as physical harm. It therefore allows evaluation and treatment before a person ends up in a dangerous place. This is a vitally important distinction of the law.
Please be aware, it is very common that those who people trust to have accurate information on involuntary commitment, like police, fire, doctors, and even behavioral health professionals, often times provide erroneous information on the subject. It is common for one of these professionals to say that because the person is not a danger to self or others, nothing can be done. This is incorrect.
The PAD standard is this: a severe mental disorder has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm, that significantly impairs judgment, reason, behavior or capacity to recognize reality, substantially impairs the person's capacity to make an informed decision regarding treatment, and has a reasonable prospect of being treatable by outpatient, inpatient or combined inpatient and outpatient treatment.
Jared Loughner, the Tucson shooter, is the poster child for PAD. He had a severe mental disorder, diagnosed after the shooting as Schizophrenia, but clearly present before. If looking at the way his life unraveled with his friends, his family, at school, and the thoughts he was tormented with, it is clear emotional and mental harm was being suffered. The videos he made and put on YouTube show his disconnect from reality. The choices he made, at school, or when he brought a gun to his friend's apartment and left behind a bullet when kicked out, show the same. Many other behaviors display his inability to make an informed decision regarding treatment. Add to this that his disorder is commonly improved by treatment and Loughner becomes the test case for PAD.
Using the dangerous standards from most other states, Loughner could not have been taken in. In Arizona however, if written in the right way, his Application for Involuntary Evaluation should have been accepted, and an evaluation would have been conducted. The problem in Loughner situation, was that no one knew this statute could be used to take him in. But, with Loughner, and in situations similar, the PAD should be used before the situation becomes dangerous.
While Loughner is a severe case, in our office we hear about overt and debilitating illness on a weekly basis. Family members come into the office and explain that their loved one is unnecessarily is refusing treatment of serious medical conditions, is spending all their money due to a manic phase, is eating out of trash cans or living on the streets, is constantly being placed in jail or assaulted. If these behaviors result from a severe mental illness, that person may be picked up and taken in for involuntary evaluation using PAD.