1. DRUGS, ALCOHOL & THE MENTAL HEALTH PROCEDURES ACT
Presented by:
Scott Pino
Sharon Regional Behavioral Health Services

2. LEARNING OBJECTIVES:
Obtain basic understanding of the development of current commitment processes.
Identify the basic criteria and requirements, under the MHPA, for Voluntary and Involuntary Evaluation and Treatment.
Understanding / clarification of addressing drug or alcohol use per the MHPA and commitment criteria.

3. Mental Health/Mental Retardation Act of 1966
Requires provision of services for individuals with MH/ID needs.
Establishes process for entering treatment, via both Voluntary and Involuntary basis.
Outlines persons subject to the provisions of the Act.
Provides for limited rights to be provided to individuals subject to the Act (detention versus treatment).

4. Mental Health/Mental Retardation Act of 1966
Establishes County Mental Health/Intellectual Development (MH/ID) Board.
Requires County Administrator appointment.
Requires provision of services for individuals with MH/ID needs.
State centers.
State hospitals.
Local systems with defined services.

5. LOCAL SYSTEMS TO INCLUDE, AT A MINIMUM:
Short-term inpatient.
Outpatient.
Partial hospitalization.
Emergency services (24 hours/day).
Consultation and education.
Aftercare services following release from state/county facilities.
Sheltered workshop.
Rehabilitative/training.
Unified intake procedures.

6. VOLUNTARY ADMISSION UNDER MH/MR ACT
Any individual 18 or older.
Parent, Guardian, Person standing in Loco Parentis.
Signed form required.
Requires physician examination.
No longer than 30 days.
No longer than 10 days following written notice of withdrawal.
Provides for rights of the individual.

7. INVOLUNTARY ADMISSION UNDER MH/MR ACT
Relative, guardian, friend, police, physician, person standing in Loco Parentis, government or recognized non-profit health/welfare agency.
Requires written petition.
Requires 2 physician certifications.
Must occur within 30 days of petition.
No longer than 10 days.
Provides for minimal rights of the individual.

8. MENTAL HEALTH PROCEDURES ACT
Enacted in 1976, amended in 1978.
Designed to assure “adequate treatment” for individuals with mental illness.
Provides for:
Voluntary and involuntary treatment.
Inpatient and outpatient treatment.
Rights to individuals subject to treatment.
Identifies exclusionary groups.

9. MENTAL HEALTH PROCEDURES ACT
Changes from the MH/MR Act were needed for a number of reasons:
Multiple judicial decisions against the MH/MR Act.
Need for Due Process under the 14th Amendment.
Establishes/provides clear guidelines surrounding examination and treatment standards.
Moved from “medical model” toward the “recovery-oriented” system we see today.
Focused on rights to individuals subject to treatment.

10. MENTAL HEALTH PROCEDURES ACT
Requires the balance of the need for treatment with the rights of the individual
The MHPA holds several key principles as a basis for the rationale for Involuntary commitment:
There is presence of Mental Illness
There is presence of “Clear and Present Danger.”
Adequate treatment, if afforded to the individual, can improve the symptoms and remove the danger.

11. PA Code, Title 55 Chapter
Mental illness—Those disorders listed in the applicable APA Diagnostic and Statistical Manual; provided however, that mental retardation, alcoholism, drug dependence and senility do not, in and of themselves, constitute mental illness. The presence of these conditions however, does not preclude mental illness. 

12. ADEQUATE TREATMENT
“…a course of treatment designed and administered to alleviate a person’s pain and distress, and to maximize the probability of his recovery from mental illness...”
“It may include inpatient treatment, partial hospitalization, or outpatient treatment. Adequate inpatient treatment shall include such accommodations, diet, heat, light, sanitary facilities, clothing, recreation, education and medical care as necessary to maintain decent, safe and healthful living conditions.”

13. MENTAL HEALTH PROCEDURES ACT
Treatment on a voluntary basis preferred.
§ Statement of policy
“Treatment on a voluntary basis shall be preferred to involuntary treatment; and in every case, the least restrictions consistent with adequate treatment shall be employed.”

14. PA Code, Title 55 Chapter
   Least restrictive alternate—The least restrictive placement or status available and appropriate to meet the needs of the patient and includes both restrictions on personal liberty and the proximity of the treatment facility to the person’s natural environment. This concept stresses the importance of helping each person in need of services to seek those services voluntarily. The degree of restriction or the degree of separation from the natural environment is dependent upon both the severity of the person’s dysfunction and his strengths and resources to function in that environment. The range of treatment alternatives, stemming from the patient’s natural environment, through supportive services to 24-hour hospitalization, must be considered in light of the person’s capability of handling daily tasks and stress and the need, if any, for varying degrees of support or supervision. 

15. PA CODE, TITLE 55, CHAPTER 5100.3 (b)
 It is the policy of the Commonwealth to seek to assure that adequate treatment is available with the least restrictions necessary to meet each client’s needs. While this policy remains a shared responsibility between State, county, and facility personnel, the accountability for recommending the transfer to the least restrictive alternatives available remains a responsibility of those directing treatment. Adequate treatment provided in an individual’s own community or as close as possible to his own home shall be preferred.

16. MENTAL HEALTH PROCEDURES ACT
Identifies exclusionary groups:
Mentally Retarded
Senile (Dementia or Organic)
Alcoholic or Drug Dependent
UNLESS they are also diagnosed as mentally ill, or there is reasonable probability that the results of the examination would result in such diagnosis.

17. MENTAL HEALTH PROCEDURES ACT
“Persons who are mentally retarded, senile, alcoholic or drug dependent shall receive mental health treatment only if they are also diagnosed as mentally ill, but these conditions of themselves shall not be deemed to constitute mental illness.”
(Reference is made to access of “underutilized State facilities” not being prohibited by the MHPA in conflict with the Drug and Alcohol Abuse Control Act of April 14, 1972)

18. DRUG & ALCOHOL ABUSE CONTROL ACT
Enacted in 1972
Primarily focuses on:
Development and availability of services (both in the community and in detention)
Assuring rights of individuals addicted to alcohol or drugs (hospitals, insurance companies, etc.)

19. DRUG & ALCOHOL ABUSE CONTROL ACT
“Establishing the Pennsylvania Advisory Council on Drug and Alcohol Abuse; imposing duties on the Department of Health to develop and coordinate the implementation of a comprehensive health, education and rehabilitation program for the prevention and treatment of drug and alcohol abuse and drug and alcohol dependence; providing for emergency medical treatment; providing for treatment and rehabilitation alternatives to the criminal process for drug and alcohol dependence; and making repeals.”

20. DRUG & ALCOHOL ABUSE CONTROL ACT
"Emergency medical services" includes all appropriate short term services for the acute effects of abuse and dependence which: (i) are available twenty-four hours a day; (ii) are community based and located so as to be quickly and easily accessible to patients; (iii) are affiliated with and constitute an integral (but not necessarily physical) part of the general medical services of a general hospital; and (iv) provide drug and alcohol withdrawal and other appropriate medical care and treatment, medical examination, diagnosis, and classification with respect to possible dependence, and referral for other treatment and rehabilitation.

21. DRUG & ALCOHOL ABUSE CONTROL ACT
"Inpatient services" includes all treatment and rehabilitation services for drug and alcohol abuse and dependence provided for a resident patient while the patient spends full time in a treatment institution including but not limited to a hospital, rehabilitative center or residential facility.

22. DRUG & ALCOHOL ABUSE CONTROL ACT
Section 5.  Admissions and Commitments.
“--Except as provided in section 12.1 of this act, admissions and commitments to treatment facilities may be made according to the procedural admission and commitment provisions of the act of July 9, 1976 (P.L.817, No.143), known as the "Mental Health Procedures Act."

23. DRUG & ALCOHOL ABUSE CONTROL ACT
Section 12.1. Commitment of Minors.
Allows parent of a minor to petition courts for commitment to treatment
Requires court-appointed representation for the minor
Requires evaluation / assessment to be completed by qualified staff

24. DRUG & ALCOHOL ABUSE CONTROL ACT
Section 12.1. Commitment of Minors.
“ (b) (2)  Shall order a minor who is alleged to have a dependency on drugs or alcohol to undergo a drug and alcohol assessment performed by a psychiatrist, a licensed psychologist with specific training in drug and alcohol assessment and treatment or a certified addiction counselor. Such assessment shall include a recommended level of care and length of treatment. Assessments completed by certified addiction counselors shall be based on the Department of Health approved drug and alcohol level of care criteria and shall be reviewed by a case management supervisor in a single county authority.”
Section 12.1. Commitment of Minors.

25. DRUG & ALCOHOL ABUSE CONTROL ACT
Section 12.1. Commitment of Minors.
Court may order treatment up to 45 days if:
“Clear and convincing evidence” is found that the minor is drug or alcohol dependent.
The minor is incapable of accepting or unwilling to accept voluntary treatment.
The court finds the minor will benefit from involuntary treatment.

26. MENTAL HEALTH PROCEDURES ACT
“Persons who are mentally retarded, senile, alcoholic or drug dependent shall receive mental health treatment only if they are also diagnosed as mentally ill, but these conditions of themselves shall not be deemed to constitute mental illness.”

27. PA Code, Title 55 Chapter
Mental illness—Those disorders listed in the applicable APA Diagnostic and Statistical Manual; provided however, that mental retardation, alcoholism, drug dependence and senility do not, in and of themselves, constitute mental illness. The presence of these conditions however, does not preclude mental illness. 

28. PA Code, Title 55 Chapter
 (c)  Persons who are mentally retarded, senile, alcoholic or drug dependent shall be afforded mental health examination or treatment if they are also diagnosed as mentally ill, or if there is a reasonable probability that upon examination such diagnosis will be established.
 (d)  Persons in treatment under the act shall be afforded necessary diagnostic or treatment procedures as defined in their treatment plan for conditions of mental retardation, senility, alcohol, or drug abuse when it is determined that the absence of such procedures will be detrimental to the progress of the person accomplishing the goals of treatment.

29. MENTAL HEALTH PROCEDURES ACT
Due Process Rights under the 14th Amendment
Key Principles:
Presence of Mental Illness (or reasonable probability of diagnosis if evaluated)
Presence of “Clear and Present Danger” (as a result of mental illness)
Adequate treatment can improve the symptoms and remove the danger.

30. MENTAL HEALTH PROCEDURES ACT
VOLUNTARY
ADMISSIONS

31. MENTAL HEALTH PROCEDURES ACT Section 7201 – Voluntary Admission
Any person 14 years of age or over, however, parents must be notified if the individual is between 14 and 18 years of age.
Under 14, must be Parent, Guardian, or Person standing in Loco Parentis
Believes they are in need of treatment
Substantially understands the nature of the voluntary commitment
Decision to do so is voluntary

32. PA Code, Title 55 Chapter
  (b)  The test of a person’s substantial understanding for inpatient treatment is met if the person gives consent to the information and explanations outlined in section 203 of the act (50 P. S. §  4203).
 (c)  Behavorial consent, as defined in §   (relating to definitions) shall be sufficient consent for persons presently receiving treatment at a facility to remain at that facility and to participate in treatment which is explained to him. Behavioral consent shall be documented under §   (relating to explanation and consent to inpatient treatment). Behavorial consent shall not be relied upon for admission to or transfer from a facility.   

33. PA Code, Title 55 Chapter
   (a)  In order to assure that a person substantially understands the nature of voluntary inpatient treatment, an explanation shall be made to him of the findings of the preliminary evaluation and the proposed treatment and goals. An explanation of planned diagnostic and treatment procedures, including the medications, restraints or restrictions which may be utilized shall be given in terms understandable by the person seeking services.
 (b)  Each applicant shall be provided with a copy of the Patient’s Bill of Rights. Form MH-782 or the Patient’s Rights Pamphlet, PWPE #605 entitled You Have a Right To Be Treated With Dignity and Respect. Consent shall be obtained by use of Form MH-781 B, C or D.
 (c)  In the event that the consent of the applicant is given but cannot be obtained in writing, a statement on a form approved by the Department documenting that the applicant acknowledged the explanation given indicated his or her consent shall be signed by the person presenting the information and at least one witness. This statement shall be made part of the patient’s record.

34. MENTAL HEALTH PROCEDURES ACT
Section – Explanation and Consent
Explanation of treatment, inclusive of any restraints or restrictions to be imposed.
Statement of rights to be provided.
Consent in writing upon DHS-approved form, including the following items:
Statement that individual understands treatment is inpatient setting.
Name of approved facility.
Consent is voluntary.
Explanation of notification to withdraw may require individual to stay up to 72 hours.
Becomes part of the medical record.

37. MENTAL HEALTH PROCEDURES ACT
INVOLUNTARY
ADMISSIONS

38. MENTAL HEALTH PROCEDURES ACT
Section – Persons Who May Be Subject to Involuntary Examination and Treatment
Person must be “severely mentally disabled”
Must be “in need of immediate treatment”
Must present “clear and present danger of harm to others or to himself.”

39. MENTAL HEALTH PROCEDURES ACT
Section – Persons Who May Be Subject to Involuntary Examination and Treatment
“(a) Persons Subject. – Whenever a person is severely mentally disabled and in need of immediate treatment, he may be made subject to involuntary emergency examination and treatment. A person is severely mentally disabled when, as a result of mental illness, his capacity to exercise self-control, judgment, and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself…..”

40. PA Code, Title 55 Chapter
Mental illness—Those disorders listed in the applicable APA Diagnostic and Statistical Manual; provided however, that mental retardation, alcoholism, drug dependence and senility do not, in and of themselves, constitute mental illness. The presence of these conditions however, does not preclude mental illness. 

48. PA Code, Title 55 Chapter
(i)  The involuntary emergency treatment of the individual, or the arrangement of such, shall be initiated immediately but shall be limited to:
   
(1)  Conducting a physical examination.
(2)  Performing diagnostic evaluations of the individual’s mental health.
(3)  Providing that necessary treatment required to protect the health and safety of the individual and others. As a first priority, the treating physician shall seek to respond to the emergency condition necessitating commitment unless the individual consents to additional treatment.

49. How does this all fit ?
   
Levels of intoxication vary, and in PA have been determined to guide sentencing.
The first commonly-used legal limit for BAC, .15, was adopted in 1938.
Act 24, which lowered Pennsylvania's legal limit of alcohol from .10 to .08, was signed into law on September 30, 2003.
Laboratory and on-road research shows that the vast majority of drivers, even experienced drivers, are impaired at .08 BAC in critical driving tasks such as braking, steering, lane changing, distance judgment, and divided attention.

50. How does this all fit ?
The MHPA and Title 55 of the PA Code provide clear definition of who falls subject to voluntary and involuntary Mental Health evaluation and treatment.
Individuals must be diagnosed as mentally ill, or there must be a “reasonable probability” that they will be diagnosed if evaluated.
Use or presence of alcohol or drugs does NOT preclude someone from also being mentally ill and in need of treatment

51. How does this all fit ?
Neither the MHPA nor Title 55, Chapter 5100 address the issue of “intoxication” for purposes of evaluation. Instead, they address and define “substantial understanding” of entering treatment.
Keep in mind the MHPA principles as a basis for the rationale for Involuntary commitment:
There is presence of Mental Illness
There is presence of “Clear and Present Danger.”
Adequate psychiatric treatment, if afforded to the individual, can improve the symptoms and remove the danger.