Learning Objectives
By the end of this section, you will be able to:
- Cite the reasons for court-ordered therapy
- Give examples of the types of court-ordered therapy
- Outline the process for putting involuntary court-ordered treatment in place
The basic reason for court-ordered treatment is that an individual presents a danger to self or others or is unable to perform self-care due to mental illness. Each state determines its own guidelines, so they differ in some details. Being referred for involuntary assessment and treatment with conditions of release is not a crime. It is a function of civil, not criminal law. In terms of criminal law, there is a branch of psychiatry for forensic cases, wherein the person may have criminal charges or eventually be adjudicated “not guilty by reason of insanity.” In those cases, the individual convicted of a crime may be ordered to receive psychiatric services as well.
The term civil commitment denotes a legal process that keeps involuntary hospitalization from qualifying as false imprisonment. Those seeking the commitment bear the burden of proof to justify the need for this care and the care must be offered in the least restrictive environment. Nurses have a significant responsibility to act as advocate for persons and families throughout the processes described in this section. Nursing care also comes into play as education, emotional support, and collaborative care with the health-care team. Nurses maintain the therapeutic relationship with persons and families and adhere to professional practice guidelines. Nurses in these situations should be mindful to reflect on their own perceptions and be self-aware of how these relationships are affecting them in order to maintain self-care.
Clinical Safety and Procedures (QSEN)
Teamwork and Collaboration
One QSEN competency is teamwork and collaboration, which stresses the importance of working in teams effectively and with the shared goal of quality client care. Consider how the nurse will monitor the therapeutic relationship in situations of court-ordered treatment.
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Reasons for Court-Ordered Therapy
When people are not able to care for themselves due to mental illness and/or drug abuse (in certain circumstance), courts of law may intervene and legally compel the person into treatment. Treatment may be inpatient in a facility, outpatient in the community, or in a clinic setting.
Court-ordered therapy is mandated and compulsory. The court may keep track of the person’s compliance, holding providers accountable to report the person’s progress. The individual receiving treatment and/or their health insurer is responsible for the payment for the services. The person or their representative must inform the court of financial hardship in order to receive financial aid. Persons mandated for treatment who do not adhere to the plan of care may be found in contempt of court, apprehended, and potentially incarcerated, hospitalized, or face further legal repercussions. The most common reasons for court-ordered therapy include custody disputes and custody issues involving abuse or neglect, being convicted of a sex crime, an alternative to jail for someone with a mental illness or who misuses drugs, a condition of release from jail, or presenting a threat to oneself or others.
Types of Court-Ordered Treatment
Each state designates the guidelines for mental health treatment when necessitated by court order. These directives address circumstances, length of time, and individual rights. Court-ordered treatment may take place inside a health-care facility, out in the community (whether residential or day treatment, including mandatory support group attendance), or in visits to mental health-care providers (Substance Abuse Mental Health Services Administration [SAMHSA], 2019a). In all these settings, providers document the client’s progress toward established treatment goals, which includes them adhering to medications as prescribed and obtaining appropriate laboratory test results. A long-acting injectable (LAI) antipsychotic medication may also be legally mandated for the client to receive on a schedule. Courts have access to the medical record.
When a person’s behavior affects others or has legal implications, a court may order various types of mandated treatment rather than incarceration. If treatment is not completed as ordered, incarceration may still occur. While in mandated treatment, the client may receive medication and work with a therapist. Table 11.2 outlines various forms of mandated therapy.
| Program | Indication |
|---|---|
| Diversion programs | Therapy and education, generally for first-time offenders with minor offenses, to avoid the criminal justice system. Participants remain liable for restitution, community service, or the cost of the program. The legal charge may be dismissed at completion of the program. |
| Drug court | Scheduled appearances before a judge who sets a treatment program due to drug use. When conditions are met, the individual is eligible to have legal consequences reduced. |
| Victim impact panel | Attendance at a panel of volunteer individuals who have been impacted by DWI/DUI accidents. Generally, first offenders may be referred to help them understand the pain and suffering caused by their actions. |
| Anger-management classes | Legal charges related to aggressive or violent behaviors. Group and individual therapy sessions for emotional regulation, conflict resolution, and effective communication. The court is kept apprised of the client’s progress. |
| Parent’s therapy | Evaluation and therapy in child custody cases, due to addiction, abuse, or criminal conviction, with the goal of maintaining or restoring custody. |
| Reunification therapy | Family conflict, due to separation or abuse, with the goal of reintegration and improved communication and parenting. Involves family therapy, with sessions for children. |
Emergency Admission and Treatment Orders
Some states permit emergency treatment orders (ETO), which allow provision of medically prescribed treatment with or without consent. ETO are obtained from the provider when the person’s behavior presents a danger to self or others. Interventions under emergency orders are time-limited and require ongoing assessments and special documentation. Documentation should include approaches providers tried prior to the emergency order. These orders have serious legal and ethical implications.
Persons received under emergency admission are reasonably determined to have mental illness making them dangerous to self or others. Persons admitted on an emergency basis remain in the facility for a waiting period of twenty-four to seventy-two hours for a psychiatric assessment and crisis treatment; this is typically known as a psychiatric hold. The action is legally and ethically justified due to the emergency aspect of the person’s need. Every U.S. state sets its own criteria for hospitalization due to mental health emergency. Generally, such clients should only be involuntarily admitted if they can benefit from the hospitalization and if it is the least restrictive means for treatment.
Link to Learning
The Treatment Advocacy Center has compiled a survey of the mental health commitment laws of the states looking at the types of involuntary admission laws, as well as issues such as outpatient commitment.
During an emergency admission, a mental health-care team is available to the person for medical and psychosocial care. Psychiatrists, social services professionals, mental health nurses, and care managers participate in coordinating and planning the person’s stabilization. After the required waiting period, some persons may be released from the facility into the care of their family members or to another treatment setting. Some persons agree to remain on a voluntary basis for continued treatment. Still others may be kept in custody through involuntary commitment—involuntary hospitalization of a client—which is the legal means to hold an individual in a psychiatric-mental health facility for a mental illness without that person’s consent. Involuntary stays can be days or weeks as determined by the attending psychiatrists and courts.
Mandated Treatment in the Community
One form of civil commitment within the community, not confined to a facility is assisted outpatient treatment (AOT). It is intended to reduce rehospitalization and assist community reentry. Again, programs vary by state. This care is mandated by the court and sometimes results in return to the hospital environment if the individual does not adhere to the mandates.
Persons may be referred to community care after release from a facility. The best candidate for community care is one who has stabilized from treatment and has a support system of people in the community. Persons in AOT may receive case management, home visits, therapy sessions, medication, and housing support. Community treatment can have benefits to the person, such as avoiding hospitalization, feeling less restricted, and experiencing less stigma, according to Mikellides et al. (2019).
Link to Learning
Review this guideline to involuntary commitment from SAMHSA, called Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice.
Process of Involuntary Evaluation and Treatment
There are two processes to initiate involuntary commitment: (1) emergency and (2) judicial. The emergency process, mentioned previously, arises when an individual poses immediate harm because of their mental illness. The commitment happens immediately. The judicial process is not an emergency, but begins when someone concerned determines that a person requires mental health treatment that they will not willingly obtain. There may be a wait while the court decides whether or not to grant the order (Disability Rights South Carolina, 2023).
Family members or other concerned individuals may call local law enforcement, clerks of court in the county where the individual resides, or the person’s primary care physician or mental health professional to initiate this judicial process and an involuntary examination to determine need for treatment. Clerks of court can file petition for an ex parte (meaning that all the parties are not yet involved) order asking a judge to authorize a psychiatric evaluation.
If the person needs an escort to the mental health-care facility, this may involve civil arrest, being taken by law enforcement (possibly in handcuffs, in a patrol car) to a psychiatric receiving facility or medical hospital emergency department. Additional resources regarding court-ordered mental health treatment include:
- Call 211 United Way referral line
- Call 988 Suicide and Crisis Lifeline
- Veterans Crisis Line: call 1-800-273-TALK (8255) and press 1; or text 838255
- Crisis Text Line: text the word 'Home' to 741741
Link to Learning
The Policy Surveillance Program compiled information by state for short-term emergency commitment. Their map, containing the data, provides sample questions the data answers.
With variations in state laws, upon completion of the involuntary psychiatric evaluation, the person may:
- be released
- give express and informed consent to stay for treatment on voluntary status
- be held for treatment on involuntary status
- be referred for mandated community treatment, a form of conditional release/discharge, meaning that the person must adhere to prescribed treatment (medication, counseling, follow-up appointments) or be returned to the hospital
If the person has health insurance, the cost of treatment will be billed to the insurance company. Sometimes, the state pays the facility to care for the person, or the court may order another source of funding.
Facilities Used for Court-Ordered Evaluation and Treatment
Determined by the individual states, facilities may include acute care general hospitals, psychiatric hospitals, designated treatment centers, crisis centers, and specialty services, such as women’s centers or child/adolescent facilities. Hospitals without psychiatric services may hold persons in the emergency department while awaiting psychiatric placement. Persons in jail will wait for forensics units or hospitals that will receive them. Due to the overrepresentation of individuals with mental illness in corrections settings in the United States (National Alliance on Mental Illness [NAMI], 2023), many clients may be found in any of these settings, depending on the state.