Wisconsin s Mental Health Laws

Wisconsin s Mental Health Laws Day Three of the Crisis Training Curriculum Developed June, 2012 Behavioral Health Training Partnership University of Wisconsin Green Bay 2420 Nicolet Dr Rose Hall 310 Green Bay, WI 54311-7001 Phone (920) 465-2101 bhtp@uwgb.edu

Wisconsin s Mental Health Laws Course Description This one-day course uses discussion and small group exercises along with lecture to help participants understand the laws and standards related to crisis work as identified in DHS 34. Mental Health Laws (Chapter 51) will be presented and the crisis worker will be prepared for the fact that not all of their cases are going to fit neatly into the Chapter 51 framework. Participants will be exposed to the other laws that may be involved in crisis response, such as Chapters 48, 938, 54, 55. Scenarios will be used to illustrate how to navigate between systems. The first day of training covered the overview of crisis services, core values, the crisis continuum, and formulating and documenting crisis response plans and crisis plans. The second day of training covered crisis assessment, suicide assessment, and assessment of harm to others. The curriculum for all three days has been developed to enhance the crisis workers knowledge and skills along the crisis continuum and complete the 40 hours necessary for new crisis workers. Target Audience The audience for the crisis overview training is Behavioral Health Crisis Workers working in, or under contract to, county Crisis Programs certified under DHS 34. This training, in conjunction with Day 1 and Day 2 of training, meets the 20-40 training hours required in the first 90 days of employment for Crisis Workers under DHS 34. Web Based Curriculum Pre-Training The participants are requested to complete the web based training (www.uwgb.edu/bhtp) These trainings introduce DHS 34 Crisis Standards, DHS 34 Legal Considerations, DHS 34 Client Rights and DHS 34 Best Practices in Crisis Intervention. The web-based training is an introduction to these concepts and parts of this training will review and reinforce them. Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 2

Wisconsin Mental Health Laws Crisis Curriculum Day 3 I. Welcome and Introductions A. Welcome and Trainer Introductions B. Purpose of Training - Learning Objectives and Agenda C. Participant Introductions II. DHS 34 Overview/Review A. Important Elements of DHS 34 sub (3) B. Chapter 34 Best Practices III. Chapter 51 Wisconsin Mental Health Laws A. Overview of Wisconsin Mental Health Law (use of video) (19-20) B. Chapter 5(1)15 Emergency Detention/Commitment Hearings C. Chapter 5(1)45 Alcohol Hold/ Protective Placement D. Process of Emergency Detention/Commitment Hearings IV. Related Chapters Basic Overview A. Chapter 48 - Wisconsin s Children Code (Juvenile in Need of Protection) B. Chapter 938 Juvenile Justice Code (Juvenile in Need of Supervision) C. Chapter 54 - Guardianships and Conservatorships D. 46.90 Adults at Risk and Chapter 55 Adult in Need of Protection V. Client Rights and Confidentiality - Chapter 94 A. Basic Client Rights B. Grievance Procedures/Stages C. Confidentiality of Treatment Records Chapter 92 VI. Case Scenarios across Systems/Populations VII. Closing A. Summary of Key Points B. Homework C. Takeaway/Evaluation Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 3

Learning Objectives: Participants will: Develop a basic understanding of Wisconsin Mental Health Law (Chapter 51) Develop a basic understanding of related statutes (Chapters 48, 938, 54, 55) Understand the criteria and process for doing an emergency detention (51.15) Understand the criteria and process for doing a protective placement for alcohol (51.45) Become familiar with client rights and confidentiality Explore the balance between the need to protect client rights and community safety Explore the issues related to dealing with populations that don t fit neatly into a single statutory category Practice decision-making based upon case examples of various populations in crisis Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 4

Wisconsin s Mental Health Laws Module 1: Introduction to Training A. Welcome and Trainer Introductions Title (Slide #1) Wisconsin s Mental Health Laws Welcome participants to training Briefly introduce yourself, providing applicable background experiences B. Purpose of the Training Agenda/Objectives/Introductions Agenda (Slide #2) (HO-01) Module 1: Welcome and Introductions Module 2: Chapter 34 Overview Module 3: Chapter 51 Module 4: Related Chapters Module 5: Clients Rights and Confidentiality Module 6: Closing Review the agenda SLIDE #2 and refer back to handout #1. Discuss the flow of the agenda using the SLIDE and handout. Highlight this training as the third day of the Crisis Training. Explain the purpose of this training as a part of the 20-40 hours training requirement for DHS 34. Briefly review the topics of the 40 hour training requirement, both web-based and classroom. (Three Day Training Structure (HO-02) Review handout which describes the make up of the training requirement for the first twenty hours of training for crisis certification. The training includes web-based pre-training (all of which they should have already completed), the classroom content, and homework assignments after each classroom training to customize the training to their individual county philosophies, requirements, and expectations. Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 5

Web-based Pre- Training Day 1 Philosophical Overview and Practice Guidelines Day 2 Suicide/Risk Assessment Day 3 Wisconsin s Mental Health Laws Classroom Content Core values, Definition of Crisis, Crisis Continuum, Collaborative Crisis Response, Developing/documenting response plans and crisis plans, crisis billing Secondary Trauma and Self-care Risk factors and warning signs and documentation of risk, Safety planning, Using supervisory support, Need to Know and Mandatory Reporting DHS 34, Confidentiality, Client Rights, Wisconsin Mental Health Law and other related laws and statutes (Chap. 48, 54, 55, etc), Emergency Detention, Diversion Homework Familiarize self with local initiatives and services. Organization structure and roles and responsibilities, Phone triage, Staffing/reporting/communication process, Crisis plan and Response plan templates and where they are kept, Billing procedures Familiarize yourself with your county suicide, risk assessment protocols, your county crisis response plan, crisis alerts, emergency detention procedures and paperwork, protocols related to supervisory consultation, Procedure related to crisis debriefing in the event of a client suicide or death. Familiarize yourself with protocols related to CPS, APS, Juvenile Justice whom to contact. Familiarize yourself with the grievance procedure at your agency. Familiarize yourself with the commitment and settlement agreement processes and protocols for monitoring those on commitments/agreements. Give brief information about the ongoing crisis training opportunities in the future. Information about future trainings can be found on the BHTP website www.uwgb.edu/bhtp Review Learning Objectives (Slides #3 and #4) (HO-01) Review the learning objectives SLIDE and refer to handout. Talk briefly about how the content and activities will accomplish the objectives Develop a basic understanding of Wisconsin Mental Health Law (Chapter 51) Develop a basic understanding of related statutes (Chapters 48, 938, 54, 55) Understand the criteria and process for doing an emergency detention (51.15) Understand the criteria and process for doing a protective placement for alcohol (51.45) Become familiar with client rights and confidentiality Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 6

Explore the balance between the need to protect client rights and community safety Explore the issues related to dealing with populations that do not fit neatly into a single statutory category Practice decision-making based upon case examples of various populations in crisis C. Creating Culture for the Training Creating Behavioral Expectations Put up the flip chart list of possible behavioral expectations for process in the training. Identify three or four behaviors (examples: everyone participates, personal information shared in the training is confidential, no sidebar conversations, etc.) Ask if the group is in agreement with the list that has been posted. Ask the group to add to the list to cover their concerns about process in the training. Explain that it is up to all group members to adhere to the behaviors and assist the trainer in holding accountability to them. Post the flip chart where all can see it. Trainer Note: Make sure that the list is behavioral in nature and as specific as possible. For example: if someone volunteers be respectful to others help them identify the behaviors that indicate being respectful to them. That will assist in developing behavioral expectations that are descriptive. D. Participant Introductions (Slide #5) Exercise: Please introduce yourself sharing a scenario when you were caught between two or more systems when responding to a crisis or providing linkage and follow up to a crisis situation. Have the participants introduce themselves and share a scenario when they were caught between two systems who were either duplicating services an/or denying the consumer access to services through their system and tried to pass the consumer to another system in a manner that was not collaborative and did not meet the needs of the consumer. Trainer Note: This exercise in introductions should help the participants begin to get in touch with those situations that are not easy because we do not always play well together and often the consumer gets in the middle of our relationships with other system representatives. This exercise should also begin to identify collaboration as a way to Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 7

work together from the beginning of a crisis response in order to find the best options with the consumer from all available resources in all eligible systems. Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 8

Module 2: DHS 34 Overview This module gives the trainees an overview of DHS 34 and reviews and builds on the Web- Based Training they should have reviewed prior to this training. DHS 34 is the Wisconsin Administrative Code for Emergency Mental Health Service Programs and establishes the standards and procedures for certification of county and multi-county emergency mental health service programs. The persons who need these services are persons who are experiencing a mental health crisis or are in a situation likely to turn into a mental health crisis if supportive services are not provided. DHS34 relates only to the certification of programs providing emergency mental health services and is not intended to regulate other mental health service programs or other emergency service programs. A. Important Elements of DHS 34 (Slide #6) Formerly HFS 34 Promulgated in 1996 Includes expectations for; Training and supervision Risk assessment and management Knowledge of Chapter 51 and related laws Documentation including crisis planning and response planning Client rights Best practices Trainer Note: The next six slides are a basic review of the important elements of DHS34 and are revisited here to ensure that the participants understand the expectations of DHS34 in policy and practice. These expectations include training and supervision, crisis skills that include risk assessment and management, integration with other legal considerations, documentation and consumer rights. (1) Training and Supervision (Slide #7) Within 90 days of hire or assignment to crisis work If staff have less than 6 months experience they need 40 hours of training specific to crisis intervention If staff have more than 6 months experience they need 20 hours of training specific to crisis intervention For every 30 hours of crisis work, 1 hour of supervision must be provided (2) Risk Assessment and Management (Slide #8) The most important element in crisis work Important to know the signs and symptoms that someone is at risk of harm to self or others Important to develop an intervention and/or response that manages the risk Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 9

Risk Assessment Review (Slide #9) Clearly identify the issue/conflict Identify and weigh the risks and liability of intervening Weigh chances of a challenge to the decision Share the risks by using colleagues, supervisors, and others on the team Ensure decisions are well reasoned Document the reasons for the decision (3) DHS Legal Considerations (Slide #10) 51.15 Emergency Detention 51.45 Alcohol Hold/Protective Custody 55 Adult in Need of Protection 48 Child/Juvenile in Need of Protection 938 Juvenile in Need of Supervision 94 Patient Rights and Grievances (4) Documentation Review (Slide #11) Crisis Plans Completed on an agency template by the consumer and treatment team and kept with either the crisis team and/or the 911 dispatcher Plan identifies whom to contact, provider staff who work with the consumer, consumer preferences related to crisis response, etc. Crisis Response Plan Completed by the consumer, crisis worker, and other team members at the time of the crisis intervention Plan follows a format that includes risk assessment, diagnostic code, and response plan as well as date/time/ persons involved and is signed off by the staff, consumer, and licensed professional within 14 days (5) Client Rights (Slide #12) Programs must comply with 51.61 and HFS 94 on the rights of clients Consumers can use either formal or informal procedures for resolving complaints and disagreements Programs must have both informal resolution process and have an established grievance resolution system Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 10

B. Chapter 34 Best Practices As we begin talking about other legal considerations in other Chapters of Wisconsin legislation, it is important that we be reminded of some of the best practices in crisis work that inform our work. In Day One we talked about the core values and practice principles that provide the framework for our crisis work with consumers. From those core values and practice principles we have identified three best practices that are relevant to our discussion about Wisconsin s Mental Health Laws and other legislation. Remember that Chapter 34 describes the minimum standards and expectations for quality practice should exceed these standards. (1) Mobile Crisis Response (Slide #13) Mobile crisis response is a cornerstone of best practice in crisis response work. How the mobile crisis unit is integrated with responses of other systems, how everyone works together and if least restrictive responses and placements are utilized are key to positive outcomes for the consumer and others participating in the response and follow up. DHS Standard: Mobile Crisis Response is available during high utilization hours. Crisis response is available 24/7. Access to supports and services is timely Adequate time is spent with the individual in crisis Individuals in self-defined crisis are not turned away Discussion: How does this work in your county? When/how does crisis staff get involved? Who else is involved from the beginning of the crisis and how well do you work with them when responding? Is access timely? Where are your frustration points with crisis response? (2) Diversions Diverting placement in a hospital or state facility if appropriate is an important part of the crisis response. In most instances, when safety can be managed, it is better for a person to be kept in their home and/or a community setting in order to maximize community treatment options and prevent the need for transition back to the community. Decisions about diverting from an inpatient setting must be made carefully and in collaboration with others and with supervision. DHS 34 Standard: Diversion back to the community when appropriate (least restrictive measures) (Slide #14) Services are provided in the least restrictive manner Emergency interventions consider the context of the individual s overall plan of services Helping the individual to regain a sense of control is a priority Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 11

When to divert? (Slide #15) (HO-03 and HO-04) Exercise: Review of Door County Review of Green Lake County Helpful hints: *Always try to facilitate a voluntary placement *Always find out what insurance the person has *Always make sure that the emergency detention appears to have merit Discussion: What is your agencies philosophy about diversion? What resources do you have to divert people from a more restrictive setting than they may require? What might be some reasons why least restrictive is an important best practice? How do discussions about diversion and least restrictive go when working with other systems? (3) Collaboration (Slide #16) In working with consumers who may be involved in more than one system, it is imperative that crisis workers work collaboratively with other systems and providers as well as with family and other identified community members. All three of the best practices we are discussing have implications for our dialogue with other systems in crisis response but this one is important when working with consumers who may be involved with other systems, or who might need to be involved with other systems. DHS Standard: There is a collaborative crisis response (plan for coordination of services) Natural supports, where available, are utilized There is documented collaboration with law enforcement and/or other concerned parties There is documented collaboration with other systems including CPS, Juvenile Justice, Elderly, etc. There is a coordinated emergency MH service plan that identifies a process to plan, implement and manage crisis system issues Discussion: What are the expectations for collaboration in your agency? Are the expectations the same for all systems and providers? How are family members and natural supports utilized? Is there one plan that crosses systems when more than one system is involved? Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 12

Module 3: Chapter 51 Mental Health Act, Wisconsin Statutes A. Mental Health Act Overview (Slide #17) Provides legal procedures for voluntary and involuntary admission, treatment and rehabilitation of individuals (adults and minor children) affected with mental illness, developmental disability, drug dependency or alcoholism. Imminent Danger JS Online VIDEO (Slide #18) VIDEO The video provides the history to the legal considerations of emergency detentions and commitment hearings. It looks at several situations where dangerousness was/was not addressed and the balance between consumer rights and dangerousness. The video sets the stage for our understanding of the Mental Health Laws as adopted. Discussion of Video B. Chapter 51.15 Emergency Detention/Commitment Hearings For the purposes of this training, the information on emergency detention and commitment is critical for the participants to understand, not only the criteria and processes for voluntary and involuntary admissions, but also their role and the role of diversion and collaboration. Trainer Note: Before beginning the training on Emergency Detention, staff should be aware of the importance of voluntary commitment. Not only does it benefit the consumer, in most instances, to be free of legal involvement, but it helps with the response relationship and being able to provide linkage and follow up services. Voluntary Services/Placement (Slide #19) Voluntary admission is preferable in most instances because it avoids the legal system involvement Voluntary service acceptance allows for the consumer to engage at will instead of a legal coercive participation When helping a consumer navigate voluntary services/placement it is important to help them with resources, insurance, expectations etc. Linkage and follow up are the same as with non-voluntary consumers Always give consumers the option of voluntary Trainer Note: The next 14 slides cover the criteria for involuntary civil commitments, definitions of the disorders, standards of dangerousness and definition of treatment. These should be reviewed rather slowly so the participants can digest the material, ask questions, and have discussion. Examples from the group would precipitate discussion. Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 13

51.15 Emergency Detention (Slide #20) Involuntary hold Used when there is reason to believe: The subject is mentally ill, drug dependent or developmentally disabled AND Behavior constitutes a substantial probability of physical harm to self or others (1) Criteria for Involuntary Civil Commitment (Slide #21) The individual has a mental illness, developmental disability, or drug/alcohol dependence The individual s illness/disability/dependence is treatable The individual is dangerous to him/herself or others due to the illness (a) Definition of Mental Illness for Involuntary Civil Commitment (Slide #22) A substantial disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the demands of life, but does not include alcoholism (b) Definition of Developmental Disability for Involuntary Civil Commitment (Slide #23) A disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, or mental retardation, which is expected to continue indefinitely, and which constitutes a substantial handicap to the afflicted individual (c) Definition of Drug Dependency for Involuntary Civil Commitment (Slide #24) A disease which is characterized by the dependency of an individual who uses one or more drugs to the extent that the individual s health is substantially impaired or his/her social or economic functioning is substantially disrupted. *Needs to be mental illness and intent to harm self or others. (d) Definition of Alcoholism for Involuntary Civil Commitment (Slide #25) A disease which is characterized by the dependency of an individual on alcohol to the extent that his/her health is substantially impaired or endangered, and his/her social or economic functioning is substantially disrupted (2) Standards of Dangerousness Required for Involuntary Civil Commitment (Slide #26/27) Recent acts, attempts, or threats of suicide or serious bodily harm to self Recent acts, attempts, or threats of serious bodily harm to others, or violent behavior which places others at reasonable fear of serious physical harm Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 14

A pattern of recent acts or omissions which evidences impaired judgment causing the individual to be an inadvertent danger to self Mental illness causes the individual to be so gravely disabled that he/she is unable to satisfy life s basic needs for nourishment, medical care, shelter, or safety Individual s psychiatric treatment history, coupled with his/her present mental deterioration due to incompetent decision to refuse psychotropic medication causes likelihood that the individual will lose ability to function independently in the community (a)standards of Dangerousness Harm to Self 51.2(1)(a)2a (Slide #28) Harm to Self: (Substantial probability of physical harm) Due to recent threats or Attempted suicide recently or Recent serious bodily harm (b)standards of Dangerousness Harm to Others 51.20(1)(a)2b (Slide #29) Harm to Others: (Reasonable fear and substantial probability of harm based on act, attempt, or threat) Recent homicidal behavior or Recent violent behavior or Others are in reasonable fear of violent behavior and serious physical harm (c) Standards of Dangerousness Gravely Disabled by Impaired Judgment (Slide #30) (Recent acts or omissions indicating a substantial probability of harm to self) 51.20(1)(a)2c Due to impaired judgment and Appropriate alternate measures have been attempted or not available in the community (d) Standards of Dangerousness Unable to Satisfy Basic Needs 51.20(1)(a)2d (Slide #31) (Recent acts or failure to act indicating imminent need for nourishment, medical care, or shelter) Incapable of obtaining care for self and Results in substantial probability of death, serious injury, debilitation, or disease and Based on Mental Illness, and Appropriate alternate measures have been attempted or not available in the community. (e) Standard of Dangerousness Incompetent to Make/Follow Treatment Decisions (Slide #32) (Incapable of understanding, expressing or applying treatment decisions) 51.20(1)(a)2e (Rare and difficult to use) Based on evidence of treatment history and recent acts or failure to act and Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 15

Person will lack services necessary if left untreated and If left untreated, person will suffer severe physical/mental harm, loss of autonomy and Based on psychiatric prediction (3) Definitions of Treatment for Involuntary Civil Commitments (Slide #33 Statutory: Those psychological, education, social, chemical, medical or somatic techniques designed to bring about the rehabilitation of an individual who has mental illness, developmental disabilities, drug dependency, or alcoholism Jury Instructions: An individual is a proper subject for treatment if the administration of treatment techniques may control, improve, or cure his/her mental illness, developmental disability, drug dependency, or alcoholism OOF-1 - Case Scenario #1(Iman) - Divide the participants into groups of 3 4 (or by table if that works) Hand out the Crisis Scenario Sheet and the Crisis Scenario Discussion Tool Have the participants read the scenario and use the tool for discussion with their group. Have them document their discussion and then document a brief crisis response plan for the consumer. Bring together the group for large group discussion. C. Chapter 51.45 Alcohol Hold/Protective Placement Alcohol holds and protective placements require that the crisis response worker (with law enforcements) is able to determine whether someone is incapacitated by alcohol. This does not apply to drugs. It also assumes that the crisis worker can help in the determination of the need for detox and medical clearance for those appearing severely intoxicated. Trainer Note: The difference in assessment, detention, and follow up between a mental health commitment and an alcohol hold/protective placement is important information for the crisis worker to have when responding to a crisis call. Law enforcement personnel work in collaboration with crisis workers when assessing alcohol incapacitation and response. Detox resources and medical clearance are particularly important when assessing and resolving alcohol crises. The next six slides define the policy statements around alcohol prevention and treatment in Wisconsin, the definition of alcohol incapacitation, and assessment for detox or other protective hold. (1) 51.45 Prevention and Control of Alcoholism (Slide #34) It is the policy of this state that alcoholics and intoxicated persons may not be subjected to criminal prosecution because of their consumption of alcohol beverages but rather should be Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 16

afforded a continuum of treatment in order that they may lead normal lives as productive members of society. (a) What This Means (Slide #35) Counties must have a plan for prevention of alcoholism and treatment of alcoholics and intoxicated persons All counties in Wisconsin either provide treatment or contract with providers who provide treatment for them (b) Definition of Alcohol Incapacitation from a Crisis Perspective (Slide #36) 51.45(11)(b) A person who appears incapacitated by alcohol shall be placed under protective custody by a law enforcement officer. Need to determine whether someone is incapacitated by alcohol This does not apply to drugs (that is covered in 51.15) (c) Alcohol Incapacitation (Slide #37) Evidenced by: Gross Impairment Slurred speech Unsteady gait Incoherent, unconscious Strong odor of alcohol on breath Impaired judgment inability to care for self Life-threatening withdrawal symptoms such as delirium tremors (seizures, shakes, elevated vitals) Intoxicated persons are at a greater risk to commit suicide (d) Resulting In (Slide #38) Inability to care for self Dangerousness to self or others Examples Intoxicated and passed out in a snow bank Having DT s (delirium due to withdrawal) (e) When does a Person Need Medical Detox? (Slide #39) Change in mental status Hallucinations Temperature above 100.4 Significant increases or decreases in blood pressure or pulse Seizures Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 17

This is why we send clients to the ER for medical clearance. Many of the consumers who present in crisis exhibit both mental health and alcohol incapacitation. It is important for the crisis response worker to be able to assess the consumer so that, if necessary, they can pursue an emergency detention or alcohol hold. Drugs, other than alcohol, are handled through 51.15, as are those consumers who are mildly intoxicated but exhibit serious mental health issues. (f) 51.45 vs. 51.15 (Slide #40) 51.45(11)(b) deals with incapacitation due to alcohol Mildly intoxicated not a candidate voluntary Mild withdrawal voluntary Mildly intoxicated and suicidal 51.15 Drugs other than alcohol and suicidal 51.15 Incapacitation is determined by symptoms and behavior (g) Role of the Crisis Worker (Slide #41) Assess for incapacitation along with law enforcement Assess for the need for detox Assess for the need for 51.15 Are they in danger due to their drug use (severely psychotic, having seizures, etc.) People under the influence are at greater risk for suicide Always re-assess after the person is sober or drug-free REF-1 SAMHSA Quick Guide Review the SAMSHA Quick Guide with the Group OOF-2 - Case Scenario #2 (Leon) Alcohol Incapacitation/Protective Hold and Crisis Response Divide the participants into groups of 3 4 (or by table if that works) Hand out the Crisis Scenario Sheet and the Crisis Scenario Discussion Tool Have the participants read the scenario and discuss use the tool for discussion with their group. Have them document their discussion and then document a brief crisis response plan for the consumer using information from the Quick Guide. Bring together the group for large group discussion. (h) 51.45(13) Involuntary Commitment for Alcoholism (Slide #42) Very rare to get an alcohol commitment Similar process as mental health commitment Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 18

Probable cause hearing within 72 hours (excluding weekends and holidays) Legal representation Commitment hearing within 14 days (excluding weekends and holidays) (i) Alcohol and Drug Commitments (Slide #43) Rarely done Requires established pattern of use, which causes substantial impairment of health and functioning and which causes dangerousness to self or others. D. Involuntary Admission Emergency Detention/Commitment Standards (1) Involuntary Admission (Slide #44) There are four ways a person can be admitted to a hospital against his/her will (involuntarily): Statement of Emergency Detention Treatment Director s Hold A Three Party Petition A Fifth Standard Petition (a) Statement of Emergency Detention (ED) (Slide #45/46/47) Law enforcement officers may take individual into custody, file a statement of emergency detention (ED), and detain that individual based upon the officers belief from either personal observation or reliable reports of others, that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and needs treatment The 72 hour timeline starts when the officer takes the person into custody The emergency detention may be dropped prior to the 72 hours if deemed inappropriate or the person agrees to voluntary treatment Law enforcement officers must consult with crisis staff/mental health workers of the county department of community programs County department must approve the need for detention of the individual before law enforcement officers can do an ED The receiving mental health facility/unit usually requires medical clearance of the individual prior to detention to check for medical problems, drug or alcohol use, and to evaluate the individual s mental state (b) Treatment Director Emergency Detention (Slide #48) The Treatment Director of a mental health facility/unit may file statement of Emergency Detention (ED) and detain patient who is admitted to the facility/unit. ED must allege that the patient is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and needs treatment Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 19

Treatment Director ED usually occurs when an individual is voluntarily admitted to a facility/unit and later refuses treatment and/or requests discharge (c) Three Party Petition for Examination (Slide #49/50) Three adults sign a sworn petition drafted by the County Corporation Counsel At least one of the petitioners (signers) must have personal knowledge of the individual s dangerous behavior Petition must allege that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and a proper subject for treatment Petitioners who have not directly observed the individual s dangerous behavior must provide a basis for their belief that the allegations are true The County Corporation Counsel files the petition with the court. After review, the judge may order detention of the individual by law enforcement to a mental health facility or may just set the case for a probable cause hearing without detention This process may take several days or more and should not be used in emergency situations (d) Fifth Standard (Slide #51) A Fifth Standard Petition is similar to the Three Party Petition, but the subject must have a history of receiving treatment, and an inability to understand the benefits of treatment while suffering from mental illness. Generally is not the requirement of a substantial probability of imminent harm A physician must be a signer of the petition The fifth standard is found in section 51.20(1)(a)2.e. (commitment standards) of the Wisconsin statutes. It was enacted in 1995 Wisconsin Act 292. It went into effect in December, 1996. B Commitment Process There are very specific legal processes in an emergency detention. When an emergency detention occurs the process moves to probable cause hearings, possible outcomes, and final hearing. The final hearing determines the need for a commitment and/or other outcomes.. Trainer Note: Crisis Staff should understand the emergency detention procedure and their role in it. Discussion throughout the use of these slides to present the process should focus on their role in the hearing process and the follow up. (1) Probable Cause Hearing (Slide #52) (HO-05 Chapter 51 Process) Court hearing must be held within 72 hours of individual s detention at a mental health facility (excluding weekends and holidays) Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 20

Witnesses testify from personal observations about the allegations of dangerousness in the petition or ED, and doctor testifies about mental illness, disability, or dependence and treatment After the hearing, the judge determines if there is probable cause (reason) to believe the allegations and cause to detain and treat the individual in a mental health facility Probable Cause Hearing Four Possible Outcomes (Slide #53/54) Case is dismissed for lack of sufficient evidence that the individual is mentally ill or dangerous Settlement Agreement is approved by the court Case is converted to temporary guardianship and protective placement or services, if the individual is developmentally disabled and not treatable Probable cause is found - If probable cause is found Final hearing is scheduled within 14 days of detention Two doctors are appointed by the court to examine the individual and to submit written reports with their opinions and recommendations to the court (2) Final Hearing (Trial) (Slide #55) Court hearing held within 14 days of the individuals detention at a mental health facility, or 30 days if there is no detention after probable cause hearing Witnesses testify from person observations about the dangerous behavior, and court appointed examiners (psychologists and/or psychiatrists) testify about mental illness, disability, or dependence and treatment After the hearing the judge determines if there is clear and convincing evidence to commit the individual either inpatient or outpatient initially, and whether the individual is competent to refuse psychotropic medications Final Hearing Four Possible Outcomes (Slide #56) Case is dismissed for lack of clear and convincing evidence that the individual is mentally ill, or is dangerous, or is treatable Settlement Agreement is approved by court Conversion to guardianship and protective placement/services if untreatable condition Order of involuntary Civil Commitment for treatment REF-2 Order of Commitment/Extension of Commitment/Dismissal Review REF-2 with the group go over the format that addresses the possible outcomes of the probable cause hearing and the final hearing for a commitment order. Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 21

(3) Settlement Agreement (Slide #57/58) A negotiated contract for treatment between the individual, his/her attorney, and the County Corporation Counsel and approved by the court Waives the court hearings for a specified period of time up to 90 days Cannot be extended at end of time period, if individual is compliant with treatment. Includes a list of treatment conditions the individual must comply with including the maximum time (number of days) of inpatient treatment Failure to comply with the treatment conditions may result in return to a mental health facility and continuation of court proceedings REF-3 Settlement Agreement and Court Approval and Order to Transport Review the Settlement Agreement format with the group (4) Order of Involuntary Civil Commitment for Treatment (Slide #59) If there is clear and convincing evidence that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others, and a proper subject for treatment, and individual may be committed by court order to the care and custody of the county department of community programs for inpatient and/or outpatient treatment for up to 6 months (5) Outpatient Treatment Conditions (Slide #60) Committed individuals are given this document upon discharge to outpatient treatment, informing them to comply with the listed conditions deemed necessary to ensure treatment and safety in the community The individual s failure to comply with the conditions may result in his/her return to a mental health facility by law enforcement Psychotropic medications may not be administered involuntarily (forcibly) as an outpatient treatment condition (6) Order to Treat (Slide #61/62) The court may order that medication may be administered to an individual regardless of his/her consent (involuntarily and/or forcibly). After a finding of probable cause, effective only until the final hearing After an order of commitment is granted, effective for the duration of the commitment The court must find sufficient evidence to believe that the individual is not competent to refuse due to illness/disability/dependence, because he/she is: Incapable of expressing and understanding of the risks, benefits, and alternatives of medications, OR Incapable of applying an understanding of the medication to his/her own condition to make and informed choice to accept or refuse Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 22

(7) Extension of Commitment (Recommitment) (Slide #63) Prior to expiration of a commitment, the county department, to which an individual is committed, may file a recommendation to extend the commitment County Corporation Counsel files petition for recommitment alleging the individual continues to need treatment, is dangerous without treatment, and is unlikely to comply without court ordered treatment Order of Extension of Commitment can be up to 12 months if the court finds that there is a substantial likelihood that the individual should become a proper subject for commitment if treatment was withdrawn (8) Monitoring Settlement Agreement/Treatment Conditions of Commitment (Slide #64) Noncompliance does not automatically result in returning the individual to a more restrictive environment (re-detention to a mental health facility) Need for red-detention is based on level of noncompliance, dangerous behavior, and/or potential for dangerousness If individual is unstable and in need of inpatient treatment and willing to comply, he/she can be voluntarily admitted without court involvement Discussion: What is your county s process and procedure for who monitors the settlement agreements? How is it done? Who is responsible to do it? C. Children and Youth The rights of children and youth are, for the most part, the same as the rights of adults in an emergency detention situation. They do, however, have the right to be represented by adversary counsel. Parents have the right to participate in the court hearings of their children/youth. When working with an adolescent in either a 51.15 or 51.45 situation, crisis workers are expected to work with supervisors and other consultants from the youth and family divisions of their agency. Collaboration is particularly important if the youth is already in the 48 or 948 systems. Chapter 51 Court Hearings Rights of Minors (Slide #65) Minors have the right to Be represented by adversary counsel at public expense Have a closed hearing Request an open hearing Remain silent Present and cross-examine witnesses Have a jury trial Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 23

Chapter 51 Court Hearings: Rights of Parents and Legal Guardians (Slide #66) Parents/Legal Guardians have the right to: Participate in the court hearings Be represented by counsel (at their own expense) Why are Minor Children Ed d? (Slide #67 Effective 8/1/06, Wisconsin law permits parents/legal guardians to sign their minor child into a psychiatric hospital for treatment without the child s consent (considered a voluntary placement) However, if the child is physically combative and/or unwilling to accept treatment, voluntary admission may be inappropriate and unavailable Crisis Referrals of Children/Youth (Slide #68) Things to think about when considering referrals of children to inpatient Can the child return home safely as part of the crisis response plan Is there a family member that the child can safely stay with as part of the crisis response plan Can a community crisis bed be utilized? Can you work with the 48 System to find an appropriate placement if the child cannot stay with family? Discussion: Have any participants initiated an emergency detention for a child/youth? What were the circumstances? Could the detention be avoided? Was resources were/were not available in your community to divert the placement of a youth in an institutional setting? What Can Families Expect from the Treatment Facility? (Slide #69) Consultation with social workers and/or treating psychiatrist Information about assessment of the child and treatment recommendations Parental consent must be obtained prior to administering any medications Family phone calls and visits allowed as appropriate Social worker will coordinate discharge plan with family and community providers Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 24

What Can Families Expect After Discharge to Outpatient Treatment? (Slide #70) If case is dismissed, there is no further court involvement unless a new involuntary civil commitment case is initiated If individual is discharged under settlement agreement or treatment conditions of commitment, county of residence will provide services and monitoring, and will determine if/when individual needs to return to inpatient treatment Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 25

Module 4: Related Laws - Basic Overview When looking at the laws that pertain to children and youth it is important to note that the issue is not conflicting laws but our inability to work collaboratively with each other. Each system plays a role when they overlap, ant it is important to understand the role of others, your own role, and how those involved can work collaboratively with the consumer, family, natural supports and others to achieve the best outcome. A. Laws Governing Children/Youth (Slide #71) The Child Welfare System is basically made up of Child Protective Services, governed by Chapter 48 and Juvenile Justice Services, governed by Chapter 938. There is a reference handout How Children Enter Foster Care that they should be encouraged to read over when they get a chance because it does a good job explaining the child welfare system. Chapter 48--Child in need of protection due to abuse and/or neglect (includes sexual abuse, emotional abuse/neglect) Chapter 938 Juveniles in need of Protection due to risk to the community (Juvenile Justice system oversight) There may be child welfare issues along with mental health issues May be confusion about which system would best serve the youth Important to collaborate with social workers in the child welfare system (1) Chapter 48 (Slide #72) Investigation of reports of abuse (physical, emotional and sexual) and neglect Regulates child protection, foster care, and other out of home placements (2) Child in Need of Protective Services (con t.) (Slide #73) A Report is filed (mandatory reporting applies for crisis workers) Agency makes a decision about whether an investigation is necessary If necessary, the agency makes an assessment and takes necessary action to keep the child safe In the home with a safety plan OR Placed out of the home (3) Chapter 938 ( Slide #74) Juveniles may be supervised for delinquency (breaking the law if they are age 10 or over) Or in need of protection or services because of running away, truancy, committing a delinquent act and being under the age of 10 or not responsible due to mental disease or defect Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 26

(4) Juvenile Justice System (slide #75) Report comes into the agency Agency evaluates the report and makes a decision about whether the child requires services If behavior is thought to be a risk to public safety, the juvenile may be placed at shelter care, secure juvenile detention or even a county jail (depending upon the level of risk to community safety) (5) Facilities for mental health referral (slide #76) Exception to placement in foster care, juvenile shelter care or detention for those in need of mental health treatment May go to an inpatient psychiatric facility Also a designated crisis bed in a foster home or group home Do not need to do a CPS or JJ referral for mental health stays Unless there is reason to believe there is also a child protection or juvenile justice issue. Trainer Note: Crisis beds are a new resource for many communities who are dealing with youth who are involved in both the 48 and 51 system. DSP Info Memo 2011-07/DMHSAS Info Memo 2011-01 uses the existing authority for voluntary child welfare placements to support voluntary stays in OHC for purposes of providing mental health crisis stabilization services. The intent is to allow the use of OHC settings for initiating voluntary crisis services without requiring the intervention of child welfare/juvenile justice intake processes. The memo provides guidance for crisis stabilization services. Crisis services provided by mental health agencies for children in OHC settings remain subject to other DHS mental health and Medicaid requirements and OHC providers remain subject to DCF OHC requirements. DSP Info Memo 2011-07/DMHSAS Info Memo 2011-01) (HO-06) Discussion: Review DSP Info Memo and talk about the possibility of Crisis Beds in their communities. What is the best use of a crisis bed? Where should the use of the crisis bed be in the continuum of placements? (6) Unborn Children of Substance Abusing Moms (slide #77) 48.133 Jurisdiction over unborn children in need of protection or services and the expectant mothers of those unborn children. When a mother habitually lacks self-control in the use of alcohol/controlled substances which places the unborn child at substantial risk Under Chapter 48, the court may take over Rarely happens Not mandatory to report Try to work collaboratively to get the mother to voluntarily seek treatment Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 27

Trainer Note: There is also a 51 provision for this action, but it is hardly ever used as there are few appropriate placements for a pregnant person who is abusing alcohol and/or drugs which place her child in danger. If there is a crisis response it is a priority if there is great danger. In most instances this action is precipitated through the 48 system and is not considered a mental health crisis response. Crisis workers should be aware of it and work in collaboration with 48 system social workers when needed. Case Scenario #3 (Sally) Pa Divide the participants into groups of 3 4 (or by table if that works) Hand out the Crisis Scenario Sheet and the Crisis Scenario Discussion Tool Have the participants read the scenario and discuss use the tool for discussion with their group. Have them document their discussion and then document a brief crisis response plan for the consumer using information from the Quick Guide. Bring together the group for large group discussion. Note: Make sure to discuss this case from a child protection point of view as well as from a crisis perspective for Sally s issues. Emphasize the need for collaboration Parental Authority Over Minors in Need of Substance Abuse or Other Treatment (Slide #78) Legislative changes were made in regard to parental authority over minors in need of substance abuse treatment (REF-Minor s Rights) Under the revisions to Sec. 51.13 Wisconsin Statutes the following can now execute a petition for voluntary admission for inpatient treatment, depending on the type of treatment to be provided (Slide #79) Voluntary admission for treatment of: Minors Age Substance Abuse Under 18 Parent only Authority needed from: Mental illness, Developmental Disability 14 or older Parent and minor Mental illness, developmental disability or substance abuse Under 14 Parent only Behavioral Health Training Partnership University of Wisconsin - Green Bay Page 28