Community Ment Health J (2010) 46:188–191 DOI 10.1007/s10597-009-9216-5 ORIGINAL PAPER Who Initiates Emergency Commitments? Annette Christy Æ Jessica B. Handelsman Æ Ardis Hanson Æ Ezra Ochshorn Received: 12 December 2008 / Accepted: 9 June 2009 / Published online: 12 July 2009 Ó Springer Science+Business Media, LLC 2009 Abstract Florida’s Mental Health Act was amended in 2005 and 2006 to include licensed mental health counselors and licensed marriage and family therapists, respectively, to the list of professionals authorized to initiate emergency commitments. The present study evaluates the volume of involuntary emergency commitments by type of initiator for a 5 year period. The results indicate that allowing licensed mental health counselors and licensed marriage and family therapist to initiate emergency commitments has not been related to increased numbers of emergency commitments or a higher proportion of emergency commitments being initiated by mental health professionals. Potential policy and fiscal implications, as well as future directions for research, are discussed. Keywords Emergency commitment
Civil commitment
Involuntary treatment
Involuntary examination
Mental health personnel
A. Christy (&)
E. Ochshorn Department of Mental Health Law and Policy, de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612, USA e-mail: achristy@fmhi.usf.edu E. Ochshorn e-mail: ochshorn@fmhi.usf.edu J. B. Handelsman Department of Psychology, University of South Florida, Tampa, FL, USA e-mail: Jessie_handelsman@hotmail.com A. Hanson de la Parte Florida Mental Health Institute Research Library, University of South Florida, Tampa, FL, USA e-mail: hanson@fmhi.usf.edu 123 Licensed mental health counselors
Licensed marriage and family therapists Introduction Florida’s Mental Health Act (FL Stat Chapter 394 2008), also called the Baker Act, allows judges, law enforcement officials, and certain types of mental health professionals to initiate emergency commitments. Emergency commitments may last for up to 72 h for individuals meeting the following three criteria: evidence of (1) mental illness, (2) harm to self, harm to others, and/or self-neglect, and (3) incompetence to consent to and/or refusal to consent to voluntary treatment Prior to 2005, the only mental health providers allowed to initiate emergency commitments were physicians, clinical psychologists, licensed clinical social workers (LCSWs), and certain psychiatric nurses. Legislative changes to the Baker Act then authorized licensed mental health counselors (LMHCs) and licensed marriage and family therapists (LMFTs) to initiate emergency commitments. LMHCs were first allowed to initiate emergency commitments within a five-county area of Northeast Florida in July 2004 as part of a pilot program, which then expanded statewide in July 2005. LMFTs were allowed to initiate statewide in July 2006. These policy revisions correspond to the changing demographics of the national mental health workforce, with LMHCs, LMFTs, and LCSWs increasingly replacing clinical psychologists in direct service roles (McFall 2006). Concerns have been raised about both the fiscal and the clinical implications of expanding the list of mental health providers authorized to initiate emergency commitments. Specifically, it was suggested that these changes would lead to increased rates of emergency commitment and, in Community Ment Health J (2010) 46:188–191 189 Methods turn, greater financial burden for the state. A legislatively mandated workgroup produced a report indicating no fiscal impact during the pilot of adding LMHCs to the types of professionals who could initiate emergency commitments (Baker Act Workgroup 2005). However, the short timeframe represented in the data raises questions about the reliability and validity of the report results. Concerns also have been raised about whether LMHCs and LMFTs have the training and experience necessary for determining when an emergency commitment is appropriate. Such turf issues between professional types are not uncommon (see Tucker 1987) and can affect the provision of service and structure of statutory language and administrative code based on the impact of advocacy efforts of various groups. Proponents of expanding the list of authorized mental health providers have argued that relevant training and licensure requirements for LMHCs and LMFTs are comparable to those for LCSWs, who have been allowed to initiate emergency commitments under the Baker Act since 1982 (F. S. 491.005 2007). The present study investigates the volume of emergency commitments initiated by different professional groups in order to better understand how the types of professionals who are allowed to initiate emergency commitments impacts the volume of emergency commitments. The Baker Act Reporting Center at de la Parte Florida Mental Health Institute maintains data on initiations for involuntary emergency commitments in Florida. This center receives forms from all Baker Act Receiving Facilities (where emergency commitments occur) as required in statute (Florida Mental Health Act 2008) and administrative rule (Mental Health Act Regulation Rule 2008). This study included analysis of data from January 1, 2002 to June 30, 2006. Approval for these analyses was obtained from the University of South Florida Institutional Review Board. Results There has been an increase in the number of emergency commitments every year since data were first collected. From 2005 to 2006, however, the increase was only 2.7% (see Table 1). Over the 5-year period (2002–2006) there was a slight decrease in the percentage of emergency commitments initiated by mental health professionals and a slight increase by law enforcement officers. Table 1 Initiation of emergency commitment by professional type for 5 years Type of initiator Judge 2002 N 3,519 2003 % 3.53 MHP 51,358 51.47 LE 44,899 45.00 Total 99,776 % Change 2004 2002– N 2003 % N 3,717 3.55 5.62 3,827 53,404 51.06 3.98 47,465 45.38 5.72 104,586 Table 2 Emergency commitment initiations by mental health professional types 4.80 % Change 2005 2003– N 2004 % 3.46 2.96 54,580 49.32 4.00 52,260 47.22 10.10 110,667 Type of initiators 5.81 3,957 3.34 3.40 3,723 58,053 49.03 6.36 3.14 -5.91 57,360 48.32 -1.19 56,386 47.62 7.90 118,396 % % Change 2005– 2006 57,629 48.55 6.98 2.20 118,712 0.27 7/1/04 through 6/30/05 7/1/06 through 6/30/07 Emergency commitments Emergency commitments % N All % % Change 2006 2004– N 2005 % N 114,690 100.00 119,815 100.00 3,894 3.40 3,637 3.04 Law enforcement 54,714 47.66 58,128 48.52 MH professional 56,082 48.89 58,049 48.45 41,913 74.74 45,639 78.62 4,345 7.75 3,862 6.65 Judge MH professional types Physician LCSW LMHC 343 0.61 2,734 4.71 Psychologist 1,454 2.59 1,469 2.53 Psychiatric nurse 1,158 2.06 1,130 1.95 LMFT Not reported 0 6,869 0 12.25 52 0.09 3,163 5.45 123 190 Table 2 presents the number of emergency commitments initiated by various types of professionals over two time periods. The first period (7/1/04–6/30/05) includes LMHCs’ abilities to initiate in the pilot area as of July 2004. The second period (7/1/06–6/30/07) includes LMHCs’ abilities to initiate statewide as of July 2005 and LMFTs’ abilities to initiate statewide as of July 2006. The number of total emergency commitments increased by 4.47% between the two time periods, with a 3.51% increase in the number of emergency commitments initiated by mental health professionals. As seen in Table 1, these findings reflect the data trend seen over a longer period of time. A total of 854 LMHCs initiated 2,734 emergency commitments in the second time period. The LMHC license number was not reported for 110 (4.50%) emergency commitments. Because the license number is used to identify individual LMHCs, the 854 practitioner total is likely an underestimate. Forty percent (n = 342) initiated more than one emergency commitment in the 6 months. The number of emergency commitments initiated ranged from 1 to 59, except for one outlier with 123 initiations. The ten LMHCs who initiated thirty or more emergency commitments in the 6 month period accounted for 18.67% of the group total. The LMHC with 123 emergency commitments single-handedly accounted for 4.68% of the total. The majority of Florida counties (57 of 67) had at least one emergency commitment initiated by a LMHC in the second time period. However, the initiation totals were not uniform across the state, with over half (n = 1,426; 52.16%) of LMHC-initiated emergency commitments occurring in just six Florida counties, and the focus of the 2004 pilot (Duval County) accounting for 472 (17.26%) of all LMHC initiated exams. Twenty LMFTs initiated 52 emergency commitments during the second time period. However, the LMFT license number was missing from 16 emergency commitment forms, suggesting the actual LMFT count may be higher. These examinations occurred in 18 counties, with an uneven statewide distribution. For example, half (n = 24; 51.06%) of LMFT-initiated emergency commitments occurred in three counties (Lee, Duval and Palm Beach), with more than one quarter (n = 13; 27.66%) occurring in one county (Lee). Discussion These analyses demonstrate that allowing LMHCs and LMFTs to initiate emergency commitments was not related to an increase in emergency commitments or a higher proportion of emergency commitments being initiated by mental health professionals. These findings have important 123 Community Ment Health J (2010) 46:188–191 policy implications. The concern expressed by legislators and staff at agencies responsible for public mental health care was that additional funds were not budgeted for emergency commitments as part of the legislation allowing LMHCs to initiate emergency commitments. There was also concern that expanding the list of authorized professionals would lead to an increase in emergency commitments. It was felt that this, in turn, would further burden an already under-funded state mental health system. This is important to consider in a resource poor state such as Florida, which is ranked 48th in per capita mental health spending (National Alliance on Mental Illness 2006). The evaluation of the fiscal impact of the policy change allowing LMHCs to initiate emergency commitment was written into statute. However, adequate time was not allowed for completion of the evaluation in a way that could yield useful information. While such evaluations are valuable, it is essential that adequate time is allocated for them. Some time needs to pass between the effective date of the statutory change and the evaluation in order for those affected by the change to learn about it, to obtain training, and for evaluators or data center managers to set up or change mechanisms for collection of data. Then, enough time needs to pass for sufficient data to be collected to adequately address the fiscal impact or other issues in the evaluation and for the analyses to be completed and summarized. Finally, the location chosen for such pilots is important because certain idiosyncrasies of some areas may yield data that are not generalizable to the entire state, which is often one of the purposes of such evaluations. For example, some areas of the state have disproportionately high percentages of emergency commitments initiated by law enforcement, while other areas may have an unusual dearth or abundance of Baker Act receiving facilities (where emergency commitments take place) that make extrapolation of data from that area problematic. Despite the focus of these analyses on the volume of emergency commitments, increased emergency commitments are not inherently ‘‘good’’ or ‘‘bad’’. For example, an increase may simply mean all people requiring the evaluation and safety precautions of involuntary treatment are receiving it. While emergency commitment may not be desirable, it may be viewed as desirable in light of the alternatives, such as arrest for physical harm to oneself or others. This study did not address the broader question of the appropriateness of allowing LMHCs and LMFTs to initiate emergency commitments. Additional research is needed to understand how these professionals are trained to evaluate people for emergency commitment, along with their behavior in the field. If LMHCs and LMFTs are permitted to initiate emergency commitments, then training in graduate programs and continuing education on this topic is essential. Otherwise, inappropriate clinical and Community Ment Health J (2010) 46:188–191 legal status decisions become a risk to both patients and the public. The transdisciplinary practice of mental health should also be a future topic of research. Mental health professionals from numerous disciplines are involved in interdisciplinary teams in single agencies or across multiple agencies. It is important that this organizational ‘world’ of mental health has teams that can work as inter-, intra-, and trans-disciplinary, both in- and out-of-house (Ruel 2000). It might be helpful in the future to create an academic/professional practice crosswalk between social work and licensed mental health counselors/marriage and family therapists to help reduce friction created in Florida’s current licensing and practice environment. Physician’s assistants may be included in this group of mental health professionals as well. Although not specifically named in Florida’s Statute as a professional type allowed to initiated emergency commitments, a recent Advisory Opinion from the Office of the Attorney General of Florida (2008) indicated that physician’s assistants with ‘‘experience regarding the diagnosis and treatment of mental and nervous disorders and such tasks as are within the supervision physician’s scope of practice’’ may initiate emergency commitments. Another issue to consider is the organizational and workflow changes that are created by legislation and implementation. With the change to statewide initiation of emergency commitment, it is important to consider that numerous organizations may have been at different stages of organizational readiness for this change. To ensure consistency in practice, evaluation, and process, training and a training infrastructure are essential to move implementation from paper to process, decision-making, and practice (Fixsen et al. 2005). 191 References Baker Act Workgroup. (2005). The fiscal impact of permitting licensed mental health counselors to initiate Baker Act involuntary examinations: A report by the Baker Act Workgroup based on findings by the Louis de la Parte Florida Mental Health Institute Study of a Baker Act Pilot Project. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. Retrieved from http://www.floridamhca.org/ bawrkgrp.pdf. FL. Admin. Code, 65E-5. (2008). Mental Health Act Regulation. FL. Stat. Chap. 491.005. (2007). Licensure by examination. FL. Stat. Chap. 394. (2008). Florida Mental Health Act, §§. 394. 451394.4789. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network. (FMHI Publication No. 231). McFall, R. M. (2006). Doctoral training in clinical psychology. Annual Review of Clinical Psychology, 2, 21–49. National Alliance on Mental Illness. (2006). Grading the states: A report on America’s health care system for serious mental illness. Accessed on February 12, 2008 from http://www.nami. org/content/navigationmenu/grading_the_states/ project_overview/overview.htm. Office of the Attorney General of Florida. (2008). Advisory legal opinion AGO 2008-31 [Baker Act - Physician Assistants]. Accessed on Oct 19, 2008 from http://www.myfloridalegal.com/ ago.nsf/Opinions/71F977AFC82AE8EC85257459006F292A. Ruel, H. J. M. (2000). Reconsidering our team effectiveness models: A call for an integrative paradigm. In M. M. Beyerlein, D. A. Johnson, & S. T. Beyerlein (Eds.), Advances in interdisciplinary studies of work teams (7th ed., pp. 173–185). Greenwich, CT: JAI Press. Tucker, C. (1987). Turf issues in CMHCs. Hospital and Community Psychiatry, 38, 1225–1226. 123