Command-Directed
Mental Health Evaluations
Background
DoD Directive 6490.1, the original so-called "Boxer
Law" (named after the California Senator who championed its supporting
legislation), was enacted on September 14, 1993. This law established the rights of active
duty military personnel and civilian employees of the Armed Services who are either
referred by their commands for outpatient mental health evaluation, or are admitted for
inpatient psychiatric evaluation or treatment, against their will. Its primary intent was
to protect all such personnel from unwarranted mental health evaluations or involuntary
hospitalization as retaliation for revealing flaws within military organizations
("whistle-blowing"). However, it was also designed to ensure that the criteria
used by military mental health care systems, for the involuntary hospitalization of active
duty service members, were essentially the same as those used for civilians throughout the
rest of the United States.
The original Boxer Law was implemented in the Navy through SECNAVINST 6320.24 on
December 14, 1994. In the fall of 1996, Congress expressed their concern to DoD Health
Affairs over the failure of the military services to take appropriate precautions with
service members evaluated by mental health professionals to be an imminent or potential
danger to themselves or to others. Pursuant to these concerns, DoD implemented changes to
their directive to provide safeguards in these situations. On October 1, 1997, the
revision and expansion of DoD Directive 6490.1 was complete. The SECNAV
implementing instruction was signed on 16 Feb 1999.
Referral for Psychiatric Evaluation
According to the above instructions, all involuntary referrals of a
patient to a mental health provider originating from the patients chain of command
must be treated differently from self-referrals or referrals from other health care
providers. In involuntary mental health referral cases:
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The member to be referred must then be presented with a letter, signed by his CO or
other designated command representative, informing the member of the scheduled mental
health appointment, the reasons for the mental health referral, and who was consulted
before making the referral. The letter must also inform the member of their rights to have
legal counsel present during the evaluation, and the right to communicate with their
Congressman or an Inspector General (IG) before the evaluation. The member must sign a
letter acknowledging receipt of the written notification of referral.
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Before beginning the evaluation, the MTF mental health provider must ensure the member
received a notification letter, as required, and that the referral seems warranted based
on the members recent behaviors, etc. If the mental health provider suspects the
referral was intended by the service member's command as punishment or harassment, the
mental health provider is required to report this suspicion immediately to higher
authorities.
Rights
involving involuntary psychiatric admission
The Boxer instructions also contain the following procedures for
protecting the rights of service members who are involuntarily admitted for psychiatric
evaluation or treatment:
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Just like civilian mental health patients, active duty service members can only be
involuntarily admitted to a psychiatric unit if they present with clear evidence of being
at immediate risk of harm to themselves or others (including property). As always, the
least restrictive alternative principle applies.
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Immediately upon involuntary admission, the member must be informed, in writing, of the
reasons for the admission as well as their right to communicate with an attorney, IG, or
member of Congress.
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In addition to the initial evaluation by the attending psychiatrist (within 2 business
days), a second, independent mental health evaluation must be performed within 72 hours of
admission. This second evaluation determines whether continued involuntary psychiatric
hospitalization is warranted based on available evidence. The member must be informed of
the results of this evaluation in writing.
Significant Change
The revised DoD directive creates a new category of cases for service members
deemed to be "imminently or potentially dangerous." Commanding officers and
mental health providers are now charged with taking precautions to protect the service
member and other individuals against death or injury (beyond psychiatric hospitalization)
any time there is reason to believe a service member is an imminent or potential threat to
kill or seriously injure someone else. These precautions include ensuring that the service
member is evaluated within 24 hours as well as notifying the intended victim, restricting
the access of the member to his potential victim, and when appropriate, effecting an
expeditious administrative separation.
Final notes
Nothing in any of the Boxer instructions affects the way emergent or
routine psychiatric referrals are handled from sick call or an emergency room. Competence
for duty, family advocacy, sanity evaluations for a court martial, and drug and alcohol
referrals are also exempt.
Reference
-
DoD directive 6490.1, "Mental Health Evaluations of Members
of the Armed Forces", 10/1/97.
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SECNAVINST 6320.24, "Mental Health Evaluations of Members of
the Armed Forces", 02/16/99.
Written by CAPT William P. Nash, MC, USN, Psychiatry Specialty Leader, Naval
Medical Center San Diego (1999). Reviewed by LCDR Michael Bandy, JAGC, USN, Medico-Legal
Affairs, Bureau of Medicine and Surgery, Washington, D.C. (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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