Slides gte mental health webinar may 2013 for posting pre event

May 29 Live Webinar: The TDO Process 5/21/2013
2013, Sarah Bisconer & Jim Martinez 1

Current statutes and procedures governing when and how the Temporary
Detention and involuntary admission process may occur
How to initiate the Preadmission Screening and Temporary Detention process
Practical considerations to keep in mind when initiating the Temporary Detention
and involuntary admission process (e.g., helpful documentation, timing, medical
clearance, transportation, readmission to facility after treatment and stabilization)
• ALF – Assisted Living Facility
• BHA – Behavioral Health Authority
• CSB – Community Services Board
• DBHDS – Department of Behavioral Health and
Developmental Services
• DSM-IV-TR – Diagnostic and Statistical Manual of Mental
Disorders (will be replaced by DSM-V in May 2013)
• ECO – Emergency Custody Order
• ISP – Individualized Service Plan
• MOT – Mandatory Outpatient Treatment
• TDO – Temporary Detention Order

 This presentation includes material about
Virginia’s involuntary treatment process for people
with mental illness, which is based on Virginia law.
 Individual states all have their own involuntary
treatment laws.
 State laws in this area are often similar, but rarely
identical, and some individual state’s laws are very
different from those in other states.
 The situations discussed here are relevant
anywhere, so it’s important to know the laws of
your state.
 Involuntary admission is the court process by
which a petition is filed to initiate involuntary
psychiatric treatment for a person who needs care
but who is unwilling, or incapable of volunteering
for treatment (Code of Virginia, §37.2-808, et. seq)
 The petition (the case) is adjudicated by a judge or
special justice at a formal court hearing.
 Due process protections are important, but
balancing rights of individuals with community
interests and public safety can be difficult.
Treatment resources are limited and controversies
abound.

* Operational procedures vary considerably from locality to locality
CSB Crisis
Contact
Emergency
Custody (ECO)
Temporary
Detention (TDO)
Petition Filed
Court Hearing
(on petition)
Release or
Dismissal
Mandatory
Outpatient
Treatment
Voluntary
Inpatient
Treatment
Involuntary
Inpatient
Treatment
• Emergency custody and temporary detention are not required
for every involuntary admission (i.e., ECO is not required for
temporary detention, TDO is not required for commitment).
• But, both procedures are needed for due process and
practical reasons, for example:
• Emergency custody allows an in-person examination, to
confirm the need for temporary detention.
• Temporary detention allows time to organize a fair
involuntary admission court hearing.

be issued by a magistrate on a petition or his/her own motion,
or
be initiated by a law enforcement officer on his/her own
observations or the reports of others
(“officer-initiated” or “paperless” ECO).
An
ECO
may:
PROBABLE CAUSE is the evidentiary standard for emergency custody to be used.
“Under an ECO, the person is taken into custody and brought to a “convenient
location”, if needed, so that CSB can complete the “in-person” evaluation required
for temporary detention. TDO may result.
Temporary
Detention
• May be ordered if the “in-person” CSB evaluation
(i.e., the ECO evaluation) has occurred,* criteria
are met and TDO is needed.
• Occurs in a safe clinical setting, (usually a
hospital) where treatment can be started.
• During temporary detention, the hearing is
scheduled, participants are organized and
relevant information is gathered.
* There are some exceptions to the requirement for prior in-person evaluation.
TEMPORARY DETENTION IS A BRIEF PERIOD OF CONFINEMENT
ORDERED BY A MAGISTRATE (TDO) PRIOR TO THE COURT HEARING.

“…. person
(i) has a mental illness and …. there exists a substantial likelihood that,
as a result of mental illness, the person will, in the near future,
(a) cause serious physical harm to himself or others as evidenced by recent
behavior causing, attempting, or threatening harm and other relevant
information, if any, or
(b) suffer serious harm due to his lack of capacity to protect himself from harm
or to provide for his basic human needs,
(ii) is in need of hospitalization or treatment, and
(iii) is unwilling to volunteer or incapable of volunteering for
hospitalization or treatment.”
* Other specific findings and determinations are associated with each procedure.
 A preadmission screening report is required to be presented,
by the appropriate CSB, at the involuntary admission court
hearing.
 The requirements for preadmission screening report are
different from ECO/TDO evaluation requirements, but
 In almost all instances, when a CSB performs an exam for a
TDO, that evaluation also serves as the CSB’s preadmission
screening report for the subsequent court hearing.

 Only qualified CSB employees or designees may perform ECO
evaluations for TDO, and preadmission screening for commitment
hearings. Requirements are:
› Master’s degree in a clinical field recognized by the Virginia
Department of Health Professions (e.g., Counseling,
Psychology, Social Work, Rehabilitation Counseling).
› Licensed Registered Nurse with 36 months professional
work experience with a psychiatric population.
› Completed DBHDS Preadmission Screening on-line
Certification Training (a series of modules)
› CSB supervisory approval
 Documentation of above (i.e., educational credentials, supervisory approval
and completion of on-line curriculum) is maintained in CSB personnel files.
 See http://www.dbhds.virginia.gov/OMH-MHReform.htm.
TYPICAL CSB
EVALUATOR
RESPONSIBILITIES
Conduct face-to-
face assessmentsof
persons in crisis for
acute mental health
and substance use
disorders;
Collate information
from individuals
being served, family
members, other
providers, medical
and other records
and any other
source;
Provide crisis
counseling,
outpatient and
inpatient referrals.
Serve as primary
gatekeepers to
community
hospitals, state
hospitals, & training
centers, including
locating and
accessing inpatient
beds for temporary
detention.
Document
assessment findings
and determinations
in the Virginia
Preadmission
Screening Report
form.
Implement Virginia’s
involuntary
admission statutes,
including attendance
at court hearings.

COURT HEARINGS
 Court hearings must be held within 48 hours of TDO, or on the next
business day if 48-hour period ends on Saturday, Sunday or holiday.
 Persons receives explanation of rights, counsel, etc.
 Independent examination required.
 CSB preadmission screening report required.
Hearing attended by judge (usually special justice), individual
and attorney, petitioner, as well as independent evaluator,*
CSB screener* (both may participate by telecom), treating MD*
or hospital representative, family or friends.
*may participate and/or report by electronic means.
Dismissal of the
petition, and
release from
court
jurisdiction;
Voluntary
inpatient
admission for a
minimum 72-
hour period, then
48-hour notice if
leaving;
Involuntary
inpatient
admission (up to
30 days on initial
order, 180 for
renewal or
recommitment);
Mandatory
Outpatient
Treatment
(MOT).
POSSIBLE
HEARING
OUTCOMES

Voluntary alternative dispositions, at any stage,
should always be encouraged, such as:
Release to care of self, or with family or friend support;
Voluntary admission to a regional crisis stabilization unit; or
Voluntary admission to a psychiatric hospital.
The involuntary admission process can be painful and traumatizing.
Many other important issues are covered in
involuntary admission statutes, such as:
• Permitted disclosures;
• Transportation, including use of
alternative transportation;
• Mandatory outpatient treatment;
• Impact on right to purchase firearms, etc.
Also, be mindful of Advance Directives
(§54.1-2981, Health Care Decisions Act)

Law permits agent
appointed in an
advance directive
or a guardian to
admit an
incapacitated
person to a
psychiatric facility
for up to 10 days
if:
Physician from
admitting facility
examines person and
finds in writing that:
The person has mental illness, is incapable of
making an informed decision, and needs
inpatient treatment;
Proposed facility is willing to admit ; and
The person’s AD authorizes admission by
agent, or the guardianship order authorizes
admission by guardian.
CSB pre-admission
screening is required
for state hospital
admission.
Hospitalization may be
continued beyond 10
days via “other
provisions of law” (i.e.,
involuntary admission).
 Virginia involuntary admission and related statutes leave room
for local variations in practice.
› It takes all partners working together to make emergency
services work well.
› Collaboration and commitment to “customers first” is
essential.
 Too much variation can complicate the process, and reduce
timely access to care for some.

Appearance (neat, clean, disheveled, unkempt, bizarre)
Behavior/Motor Disturbance (agitation, aggression)
Orientation (person, place, time, situation)
Speech (rapid, pressured, slowed, slurred)
Mood/Emotions/Impulse Control
Range of Affect (labile, flat, blunted, full range)
Thought Processes (disorganized, flight of ideas, tangential)
Thought Content (religious delusions, paranoid thoughts)
Sensory Perceptions (auditory, visual, tactile, olfactory
gustatory)
Memory (immediate, recent, remote)
Appetite/Sleep
Insight and Judgment
Risk Assessment (suicide or homicide ideation, intention, plan,
means)
A Mental Status
Assessment is a
systematic evaluation of a
person’s level of
functioning and helps
staff monitor changes
from baseline level of
functioning.
A person develops
psychotic symptoms
including delusional
thoughts or hallucinations.
A person develops manic
or depressed mood
symptoms.
A person voices suicidal or
homicidal thoughts with
intent to harm self or
others.
A person experiences
command hallucinations or
voices telling him to harm
self or others.
A person becomes
disorganized, confused,
and disoriented in a matter
of hours or days.
PSYCHOSIS
MANIA
SUICIDE
COMMAND
HALLUCINATIONS
DELIRIUM

What are
delusional
thoughts?
• Paranoid (Believes CIA or FBI
is monitoring him)
• Religious (Believes Jesus talks
to with him)
• Somatic (Believes electronic
devise is implanted in his brain)
• Grandiose (Believes he is
president of the U.S.)
What are
hallucinations?
• Auditory (Hearing voices)
• Visual (Seeing things)
• Olfactory (Smelling things)
• Gustatory (Tasting things)
• Tactile (Feeling things on skin)
A person
becomes
psychotic.
What is a fixed
delusion?
• A fixed false belief that is
resistant to reason or actual fact.
Who develops a
fixed delusion?
• People with schizophrenia and
other psychotic disorders.
Is a fixed
delusion an
acute psychiatric
emergency?
• Not necessarily!
Examples:
• Person believes she has 4000 babies
and is pregnant again.
• Person believes he was abducted by
the CIA as a baby.
• Person believes he is transmitting his
thoughts via radar.

A person
becomes manic.
WHAT IS MANIA?
• Inflated self esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas or racing thoughts
• Easily distracted
• Increased activity or psychomotor agitation
• Excessive involvement in pleasurable activities
A person
becomes
depressed.
WHAT IS DEPRESSION?
• Sad, empty, tearful
• Diminished interest or pleasure in activities
• Sleeping too little or too much
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feels worthless or excessive or inappropriate guilt
• Poor attention and concentration
• Recurrent thoughts of death or suicide

A person wants to
kill themselves.
WHAT ARE RISK FACTORS FOR SUICIDE?
• Active psychosis (hallucinations, delusions)
• Self injurious, reckless,or impulsive behavior
• Current alcohol or drug abuse
• Presently clinically depressed(hopelessness,anxiety)
• Chronic debilitating medicalillness with poor pain management
• Suffered recentmajor loss (death, divorce,home)
• Isolated from others socially
• Thoughts or fantasies about suicide
• Unexpectedly giving gifts or giving away personal items
• Unexpectedly writing a will or making funeral arrangements
A person wants to
kill another
person.
WHAT ARE RISK FACTORS FOR HOMICIDE?
• Active psychosis (hallucinations, delusions)
• Acute manic mood symptoms
• Paranoid beliefs that others want to hurt him/her
• Overt anger and hostility toward others
• Verbal threats to hurt or kill others
• Recent physical aggression toward others
• Thoughts or fantasies about killing someone
• History physical aggression toward others

What are
command
hallucinations?
•Auditory hallucinations or voices telling you to
do something.
•Acting on the command can be life
threatening.
•Sometimes voices tell you to kill yourself or kill
someone else.
•Sometimes voices tell you to jump off a
building because you can fly.
•Sometime voices tell you to do something
more neutral (e.g., brush your hair).
•All command hallucinations should be taken
seriously.
Who might
experience
command
hallucinations?
•Persons with schizophrenia or schizoaffective
disorder.
•Persons with bipolar disorder during manic or
depressed mood phases.
•Persons with dementia.
•Persons with acute delirium.
A person
experiences
command
hallucinations.
Disorganized
speech –
Change in the
way a person
communicates
•Odd or incoherent sentences
•Forgetting words or names or making
up words
•Changing topics repeatedly and rapidly
Disorganized
behavior –
Change in
normal
behavior
patterns
•Naked in public settings
•Wearing costumes or many layers of
clothing
•Incontinent or voiding in inappropriate
places
•Taking things that do not belong to
them
•Wandering into other person’s rooms
Confusion and
disorientation
– person …
•Does not recognize well-known staff or
family
•Cannot find his bedroom or the dining
room
•Does not know the time, day, month,
year, season
•Does not know the name of the facility
•Does not know the town, state, country
where he resides
•Cannot share his life history
A person
becomes
disorganized,
confused,
disoriented in
a matter of
hours or days.

Delirium is Always an Acute Medical Emergency.
Delirium is an acute, transient (comes and goes), reversible state of confusion
characterized by disorganized thoughts and behavior, confusion,
disorientation, poor attention and concentration, sleep disturbance, agitation,
hallucinations and other psychotic symptoms.
Likelihood of developing delirium increases exponentially with age.
Delirium can be
caused by the
following factors:
Alcohol or drug use or abuse
Over-the-counter drugs (laxatives, sleeping aids, antacids, pain relievers)
Polypharmacy adverse interactions
Acute physical illness (blood sugar, blood pressure, thyroid, kidney)
Brain injury, lesions, stroke
Vitamin B12 and folate deficiencies
Sodium and potassium imbalances
HIV/AIDS
Surgical procedures and anesthesia
Psychosocial stressors (family death, social isolation)
Sleep deprivation
Urinary tract infection / dehydration
Lack of sensory stimulation and immobilization

Drugs
commonly
associated with
delirium
Anticholinergics
Artane, Benadryl, Cogentin, Symmetrel
Anti-Parkinsons
Levodopa, Carbidopa
Anxiolytics –
sedatives – hypnotics
Ativan, Klonopin, Ambien
Histamine-2 receptor
blockers
Tagament, Zantac
Narcotic analgesics
Demerol, Dilaudid, Fentanyl, OxyContin,
Percocet, Vicodin
Following is the DSM-IV-TR Diagnosis:
 The development of multiple cognitive deficits manifested by both (a) memory
impairment (impaired ability to learn new information or to recall previously learned
information) (MEMORY PLUS ONE):
 one (or more) of the following cognitive disturbances:
 Aphasia (language disturbance)
 Apraxia (impaired motor functions)
 Agnosia (failure to recognize or identify objects)
 Disturbance in executive functioning (planning, organizing, sequencing,
abstracting)

AssociatedFeatures
Learning Problems
Memory Problems
Dysarthria or Involuntary Movement
Hypo-activity
Hyper-activity
Psychosis
Depressive Mood
Sexual Dysfunction
Sexually Deviant Behavior
Odd or Eccentric or Suspicious Personality
Anxious or Fearful or Dependent Personality
Dramatic or Erratic or Antisocial Personality
 Medical screening and assessment is an important part of screening for
hospitalization.
 “…psychiatric hospitals today justifiably emphasize the importance of
careful medical screening and assessment prior to admission of any
person, and most hospitals will not admit a person unless such screening
has been completed.”
 To bring more consistency to practice, Virginia developed Medical
Screening and Assessment Guidance Materials in 2007 (see
http://www.dbhds.virginia.gov/documents/omh-reform-
MedicalScreenGuide.pdf
 These materials are in the process of revision and will likely be completed
Summer 2013.

CAUSE
A first logical step in
an acute psychiatric
emergency is to rule
out a medical cause
for changes in mental
status and behavior.
PHYSICAL
Physical exam, blood
and urine lab work,
and other medical
tests are conducted
to rule out a medical
problem. Mental
status and behavior
often stabilizes with
medical treatment.
PSYCHIATRIC
Once a medical
cause is ruled out a
psychiatric bed can
be obtained.
CLEARANCE
Medical clearance is
almost always
required by a
psychiatric hospital
before accepting a
person for admission
specifically to rule out
medical causes for
change in mental
 Elders with a dementia diagnosis can benefit from inpatient psychiatric
treatment if they have:
› Acute symptoms of psychosis
› Acute symptoms of depression or mania
› Acute symptoms of anxiety and agitation
› Current Alcohol or substance abuse
 Medical Record should reflect systematic changes in mental status and
behavior.
 Good documentation helps the Preadmission Screener with decision to
hospitalize or not.

 Inpatient psychiatric hospitalization is appropriate if there is reason
to believe that the acute psychiatric symptoms will IMPROVE with
treatment.
 Chronic behaviors and symptoms should be managed by an
outpatient physician and by implementing behavioral interventions
in the residential setting.
Elders with a
dementia diagnosis
likely will not be
accepted for
inpatient
psychiatric
treatment if:
Acute symptoms are
not dangerous to self
or others and can be
treated and
monitored by an
outpatient physician.
Symptoms or
behaviors are chronic
and persistent and
have not responded
to psychiatric
medication trials in
the past.
Symptoms or
behaviors are not
expected to improve
with psychiatric
medication.

 Condition for admission to any hospital:
› Facility Administrator often must state in writing that the
person can return to the facility when the accepting hospital
determines the person is ready for discharge.
› Without a letter many hospitals will not admit the person.
› Average length of stay 3 to 14 days.
Anyone can
request an
evaluation or a
Preadmission
Screening
Assessment:
Any person
Family or friend
of person
PoliceHospital
Other care
provider

CSB office
Crisis center
Hospital
Assisted living setting
Jail or police department
Home or private location (per CSB policy)
Assessment is
completed in a safe
setting approved by the
Crisis Counselor
If person is an acute danger,
severely disorganized,
uncooperative, assessment is
done under police supervision
in a secure setting
• Magistrate issued ECO
• Officer initiated ECO
If person is cooperative and
not dangerous, assessment is
done without police
supervision at a location
determined by the Crisis
Counselor.

SUMMARY
First and foremost you should
always feel free to call
Emergency Services to
consult about a case.
Watch for, recognize, and
document early symptoms
and early changes in mental
Rule out medical causes for
changes in mental status and
behavior.
If you are a facility, consider
implementing an evidence based
behavior and environmental
management program for
persons with challenging
behaviors..
Finally, and most importantly, develop
and nurture relationships with your
community partners and work with
them to provide best practice care for
people experiencing a psychiatric or
behavioral crisis.

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