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Definition. Limited Engagement refers to situations where a young adult is only partly engaging, inconsistently engaging, or refusing to engage with parents, providers, school supports, or some combination of these.

System Constraints

One of the hardest parts of a mental health crisis is when people involved may recognize there is concern or risk, but are limited in what they may share or do for legal reasons. This section explains some of the main constraints.

Privacy

Privacy laws restrict what schools and clinicians may disclose to parents, while still allowing parents to provide information to schools and clinicians.

Here are laws, and how they look in practice.

HIPAA

Under HIPAA, providers cannot share a young adult’s protected health information with family unless the patient consents, the patient is unable to make decisions, or there is an emergency or safety concern.

HIPAA in practice:

  • You may call clinicians and offer background, observations, and concerns.
  • Clinicians may listen even if they are not able to discuss treatment details.
  • If you don’t know the exact names of clinicians or facilities, it may be difficult to get your information through.
  • If the young adult chooses to sign a release, communication is much easier. Clinicians time and schedule may still affect how they respond.

FERPA

There is an exception in which schools may (but are not required to) disclose information in connection with a health or safety emergency.

FERPA in practice:

  • You may contact school administrators with concerns. The Dean of Students office is often a good place to start.
  • The school may not confirm details or provide information back to you.
  • Schools may act on safety concerns even if they are not able to fully discuss them with you.

Hospitalization (voluntary/involuntary)

Voluntary treatment is preferred whenever possible.

When a young adult consents to treatment, they are often more likely to collaborate on treatment decisions, which may result in longer engagement in care.

Involuntary treatment is used mainly when someone is not safe or not functioning on their own, meets the legal criteria for involuntary treatment, and less restrictive interventions were not enough.

Involuntary Commitment Laws:

In most places, there are laws that allow people to be temporarily hospitalized without their consent if they are a threat to themself or others, or unable to meet their basic needs due to mental illness, often described as “grave disability”. These laws vary by location. Depending on the location, law enforcement, clinicians, or family members may request an evaluation, but the process and decisions will depend on the specific laws in place.

Involuntary Commitment laws in practice:

  • ‘Intent to harm self or others’ is more likely to result in a psychiatric hold.
  • Psychosis alone does not automatically result in involuntary hospitalization.
  • The threshold for “grave disability” varies by location and is typically high.
  • Procedures, hold duration, and outcomes vary significantly across states and facilities.

Criminal Justice System

Mental health crises may sometimes involve law enforcement, although not necessarily due to criminal intent.

Crisis response systems and criminal justice systems overlap, and sometimes behaviors resulting from a mental health crisis are also against the law. Even when a mental health issue is the primary concern, a person could be arrested, cited, or charged with a crime, if they also did something illegal.

Mental health courts and other diversion programs may route people with mental illness to treatment instead of going through the traditional criminal justice system. Availability of these options varies, and the young adult or their family may need to ask which options exist locally.

Tools for Collaboration and Consent

If the young adult is working together with you to get through the crisis, there are several strategies to help with these constraints.

Most importantly, the young adult may sign a release of information (ROI) for FERPA and HIPAA with the school and with providers. They may have to sign multiple documents for different departments, schools, or clinicians.

The Psychiatric Advance Directive (PAD) or Mental Health Advance Directive (MHAD) documents an individual’s preferences for treatment. Effectiveness varies depending on state laws and whether hospitals honor them during a crisis. The process of creating one helps clarify preferences for mental health care.

For families in ◐ Limited Engagement situations, it’s common for the young adult to choose not to sign ROIs and not include parents or caregivers in advanced directive planning or safety planning.