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Notes -
ongoing shooting in lewiston, maine
reportedly 22+ dead, 60+ shot. shooter is rumored to be an ex army guy. perhaps shaping up to be the next las vegas massacre. stay safe and prepare for the gun control debate to be revved up full force tomorrow
Apparently fire arms instructor, Army reserve, just recently spent 2 weeks mental institution? https://twitter.com/BNONews/status/1717374410795934053
If true, this guy reported those voices, got briefly institutionalized, and then... what happened? Stopped taking meds (if he got them), and then shot up three+ places?
Isn’t the problem that SCOTUS hugely narrowed over time the reasons why someone can be institutionalized indefinitely over the late 20th century? I remember reading that somewhere.
Deinstitutionalisation come more from public policy than court rulings.
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The main legal challenges at SCOTUS level are O’Connor v. Donaldson (must be a danger to self or others, or incapable of surviving outside of institutionalization, not just mentally ill) and Addington v. Texas (must be 'clear and convincing' proof), both in the 1970s.
There's some internal discussion from ACLU-driven lawsuits, especially at lower courts, where this was meant to add so much paperwork as to make commitment impractical (see Scott's My Brother Ron summary), but while I can't speak of how serious their strict ramifications are for this case, in general a lot of the central examples in favor of institutionalization would still be readily and easily proven under these standards. The bigger issue's just that institutionalization and longer-term involuntary commitment became culturally untouchable.
Short-term holds are wildly available and, thanks to the Scylla and Charbydis of standing and mootness doctrine, especially difficult to challenge even when due process is missing entirely. My go-to example is Pennsylvania's Section 302 commitments, which can hold people for up to 5 days based on a petitioner's statement and a single doctor's signature. This tends to be the biggest issue for gun ownership, since some police use it as a glorified drunk tank and it counts for Pennsylvania law if you try to buy a gun, but there's been other abuses, and it's basically impossible to challenge.
But most psych offices and legal spheres will avoid calling for long-term commitment without a criminal conviction, even in cases where dangerousness is pretty obvious.
I think it might be helpful to lay out how this looks from the medical perspective. Every state is a little different but the broad strokes are pretty similar (although some differences can be substantial - most states will allow commitment only if a threat to self/others but some will also add "property" to the mix. Likewise the extent to which "not taking care of oneself" matters for threat to self).
It's also worth noting that you'll hear a lot of horror stories about commitment and mental hospitals but it's almost always (well these days at least) signal boosting rare events or stemming from people who are in denial about the fact that they have mental illness, which is most of the sickest patients (because if they had insight into their illness they would take medication, stay out of trouble and uh not be sick). I uh cough cough have nothing positive to say about the ED portion of this though.
So okay.
A patient comes to the attention of health care - the police bring them in, the patient brings themself, family brings them in, roving outreach social workers find them etc etc. They are seen by some combination of social work, ED physicians, and Psychiatry (depends on state and setting). At that time a patient might be sent home, asked to stay voluntarily (or the patient asks), or committed. The involuntary commitment generally involves some form of VERY short hold until additional resources can weigh in (ex: 24 hours for you to get two psychiatrists to say "yup"). Then that turns into a longer but still short involuntary commitment. For purposes of gun restrictions and other things it's triggered here. You could be high as shit on PCP, get committed for a day, then discharged and it's still an involuntary stay.
This creates all kinds of strange interactions - a suicidal 18 year old college student who wants to go home and study or a cop (who would lose his job) might be HEAVILY encouraged to sign in under a voluntary status even though staff isn't supposed to do that (if the patient is not voluntary they are involuntary...) because everyone wants to avoid long term repercussions for the patient. The facility may also "convert" an involuntary stay to a voluntary one in situations like the PCP guy. No idea how that is supposed to work legally but it seems to be extremely common practice.
Once someone is committed under an involuntary status the process of getting them out of the hospital starts. This has all kinds of tensions, yes hospitals benefit from having patients in them, but insurance isn't going to pay forever and the patient will have periodic court hearings and in many jurisdictions the conversation with the judge goes something like "yes he threatened to fuck your mother to death yesterday, but what has he done today?"
Therefore most people who have their commitment upheld and/or get sent to a longer term facility are generally very sick, aggressively malingering (think homeless person who wants to be off the street) or a huge pain in the ass (think borderline personality disorder patient who probably wont kill themselves but keeps insisting they are suicidal). At that point these people typically get transferred to a longer term or state facility to attempt stabilization/await someone ballsy enough to discharge. Sometimes creative things will happen like discharging to the police.
Sick people will absolutely be held more or less indefinitely if it's really necessary, but again if someone has two good days before their court hearing they might get sent home by the judge even if the patient's family brings them straight back to the ED an hour later (a sad but hilarious thing I saw many times in medical school while in an inner city hospital).
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