Imperial County’s use of psychiatric holds appears to violate state law

This story was originally published in inewsource with support from the 2022 California Fellowship

Imperial County officials routinely keep people on psychiatric holds for longer than 72 hours, often in ill-equipped facilities and without a formal hearing that’s required by law, an inewsource investigation found.

Data shows the county has continued to record dozens of such cases each year despite consultants warning officials about the risk of civil rights violations, and inewsource also found that lax oversight of this practice statewide makes it impossible to determine how many other counties around the state allow it to happen.

The holds are commonly referred to as “5150s,” a nod to the section of state law that governs the process: For up to 72 hours, a person can be held against their will if they’re deemed a danger to themselves or others, or considered gravely disabled. Keeping them any longer ultimately requires a hearing.

Yet in Imperial County, where residents already suffer from poor health factors and a shortage of resources for mental health services, officials have used back-to-back holds more than 1,000 times in the past decade. 

Why this matters

Placing a person on back-to-back 72-hour holds for a psychiatric crisis risks civil rights violations and in some counties, places people in facilities not equipped to provide proper services and treatment.

They’re known as “serial” or “stacked” holds: When the 72-hour window closes and officials believe the patient should not be released, instead of holding a hearing to justify a longer stay, they write a new 5150.

Annual numbers show little consistency to how often the county has used serial 5150s: In some years, the count exceeded more than 100 cases, but it also dipped as low as 12 in fiscal 2010-11. 

Interpretations of the law vary. But Disability Rights California, which previously sued another county in the state over its serial holds and other violations, contends the practice is illegal.

“The longer people stay in emergency departments, they’re not in a place that is suited to address the crisis that they’re in,” said Kim Pederson, one of the agency’s senior attorneys.

Despite providing inewsource with data they labeled “Admissions for Serial 5150,” county officials denied they use them. Officials also refused multiple requests for interviews, and ignored additional inquiries for information. 

The Imperial County Behavioral Health Services building is shown on Sept. 13, 2022. (Zoë Meyers/inewsource)

The Imperial County Behavioral Health Services building is shown on Sept. 13, 2022. (Zoë Meyers/inewsource)

In lieu of answering a list of questions earlier this year, one county employee — Maria Rodriguez-Ruiz, deputy director of mental health triage and engagement services — inadvertently replied to the reporter instead of county colleagues, writing in Spanish, “This lady doesn’t stop.” 

Imperial County appears to be one of just a handful across the state that actually monitor serial 5150s. The vast majority of behavioral health departments told inewsource they do not track them, and most didn’t answer how they otherwise assess whether serial holds are a local problem.

Michelle Doty Cabrera, head of the County Behavioral Health Directors Association of California, acknowledged some counties have struggled with serial holds.

“(Counties’) biggest concern is with the safety and well-being of that person and the protection of their life, and the lives of other people around them,” Cabrera said. “Where I’ve heard people really struggle around this concept of stacked holds is where they are struggling to find a bed.

“And they’re very concerned that if they release the hold, allow the person to walk out those doors, that the outcome could be death.”

‘The most pressing challenge’

During a 5150, a person is quickly shifted from voluntary treatment — or from a refusal to accept it — to forcible methods. It can start with a mental health crisis at home or elsewhere, and often involves law enforcement transporting the person to a hospital.

Experts warn it can be a traumatic experience: Sometimes, a person may be medicated, restrained and detained in a locked setting during the hold.

And in places like Imperial County, a rural and geographically vast region of 180,000 residents, it can happen where officials are struggling to provide services to all who need them. The federal government has deemed the county as a “shortage area” for mental health professionals, with more than 20,000 residents for every local psychiatrist. 

Along with more than 20 others across the state, the county lacks a 24-hour facility designated for involuntary psychiatric holds. 

Involuntary holds involve several decision makers. In Imperial County, law enforcement often initiates the 5150 when responding to mental health crises; medical providers decide if, and for how long, a person should be held; and county officials are involved in oversight that includes deciding whether to pursue conservatorship for people with serious mental illness who are gravely disabled.

Imperial County Deputy Sheriff Pedro Millan enters notes after responding to a possible 5150 call in El Centro, Sept. 13, 2022. In Imperial County and elsewhere in California, many 5150 holds are initiated by police. (Zoë Meyers/inewsource)

Imperial County Deputy Sheriff Pedro Millan enters notes after responding to a possible 5150 call in El Centro, Sept. 13, 2022. In Imperial County and elsewhere in California, many 5150 holds are initiated by police. (Zoë Meyers/inewsource)

There are two hospitals in the county: Pioneers Memorial in Brawley and the El Centro Regional Medical Center. Neither has psychiatric beds nor an official designation to place people on 5150s. Emergency rooms are only supposed to take them when medical clearance is necessary.

The Mental Health Triage Unit, a county-operated outpatient clinic with just seven beds that’s typically only open during regular working hours, is the only facility that is supposed to handle the area’s hundreds of 72-hour-holds each year.

Yet consultants hired by the county’s Local Health Authority found that the hospitals acted as alternative locations for 5150s and that one-third of people ultimately served at the county’s triage unit also visited an emergency room. Many stayed “for much longer than a medical clearance,” according to their 2020 report.

Data reviewed by county consultants showed that while most people were discharged from emergency rooms within six hours in 2018, about 14 stays exceeded three days — and one lasted as long as 44 days.

Requests for an interview with an official from the El Centro hospital, the county’s largest, went unanswered. 

Consultants called the lack of adequate facilities “the most pressing challenge” in the county’s 5150 process. They also pointed to significant safety issues for both staff and people placed on holds, and found during their review that community partners involved in the system “experienced increasing difficulty with communication and collaboration.”

The county reported 65 serial holds at its triage unit last fiscal year, and 78 the year prior. But annual counts reached as high as 143 over the past decade.

The county’s facility is limited not just by bed availability but by who the clinic serves: If a person is violent or aggressive or “has medical needs that require medical oversight, including substance use or intoxication,” they’re transferred to an emergency department. 

Residential treatment options within the county are limited and if a person needs to be held longer in a locked inpatient facility, most are transferred elsewhere, including San Diego. Joan Durham, a county Behavioral Health employee who retired in 2019, told inewsource that even while officials had good relationships with out-of-county facilities, they faced difficulty finding beds.

“If we street this person, what liabilities do we have if that person goes out and kills someone? Or kills themselves?” Durham said. “So, although a back-to-back 5150 may not be legal, it’s in some cases, highly necessary.”

Across the state

The vast majority of California counties — including the state’s largest, among them San Diego — told inewsource they don’t track serial 5150s. Some pointed to the inability to collect the data from non-county facilities operated by private providers, and at least one county cited the lack of a state requirement to track the information. Others said they couldn’t track down the data due to lack of staffing and time.

In addition to Imperial, just six counties — Butte, San Benito, Del Norte, Sierra, Tulare and Ventura — confirmed instances of serial holds.

Stacked holds were flagged by a 2015-16 grand jury in San Benito, a county of about 65,000 east of Monterey. Patients were often held for longer than 72 hours and “not infrequently” beyond a week, according to the grand jury’s report, and some patients were being held in an emergency room for as long as 14 days.

The county had argued that the Lanterman-Petris-Short Act, the state law that governs involuntary holds and mental health conservatorships, left an unclear definition of when the 72-hour limit begins. But the grand jury said it “found the law to be well defined” — and that “resolving the time issue of a 5150 hold will not solve the county’s larger mental health care systemic problems.”

A person who has been involuntarily detained during a mental health crisis has a right to due process, though the state statute and case law differs on exactly when. The next step beyond a 72-hour hold is known as a 5250, and allows a facility to hold a person for up to 14 days. 

State law says a person is entitled to what’s known as a certification review hearing, held within the facility, within four days after being placed on a 5250. A federal appeals court has found that due process requires that a  person be given a hearing within seven days of being picked up by police, regardless of the type of hold.

But people being put on serial 5150s may never be placed on a 5250 — and may not get that hearing, Pederson said.

“So you can imagine, if someone is in Imperial County and they’re in the emergency department for six days, seven days on multiple different 5150 holds, they never have access to that due process that they’re entitled to under the case law,” she said. “Which is important because it’s the only way a person who is subject to an LPS hold meaningfully has access and the right to challenge a hold.”

Disability Rights California sued San Benito in 2019, saying its behavioral health department’s failure to designate any facility to treat 5150s delayed people’s access to evaluation and treatment.

The two agencies last year reached a settlement, in which the county acknowledged a person can only be held for up to 72 hours and agreed to take all steps to safely release or transfer a person to a proper facility when a bed or alternative placement is available. San Benito also agreed to work on expanding supportive housing for people in need of mental health services, among other efforts.

Pederson said Disability Rights believes the number of beds is sufficient in California, but that obstacles are at every stage, and people would benefit instead from community-based services.

“You have a bottleneck of people going out, bottlenecks of people coming in,” she said. “And we strongly believe that these bottlenecks would be alleviated if people had more meaningful, less restrictive alternatives than hospitals.”

Cabrera said behavioral health directors are running into additional issues: Facilities are “cherry-picking” who they will accept from counties that are trying to place people in longer-term care, staffing shortages across the state and limiting health insurance funding structures.

It’s not the same way physical health care is structured, she said, and she sees “practically speaking, in people’s everyday lives, it also leads to a tremendous amount of unnecessary suffering.”

Cabrera also said behavioral health directors are aware of the lack of data and struggle with collecting such information from facilities that aren’t county-operated. Her association sponsored a state bill this year that aims to improve data collection for 5150s. The behavioral health directors association said requiring data to be reported with sociodemographic factors would allow officials to identify disparities and “improve the quality of treatment and services available to all Californians.”

“We think it’s a really important thing to be able to have more transparency,” Cabrera said, “and our folks would be really happy to see and be able to know what’s happening in the landscape.”

Another bill, supported by Disability Rights California, seeks to clarify the 72-hour rule for 5150s by specifying that the clock begins at the time of detention, not when someone is admitted to an officially designated facility.

Both bills cleared the state legislature and await action by Gov. Gavin Newsom.

inewsource intern Danielle Dawson and investigative data reporter Jake Harper contributed to this report.