In the United States, we witnessed several situations within the last year where a violent individual’s mental health issues were called into question. It is easy to assume that if someone had received the appropriate mental health treatment, or if certain mental health professionals had noticed the “red flags” along the way, senseless violence could have been averted.

For example, the choices of mental health workers who were in contact with Nikolas Cruz prior to the Parkland, Florida shooting in February 2018 have been scrutinized, as Cruz previously displayed signs of harming himself, aggression and physical violence. Police departments and other services were blamed when it was revealed the shooter who stormed the Capital Gazette was a chronic harasser, the victim of which sought legal assistance. The Waffle House shooter in Nashville, Tennessee also was noted for harassment and had a distinct history of resisting authorities.

However, even if concerned individuals attempt to garner assistance for these subjects, they can encounter multiple barriers. While mental health treatment increasingly is seen as a social imperative and even a significant security consideration, the journey to receive this treatment is often misunderstood and challenging. Having knowledge surrounding this process can help the public to better understand what kind of services could — and could not — have been offered to a potentially dangerous and ill individual.

The journey from mental health crisis to psychiatric commitment

When an individual is experiencing a mental health crisis, a major consideration is ensuring that the person does not harm himself or herself or harm someone else. In order to have an individual committed to a psychiatric facility or ward, most states use a subjective baseline to determine whether admission is required. Typically, this process begins after the individual has contact with emergency services and an attending psychiatrist conducts an interview. It is the attending physician, ideally a psychiatrist’s, clinical opinion that decides if an individual is admitted to the hospital or facility.

In addition to this practice, mental health statutes regarding admission can vary, which adds more nuance to the process. In Illinois, one person can advocate for another to be psychiatrically admitted if the individual is unable to care for himself or herself or if he or she are an imminent risk to himself or herself or to others. In Florida, the Baker Act allows a person to initiate the process of psychiatric hospitalization for an individual in crisis so that he or she can receive a psychiatric evaluation.

It can be difficult to have an individual involuntarily committed to a psychiatric facility if the attending physician decides he or she will not be admitted, disregarding the emergency services personnel, family members or mental health professionals who are advocating for the admission. Unfortunately, other factors can impact the likelihood of admission to a hospital and the length of the stay, including not having health insurance, space available in the psychiatric unit or facility and even the client’s characteristics, such as violent, aggressive or antagonistic traits.

The difference between voluntary and involuntary admission to a psychiatric facility

Another route for admitting a person in crisis is discussing the benefits of voluntarily admitting himself or herself. When an individual is voluntarily admitted, the duration of his or her stay is dependent on the patient.

On the other hand, most states will only keep an individual who is involuntarily admitted for up to 72 hours before reevaluating and then possibly discharging the individual. The goal of an emergency hospitalization is to stabilize the patient, and the admission is not considered a long-term solution. During this 72-hour period, the individual will likely receive psychotropic medication, a psychological evaluation and milieu therapy.

Milieu therapy consists of group therapy, brief individual therapy and constant and continued observation during an individual’s admission. It is not extensive therapy, and continued mental health services after discharge can be intensive and long-term if necessary.

Upon discharge, the patient may be referred for continued psychiatric and psychological services that are voluntary in nature. This inherently makes interventions and continued treatment difficult, particularly without support from loved ones or mental health staff.

After all of these hurdles, if a patient is successfully discharged and complies with after-care recommendations, he or she must also have the insight and wherewithal to understand his or her illness and to commit to remaining well.

When we better understand the facilities and support system surrounding these individuals, we can better understand how to prevent the most troubled from committing a violent act.