CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

A. Related Literature

1. Overview of Mental Health

Mental health is critically important to everyone, everywhere. All over the world,

mental health needs are high, but responses are insufficient and inadequate. In all

countries, mental health conditions are highly prevalent. About one in eight people in

the world live with a mental disorder. The prevalence of different mental disorders varies

with sex and age. In both males and females, anxiety disorders and depressive

disorders are the most common.1 Mental health conditions are also severely

underserved. Mental health systems all over the world are marked by major gaps and

imbalances in information and research, governance, resources, and services. Other

health conditions are often prioritized over mental health, and within mental health

budgets, community-based mental health care is consistently underfunded. On average,

countries dedicate less than 2 percent of their healthcare budgets to mental health.

More than 70 percent of mental health expenditure in middle-income countries still goes

towards psychiatric hospitals.2

1
World Health Organization, “World Mental Health Report: Transforming Mental Health
for All”, available at https://www.who.int/publications/i/item/9789240049338 (last accessed December 27,
2023).
2
Id.
 In a WHO study, around half the world's population lives in countries where there

is just one psychiatrist to serve 200,000 or more people. And the availability of

affordable essential psychotropic medicines is limited, especially in low-income

countries. Most people with diagnosed mental health conditions go completely

untreated.

In all countries, gaps in service coverage are compounded by variability in quality

of care. Several factors stop people from seeking help for mental health conditions,

including poor quality of services, low levels of health literacy in mental health, and

stigma and discrimination. In many places, formal mental health services do not exist.

Even when they are available, they are often inaccessible or unaffordable. People will

often choose to suffer mental distress without relief rather than risk the discrimination

and ostracization that come with accessing mental health services.3

Investing in mental health is needed to stop human rights violations. Around the

world, people with mental health conditions are frequently excluded from community life

and denied basic rights. For example, they are not only discriminated against in

employment, education, and housing but also do not enjoy equal recognition before the

law. And too often they are subjected to human rights abuses by some of the very

health services responsible for their care. By implementing internationally agreed

human rights conventions, such as the Convention for the Rights of People with

Disabilities, major advances can be made in human rights. Anti-stigma interventions–

3
Id.
particularly social contact strategies through which people with lived experience help to

shift attitudes and actions–can also reduce stigma and discrimination in the community.4

Before the COVID-19 pandemic wreaked havoc globally, mental health was

already one of the least prioritized areas of public health even in developed countries.

The World Health Organization (WHO) shares some sobering statistics: Almost 1 billion

people live with a mental disorder around the world; 3 million people die annually

because of unhealthy alcohol use; and 1 person dies by suicide every 40 seconds.5

People with mental health conditions are now considered persons with

disabilities or PWDs. "Disability" is not formally defined in the CRPD, allowing individual

State Parties considerable latitude in how they define disability in their domestic law.

People with disabilities are characterized as follows: Persons with disabilities include

those who have long-term physical, mental, intellectual, or sensory impairments which

in interaction with various barriers may hinder their full and effective participation in

society on an equal basis with others. The use of the word 'include' in the statement

above allows for a non-exhaustive description of "disability" that is not settled; neither

are the meanings of terms such as "long-term" and "impairments." It is accepted by the

Committee on the Rights of Persons with Disabilities that people with a 'mental illness'

(referred to as having a “psychosocial disability”) fall under the Convention. Whether all

4
World Health Organization, supra note 21
5
Commission on Human Rights, “Right to Mental Health: Handy Resource Book”, available at
https://chr.gov.ph/wp-content/uploads/2023/07/Handy-Resource-Book-PDF-Downloadable.pdf, (last
accessed December 27, 2023)
people with a “mental illness” are appropriately considered as having a “disability” is a

moot question.6

2. Mental Health in the Philippines

In 2015, the United Nations (UN) included mental health as one of its 17

Sustainable Development Goals (SDGs). Member nations of the UN are expected to

meet these goals—which were put together as a “blueprint for peace and prosperity”—

by 2030. The third SDG—good health and well-being—aims, by 2030, to “reduce by

one-third premature mortality from non-communicable diseases through prevention and

treatment and promote mental health and well-being.” 7 As such, the Philippines as a

member nation is expected to meet these goals.

At the height of the COVID-19 pandemic, the Department of Health (DOH) gave

out some troubling numbers describing the state of mental health in the Philippines.

Frances Prescilla Cuevas, chief health program officer of the DOH’s Disease Prevention

and Control Bureau, listed them down: at least 3.6 million Filipinos were battling mental

health issues; about 1.14 million Filipinos were suffering from depression; of these,

847,000 were dealing with disorders caused by alcohol use; a further 520,000 were

diagnosed with bipolar disorder.8

In itself, this is already troubling news. But because of a glaring lack of support,

the situation gets worse, as explained by Dr. June Pagaduan Lopez, M.D., one of the
6
Mental Health Law and the UN Convention on the Rights of Persons with Disabilities , available
at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024199/?report=printable (last accessed December
30, 2023)
7
Id.
8
Commission on Human Rights, “Right to Mental Health: Handy Resource Book”, available at
https://chr.gov.ph/wp-content/uploads/2023/07/Handy-Resource-Book-PDF-Downloadable.pdf, (last
accessed December 27, 2023)
founders of MAG and a retired professor of psychiatry at the University of the

Philippines. According to Lopez, the number of practicing mental health professionals in

the Philippines is extremely inadequate. In May 2022, as reported by the Philippine

Statistics Authority (PSA), the Philippines had a population of over 109 million. Servicing

these millions at the height of the pandemic were 700 psychiatrists—7 psychiatrists for

roughly 1.09 million people. Assisting the psychiatrists were over 1,000 nurses working

in psychiatric care—one psychiatric nurse for about one million. These mental health

workers are spread out over equally scarce mental health institutions. The following

cater to the entire country, distributed among major cities: 2 mental hospitals offering

tertiary care; 46 outpatient facilities; 4 day-treatment facilities; 19 community-based

psychiatric inpatient facilities; and 15 custodial home-care facilities.9

a. The National Center for Mental Health

The National Center for Mental Health (NCMH) is the only mental hospital in the

National Capital Region, which has a population of 13.5 million. NCMH houses 4,200

beds. Alarmingly, the hospital is being transitioned to become a general hospital. Once

the transition is complete, NCMH will lose its tertiary care capabilities. This leaves only

a small mental hospital in Mariveles, Bataan with tertiary care.10

The NCMH is dedicated to delivering preventive, curative, and rehabilitative

mental health care services. It was categorized as a Special Research Training Center

and Hospital under the Department of Health on January 30, 1987. The leading mental

health care facility in the country, NCMH provides a comprehensive range of preventive,

9
Id.
10
Id.
curative, and rehabilitative mental health services. It has an authorized bed capacity of

4,200 patients and a daily inpatient average of 3,000 patients. It serves an average of

56,0000 outpatients per year. Most of NCMH's patients are from Metro Manila and

nearby provinces in Region III and IV. As a national resource, NCMH also caters to

patients from other regions of the country, especially forensic cases referred by the

courts of law. Treatment of about 87 percent of inpatients belonging to classes C and D

are subsidized by NCMH.11

In a study by the WHO-AIMS in 2007, it was found that forty-six outpatient

facilities treat 124.3 users per 100,000 populations. The rate of users per 100,000

general population for day treatment facilities and community-based psychiatric

inpatient units are 4.42 and 9.98, respectively. There are fifteen community residential

(custodial home care) facilities that treat 1.09 users per 100,000 general population.

Mental hospitals treat 8.97 patients per 100,000 general population and the occupancy

rate is 92 percent. The majority of patients admitted have a diagnosis of schizophrenia.

There has been no increase in the number of mental hospital beds in the last five years.

All forensic beds (400) are at the National Center for Mental Health. Involuntary

admissions and the use of restraints or seclusion are common.12

The 2016 data from DOH's Bureau of Health and Facilities Services show that

there are only two government-owned psychiatric health centers, Mariveles Mental

Hospital in Bataan and Cavite Center for Mental Health. The NCMH, on the other hand,

11
The Philippines: National Center for Mental Health available at
https://mentalhealth.apec.org/partners/republic-philippines/philippines-national-center-mental-health (last
accessed December 28, 2023)
12
World Health Organization, “World Mental Health Report: Transforming Mental Health for All”,
available at https://www.who.int/publications/i/item/9789240049338 (last accessed December 27, 2023).
is classified as a specialty mental hospital, as it is the only tertiary medical center for

mental health disorders, which is why it is not on this list. The same report reveals that

there are 58 private psychiatric health facilities across the country—32 of which are all

in NCR, and the rest scattered among Regions 1 to 5, 7, 10, and the Cordillera

Administrative Region.13

In the Philippines, the mental health system has different types of mental health

facilities, and some need to be strengthened and developed. At present, mental

hospitals are working within their capacity (in terms of number of beds/patient), even

though there has been no increase in number of beds in the last five years. Some

facilities are devoted to children and adolescents. Access to mental health facilities is

uneven across the country, favoring those living in or near the National Capital Region.

There are informal links between the mental health sector and other sectors, and many

of the critical links are weak and need to be developed (i.e., links with the welfare,

housing, judicial, work provision, and education sectors). The mental health information

system does not cover all relevant information in all facilities.

In the last few years, the number of outpatient facilities has slightly grown

throughout the country from 38 to 46. Moreover, efforts have been made to improve the

quality of life and treatment of patients in mental hospitals. Some aspects of life in

hospitals have improved, but the number of patients has grown steadily. Unfortunately,

the low priority on mental health is a significant barrier to progress in the treatment of

patients in the community.14

13
Portia Ladrido, Inside the Biggest Mental Institution in the Philippines, CNN Philippines,
October 20, 2017, available at https://www.cnnphilippines.com/life/culture/2019/6/11/Inside-the-biggest-
mental-institution-in-the-Philippines.html (last accessed January 2, 2024)
14
Id.
 Aside from government-funded facilities, private institutions catering to persons

with mental disability also are available for those seeking medical and professional help.

For a private mental health facility like Metro Psych in Pasig, patient admissions

have generally been involuntary. Dr. Fareda Flores, the co-founder of the facility, says

involuntary admissions are normal as one of the symptoms of mentally ill patients is

their denial of their condition.15

b. The Right to Health under the Philippine Constitution

The Philippine Constitution mandates the state’s legal obligation to uphold and

protect health, which necessarily includes mental health, in relation to the rights of

persons with disabilities.

It is a settled doctrine that Article II, Sec. 15, or the right to health is also self-

executing.16 Section 15, Article II under the Declaration of Principles and State Policies,

provides that: “The State shall protect and promote the right to health of the people and

instill health consciousness among them.”17

Moreover, Sections 11, 12, and 13 of Article XIII under Social Justice and Human

Rights provide:

Section 11. The State shall adopt an integrated and comprehensive approach to
health development which shall endeavor to make essential goods, health, and
other social services available to all the people at affordable cost. There shall be
priority for the needs of the underprivileged sick, elderly, disabled, women, and
children. The State shall endeavor to provide free medical care to paupers.

15
Id.
16
Imbong v. Ochoa, G.R. No. 204819, Apr. 8, 2014
17
Phil. Const, Art. II, S 15
 Section 12. The State shall establish and maintain an effective food and drug
regulatory system and undertake appropriate health manpower development and
research, responsive to the country's health needs and problems.

Section 13. The State shall establish a special agency for disabled persons for
their rehabilitation, self-development, and self-reliance, and their integration into
the mainstream of society.18

In his commentary, Fr. Joaquin Bernas, a Constitutional law expert, opined that

the Philippine Constitution recognizes a right to health. The Philippines is a party to the

Universal Declaration of Human Rights and the Alma Conference Declaration of 1978

which recognize health as a fundamental human right. Health is defined as the state of

complete physical, mental, and social well-being, and not merely the absence of

disease or infirmity."19

The key concepts in Section 11 are "integrated and comprehensive" and

affordable. Integration connotes a unified delivery of the health system, a combination of

the public and private sectors, and a blend of Western medicine and traditional

healthcare modalities. It should be noted that, although the right to health should be

enjoyed by all, Sections 11 to 13 express a clear bias for the underprivileged.20

B. Related Studies

Many countries the world over have mental health legislation that authorizes

involuntary mental health assessment and/or treatment. The World Health Organization

(WHO) regards such legislation as a key component of good health governance.21

18
Phil. Const, Article XIII, S 11-13
19
Fr. Joaquin Bernas S.J., 2009, The 1987 Constitution of the Republic of the Philippines: A
Commentary, Manila, REX Book Store, 1270
20
Id.
21
Sangeeta Dey et al, 2019, Comparing Legislation for Involuntary Admission and Treatment
of Mental Illness in Four South Asian Countries, International Journal of Mental Health Systems, available
 One of the central issues in mental health care is the concept of involuntary

admission and involuntary treatment of patients with mental conditions. Their massive

impact on the liberty and freedom of the persons concerned has made them a topic of

controversial legal and ethical debates for more than 100 years. These debates evolve

from the necessity to apply coercive measures in certain circumstances, a fact which

singularly distinguishes psychiatry from most other medical disciplines. Thus, during the

19th and 20th centuries, different approaches to regulating the application of coercive

measures were developed all over the world that depend on a variety of cultural or legal

traditions, as well as on different concepts and structures of mental health care delivery.

The application of coercive measures in mental health care has to balance three

different and often controversial interests: the basic human rights of the persons

concerned; public safety, and the need for adequate treatment of the person

concerned.22

1. The History of Involuntary Treatment and Confinement

Mental health legislation has changed significantly, starting in Europe and North

America, and eventually beginning to globalize from the 1960s onward, with

macroscopic exceptions. The focus shifted from explicitly expelling the mentally ill for

the protection of society to curing mental illness itself. In the 19th and part of the 20th

centuries, mental health laws were forged from the models for criminal procedures.

Mental illness was treated as a transgression and hospitalizations resembled prison

at https://ijmhs.biomedcentral.com/articles/10.1186/s13033-019-0322-7, (last accessed December 30,

2023)
22
European Commission, Compulsory Admission and Involuntary Treatment of Mentally Ill
Patients –Legislation and Practice in the EU-Member States, available at
https://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion_2000_frep_08_en.pdf (last
accessed January 3, 2024)
stays, under worse conditions, considering that the duration of detention for the mentally

ill was undetermined.

The world’s most famous asylum, London’s Bethlem Royal Hospital, also known

as Bedlam, was established in 1307 as a general hospital and converted into an asylum

for the mentally ill in 1403. Centuries later, the United States began to build asylums

that also followed the idea of indefinite confinement and used methods that included

seclusion, sedation, and experimental treatments with opium, without any actual benefit.

They were custodial institutions rather than places for treatment and recovery. The de-

institutionalization of the mentally ill in the US began in 1960, and in 1963, President

Kennedy signed Act 1 to facilitate the transition from asylums to community mental

health centers. This contributed to a decrease in the number of hospitalized patients

from 550,000 in 1950 to 30,000 in 1990.23

Parallel to the transformation of psychiatry, social changes determined a radical

overturning of the role of the judicial authority. Originally represented as a depository of

power over the custody of mentally ill patients, the judicial authority later became a

guarantor of their rights, hearing their appeals against involuntary treatment. In fact, the

Council of Europe's "White Paper on the Protection of Human Rights and Dignity of

People Suffering from Mental Disorders, Especially Those Placed as Involuntary

Patients in a Psychiatric Establishment" provided inter alia that the patient should be

examined by a doctor or experienced psychiatrist and that the admission decision

should be confirmed by an independent authority. It also provided that treatment must

23
Anna Saya et al, 2019, Criteria, Procedures and Future Prospects of Involuntary Treatments in
Psychiatry Around the World: A Narrative, available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501697/, (last accessed January 11, 2024)
be based on an individualized plan, discussed with the patient, and periodically

reviewed by adequately qualified staff.24

Current national laws on mental health are inspired by two concepts: the principle

of parens patriae, which gives the government the responsibility to intervene for citizens

who are unable to protect their interests, and police power, which protects the safety of

its citizens. The government enacts statutes for the welfare of its society, and

involuntary hospitalization is placed in the broad and detailed context of how much the

State can and should intervene, even to the cost of restricting the freedom of some

individuals.25

While there are many studies regarding involuntary treatment in Europe, North

America, and Oceania, there is some difficulty in finding valid recent studies for Asia,

Africa, and Latin America. This imbalance can be attributed to a lack of investment in

the health systems where limited resources are dedicated to treatments rather than

research, the disruptions of political instability and war, and public health emergencies

and epidemics that direct resources away from psychiatric care.26

Interestingly, in the Philippines, the cases of involuntary admissions in mental

hospitals run by the government are unreported based on the latest Mental Health Atlas

released by the WHO in 2021. However, some 5,409 admissions were reported. Of

these admissions, 5,093 were treated for less than one year, 353 patients are staying in

24
Id.
25
Anna Saya, supra note 43, at 40
26
Id.
the facility for about 1-5 years while 147 have been documented staying more than 5

years.27

The latest study covered one (1) mental hospital and 84 psychiatric units in

general hospitals in the Philippines. In terms of mental health financing, the WHO report

said that the government's total expenditure on mental health as a percentage of total

government health expenditure is at 2.9 percent.

The Mental Health Atlas is a compilation of data provided by countries around

the world on mental health policies, legislation, financing, human resources, availability

and utilization of services, and data collection systems. The latest 2020 study includes

information and data from 171 out of 194 (88 percent) WHO's Member States regarding

the progress made towards achieving mental health targets for 2020 set by the global

health community and included in WHO's Comprehensive Mental Health Action Plan. It

includes data on newly added indicators on service coverage, mental health integration

into primary health care, preparedness for the provision of mental health and

psychosocial support in emergencies, and research on mental health. It also includes

new targets for 2030.28

2. Civil Commitment Laws in the United States

Currently, involuntary commitment laws exist in every state in the United States.

These laws focus primarily on dangerousness and grave disability, which implicates

27
Mental Health Atlas 2020 Member Profile: The Philippines, World Health Organization,
available at https://cdn.who.int/media/docs/default-source/mental-health/mental-health-atlas-2020-
country-profiles/phl.pdf?sfvrsn=45d0ca2b_5&download=true (last accessed January 15, 2024)
28
Mental Health Atlas 2020, World Health Organization, available at
https://www.who.int/publications/i/item/9789240036703, (last accessed January 15, 2024)
one's inability to satisfy their basic needs. The shift to a "dangerousness" standard was

important for protecting the rights of individuals with behavioral health conditions.

However, this shift also created a gap in behavioral health services for people who no

longer qualified for involuntary commitment. Additionally, because the dangerousness

standard is not well defined, it can lead to varying interpretations, even by behavioral

health professionals.

In O’Connor case, the (US) Supreme Court defined dangerousness as

“dangerous to himself or others” and considered whether the patient had committed

dangerous acts or been suicidal. Yet this definition is circular in nature: finding

“dangerousness” when there are “dangerous act[s],” without stating what “dangerous

acts” are, leads to a lack of clarity in determining whether a person is "dangerous" or

not. Modern civil commitment also shifted from a purely medical issue to an issue

uniquely situated at the Intersection of the medical field and the legal field. Two

concepts provide the legal basis for civil commitment: (1) police power of the state, and

(2) parens patriae.29

In some jurisdictions, the following are set forth to justify civil commitment or

involuntary treatment. Patients who meet the commitment criteria generally: (a)

demonstrate a mental disorder, (b) are considered dangerous to either themselves or

others, (c) are committed consonant with the principle of the least restrictive placement,

and (d) cannot make an informed decision involving treatment.30

29
Hannah Garland, Committed to Commitment: The Problem with Washington State’s Involuntary
Treatment Act, January 12, 2022, Washington Law Review, University of Washington School of Law,
available at https://digitalcommons.law.uw.edu/cgi/viewcontent.cgi?article=5235&context=wlr, (last
accessed January 11, 2024),
30
Involuntary Commitment, Encyclopedia of Human Behavior, 2012, available at
https://www.sciencedirect.com/topics/medicine-and-dentistry/involuntary-treatment (last accessed
 Amid this broader reassessment of the rights of persons with mental health

problems, two issues of core concern are the processes of involuntary placement and

involuntary treatment. These are linked to two central fundamental rights: dignity and

equality.31 The involuntary placement and involuntary treatment of persons with

disabilities are sensitive, complex, and topical issues. Sensitive because they may

involve human rights violations, which remain largely unrevealed for long periods;

complex because traditionally–reflecting the 'medical model' of disability–the need for

treatment was considered to precede human rights considerations; and topical because

reforms are ongoing in EU Member States and at the Council of Europe.32

In another study conducted comparing mental health legislations in Southeast

Asia, it was discussed that the entwinement of the doctrine of "parens patriae” and the

“police powers” of the state were important features of early mental health laws. Parens

patriae translates as "parent of the country", justified detaining and/or treating a person

compulsorily on the basis that the person was not able to look after their own interests.

The "police powers" justified intervention as protecting other people from the person

deemed "mad", typically from physical violence. In modern legislation, "risk of harm to
33
self or others" remains the basis of involuntary admission and treatment.

a. Lanterman-Petris-Short Act (California, United States)

December 28, 2023)

31
European Union Agency for Fundamental Rights, Involuntary Placement and Involuntary
Treatment of Persons with Mental Health Problems, 2012, available at
https://fra.europa.eu/sites/default/files/involuntary-placement-and-involuntary-treatment-of-persons-with-
mental-health-problems_en.pdf, (last accessed December 30, 2023)
32
Id.
33
Sangeeta Dey, supra, note 41
 Prior to 1967, California's mental health system looked very different than it does

now. Many more individuals with mental health disabilities lived in state hospitals and

large facilities, often for long periods of their lives. Then California passed the

Lanterman-Petris-Short Act (Welfare and Institutions Code Sections 5000 et seq).

Named after its authors, State Assemblyman Frank Lanterman and California State

Senators Nicholas C. Petris and Alan Short, the LPS Act sought to, "end the

inappropriate, indefinite, and involuntary commitment of persons with mental health

disorders." It also established a right to prompt psychiatric evaluation and treatment, in

some situations, and set out strict due process protections for mental health clients. 34

California’s LPS Act provides that members of a crisis team, or other professional

figures designated by the state, could hospitalize someone in an institution designated

by the state for up to 72 hours for treatment and evaluation. Following that initial period,

and after informing the patient of their rights, a 14-day hospitalization is permitted with

medical certification, renewable for another 14 days if the patient is still a danger to

themselves. If the patient is considered to be a danger to others, staff can contact the

court for authorization of further treatment up to a maximum of 90 days. Each

hospitalization requires a complex procedure to avoid indefinite admissions. Involuntary

admissions due to severe disability require a court procedure and can last for a

maximum of one (1) year. The Mental Health Information Service provides patients with

an ombudsman who informs them of their rights.35

b. Involuntary Treatment Act (Washington, United States)

34
Disability Rights California, Understanding the Lanterman-Petris-Short Act,
https://www.disabilityrightsca.org/publications/understanding-the-lanterman-petris-short-lps-act, (last
accessed January 2, 2023)
35
Anna Saya, supra, note 43
 In Washington State, civil commitment law is known as the Involuntary Treatment

Act (ITA) and is codified in the Revised Code of Washington (RCW) section 71.05.

Washington’s legislature enacted the ITA in 1973 and has since revised it several times.

The legislative intent of the ITA is explicitly named in the legislation. In addition to

protecting the health and safety of people in behavioral health crises and protecting the

public, the legislation’s named intent is “[t]o prevent inappropriate, indefinite

commitment of persons living with behavioral health disorders and to eliminate legal

disabilities that arise from such commitment”; “[t]o safeguard individual rights”; “[t]o

provide continuity of care”; and “[t]o encourage, whenever appropriate, that services be

provided within the community.”

The Washington State legislature reaffirmed the ITA’s intent in 1998, stating: “[i]t is

the intent of the legislature to: provide additional opportunities for mental health

treatment for persons whose conduct threatens himself or herself or threatens public

safety and has led to contact with the criminal justice system.” These statements of

intent demonstrate what a properly functioning ITA would accomplish. 36

3. How Does the Involuntary Treatment Act in Washington Work?

The civil commitment process includes four stages: evaluation, initial detention,

hearing, and commitment. In Washington, a Designated Crisis Responder (DCR)

evaluates people who are undergoing a behavioral health crisis. A DCR can provide

evaluation in an emergency room or non-emergency room setting. Through evaluation

and a brief investigation—which frequently includes speaking to law enforcement,

family, friends, or other witnesses present for the evaluation—the DCR decides whether
36
Hannah Garland, supra, note 49
the individual meets the legal threshold for initial involuntary detention. This legal

threshold requires the individual to be gravely disabled, meaning they cannot care for

their own basic needs, or are at risk of harming themselves, others, or property.37

If the DCR decides that initial detention is appropriate, they prepare and file a

petition for initial detention and attempt to find the individual an available inpatient bed

at an evaluation and treatment facility (E&T). If placement at an E&T is not available

within the county the individual is in, they may be transferred to an E&T in another

county. If a placement in an E&T bed is not available at all, the DCR can apply for a

single bed certification (SBC), where the individual will be held until an E&T bed

becomes available. These placements are often in nonpsychiatric emergency room

beds. If neither an E&T nor an SBC is available, the DCR will file a No Bed Report,

and the individual can no longer be legally held under Washington’s civil commitment

laws.38

There is no court hearing involved in the initial evaluation process. After the DCR

files an initial petition for detention, an individual can be held at an E&T or on an SBC

for up to 120 hours, excluding weekends and holidays. If the detaining facility believes

the individual warrants detention beyond the initial 120 hours, they must file a petition

with the court for fourteen days of involuntary treatment. The fourteen-day petition must

be signed by two medical professionals. The individual must be assigned an attorney

before the court hearing which determines the fourteen-day commitment. During the

fourteen-day probable cause hearing, a deputy prosecuting attorney from the county

37
Id.
38
Id.
where the individual is detained represents the detaining facility and generally

advocates for the commitment of the individual.39

Similar to a criminal case, the prosecuting attorney has a considerable amount of

power in deciding whether and how to move forward with the case. If the treatment

facility recommends commitment, but the prosecuting attorney does not believe the

legal threshold for commitment is met, the prosecuting attorney may advocate for a less

restrictive order or attempt to negotiate an alternative agreement with the individual’s

assigned defense attorney.

The judge then determines whether a person is gravely disabled and/or presents

a likelihood of serious harm, utilizing “all available evidence concerning the

respondent’s historical behavior.” If the judge finds the legal threshold for involuntary

treatment is met, the individual will remain in the treatment facility for up to fourteen

days from the date of the hearing. The evidentiary standard for this stage of the hearing

is also preponderance of the evidence.40

Detainment facilities can discharge individuals at any point, even after a judge

decides they meet the legal threshold for detention. If an individual remains in the

treating facility at the end of the fourteen days, and the facility believes they require

further involuntary care, the petition and hearing process repeats. The individual then

faces civil commitment for ninety days. The evidentiary standard is raised to be clear

and convincing for this longer detention and any hearing that occurs thereafter.

39
Id.
40
Id.
 The ITA also allows for involuntary outpatient treatment, often court-ordered

through a less-restrictive order (sometimes referred to as a "less restrictive alternative”).

This procedure closely mirrors that of involuntary inpatient treatment. As discussed

above, an individual may be ordered a less restrictive alternative at the time of the

fourteen-day hearing. Alternatively, a facility may discharge a person on a less

restrictive order at any point, if that order is agreed upon by the facility and the patient.

Violation of a less restrictive order may lead to a return to involuntary inpatient

treatment.41

C. Synthesis

The right to health, including mental health, is one of the basic rights upheld in

the Philippine Constitution and constitutions the world over. In the Philippines, the

passage of the Mental Health Act is a major step towards affirming the high premium

that should be placed on an individual's mental health. However, the current state of the

mental health system in the Philippines is not in parity with those of its neighboring

states in the region. The Philippine government spends only 2.9 percent of its total

healthcare budget on mental health.42

As in other jurisdictions, the existing national laws on mental health are inspired

by two concepts: the principle of parens patriae and police power, such that the concept

of involuntary treatment and confinement has catapulted to a complex and sensitive

issue, becoming a subject of a string of legal and political debates.

41
Id.
42
World Health Organization, supra note 43
 Involuntary confinement and treatment characterize many mental health services

across the world. However, reports and research on involuntary treatment and

confinement in Asia are significantly fewer compared with those from Europe, North

America, and Oceania. This can be attributed to a lack of investment in the health

systems where limited resources are mainly dedicated to other public health

emergencies and epidemics that direct resources away from mental health care.

Studies by the WHO confirm that the mental health system in the Philippines

needs to be strengthened and developed. In the same vein, the current mental health

legislation also needs to be passed to address and comply with international guidelines.