1. Determining Dangerousness for Involuntary Commitment
Presented by:
Scott Pino
Sharon Regional Medical Center
Behavioral Health Services

2. Mental Health Procedures Act
Enacted in (amended 1978)
Designed to assure “adequate treatment” for
individuals with mental illness
Provides for Voluntary and Involuntary treatment
Provides for Inpatient and Outpatient treatment
Provides rights to individuals subject to treatment

3. Mental Health Procedures Act
Changes from the MH/MR Act of 1966 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.

4. Mental Health Procedures
Identifies exclusionary groups
Mentally Retarded
Senile (Dementia or Organic)
Alcoholic or Drug Dependent
UNLESS they are also diagnosed as mentally ill
Voluntary treatment is ALWAYS preferred

5. Mental Health Procedures
To pursue INVOLUNTARY evaluation and treatment, the following MUST exist:
Evidence that an individual may be suffering from a severe mental illness
Evidence of dangerous behavior
Probability of Continuance or Recurrence
Immediate need for treatment
Expectation that treatment will be effective

6. PA Code Title 55 Chapter
There is a definite need for mental health intervention without delay to assist a person on an emergency basis;
The clear and present danger is so imminent that mental health intervention without delay is required to prevent injury or harm from occurring;
There is reasonable probability that if intervention is unduly delayed the severity of the clear and present danger will increase; or
There is reasonable probability that the person, with his presently available supports, cannot continue to adequately meet his own needs if mental health intervention is unduly delayed.

7. Evidence of Mental Illness
Mental Health Procedures Act:
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.

8. Evidence of Mental Illness
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.”

9. Evidence of Dangerous Behavior
There are four categories of dangerous behaviors identified within the MHPA and on the MH 783 (DHS-approved 302 form):
1. Harm to Others
2. Inability to Care for Self
3. Attempted Suicide
4. Self Mutilation

12. Evidence of Dangerous Behavior
Clear and present danger to others
“shall be shown by establishing that within the past
30 days the person has inflicted or attempted to
inflict serious bodily harm on another and that there
is reasonable probability that such conduct will be
repeated.”

13. Evidence of Dangerous Behavior
Clear and present danger to others
“may also be demonstrated by proof that the person
has made threats of harm and has committed acts in
furtherance of the threat to commit harm.”

14. Evidence of Dangerous Behavior
Clear and present danger to self
“….by establishing within the past 30 days the person has acted in such a manner as to evidence that he would be unable, without care, supervision and the continued assistance of others, to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety, and that there is reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded”

15. Evidence of Dangerous Behavior
Clear and present danger to self
“the person has attempted suicide and that there is
reasonable probability of suicide unless adequate
treatment is afforded under this act. For the purpose
of this subsection, a clear and present danger may be
demonstrated by the proof that the person has made
threats to commit suicide and has committed acts
which are in furtherance of the threat to commit suicide”

16. Evidence of Dangerous Behavior
Clear and present danger to self
“the person has substantially mutilated or attempted to mutilate himself substantially and that there is the reasonable probability of mutilation unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger shall be established by proof that the person has made threats to commit mutilation and has committed acts which are in furtherance of the threat”

17. Evidence of Dangerous Behavior
What do you use to identify?
Written or oral statements from individuals who have witnessed the behaviors
Actions or behaviors of the 302 candidate
Probability of recurrence
Threats of harm plus “acts in furtherance”
Timing - Must have occurred within the past 30 days

18. Evidence of Dangerous Behavior
What do you use to identify?
Intent of the individual – behaviors do not necessarily have to be lethal (e.g.: three aspirin)
Beliefs/perceptions of the individual that place them at risk (e.g.: walk across busy street)
Lack of self-care/inability to care for self must be distinguished from poor hygiene or laziness

19. Mental Health Procedures
To pursue INVOLUNTARY evaluation and treatment, the following MUST exist:
Evidence that an individual may be suffering from a severe mental illness
Evidence of dangerous behavior
Probability of Continuance or Recurrence
Immediate need for treatment
Expectation that treatment will be effective

20. Probability of Recurrence
What do you use to identify?
The age, medical condition, available support systems,
and any known history of the individual (may extend
beyond the last 30 days)
Time elapsed between behavior and reporting to the
Delegate
The general emotional state of the individual
Current conditions related to weather, season/time of
year and other pertinent information

21. Probability of Recurrence
If the person is voicing threats to repeat or continue dangerous actions toward self or others, it is safe to consider probable recurrence of previously demonstrated acts
If the person is going through behaviors or actions similar to those that preceded the previous dangerous acts, it is generally safe to presume that another dangerous act will occur

22. Mental Health Procedures
To pursue INVOLUNTARY evaluation and treatment, the following MUST exist:
Evidence that an individual may be suffering from a severe mental illness
Evidence of dangerous behavior
Probability of Continuance or Recurrence
Immediate need for treatment
Expectation that treatment will be effective

23. Immediate Need for Treatment
Immediacy may be defined as:
A situation which requires prompt intervention in order to prevent serious harm to the person or to someone else, where a delay would produce serious consequences.

24. Immediate Need for Treatment
What do you use to identify?
Current actions endangering the individual or others are ongoing
Steps to fulfill a threat or plan for harm to the individual or others are undertaken
Threats have been made to repeat a previous dangerous action that occurred within the last 30 days

25. “Acts In Furtherance” Not specifically defined within the MHPA
Steps or actions taken toward the fulfillment of the threat
Requires the gathering of detailed information or direct observation
MHPA provides protection for the individual making these decisions: .

26. Mental Health Procedures Act
Section 7114
Holds harmless any Administrator, Director, Physician, or other Authorized Person involved in the process, in the “absence of willful misconduct or gross negligence.”
Harmless for either approval or denial of involuntary examination and treatment
Includes criminal or civil liability

27. 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”

28. Mental Health Procedures Act
Protection of the Individual’s Rights
Provisions of the MHPA must be followed, regardless of the individual’s living arrangements
A “doctor’s order” is not sufficient without the necessary petition and paperwork
Criteria must be met in order to complete evaluation on an involuntary basis.
Least restrictive measures must be utilized.
Confidentiality must be maintained

29. Mental Health Procedures Act
§ 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.”

30. 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.

31. Mental Health Procedures Act
Section – 7112
Outline Written Application/Forms/Unsworn Statements, and Confidentiality of Records:
DPW approved forms
Unsworn falsification to authorities is criminally liable
Disclosure of confidential information requires consent except for disclosure to:
Those engaged in providing treatment
County Administrator
Court in the course of legal proceedings under this act
Unless otherwise allowed by Federal rules/statutes/regs

32. Determining Dangerousness
DISCUSSION
&
QUESTIONS