Why Colorado Teens Can Refuse Mental Health Treatment—Against Their Parents’ Wishes

Maria’s 14-year-old daughter, Anabel, started having nightmares in the fall of 2020. She had spent the previous summer living with her father who, Maria says, emotionally and physically abused the teenager. As Anabel’s sleep patterns deteriorated further that winter, Maria pleaded with her child to visit a mental health professional to discuss the abuse. Anabel refused. Maria, who asked that her family’s real names be withheld to protect her daughter’s privacy, called psychologists anyway, but none would see Anabel—not without obtaining the minor’s permission first.

In 2019, the Colorado Legislature passed a law aimed at expanding adolescent access to mental health care. Many mental health professionals, however, interpret a portion of that statute to say children must consent before they can be treated, even if their parents believe care is necessary. Anabel could have been admitted to an inpatient facility without her permission if she’d been deemed an imminent threat to herself or others. But the teenager’s symptoms hadn’t escalated to that point.

Not until early 2021, that is. “She took some knives from the kitchen,” Maria says. “She was crying in pain, saying, ‘I don’t want to live. I don’t want to be alive. This is too painful.’  ” Maria called Colorado Crisis Services, which sent an emergency response team to her house. But after Anabel was no longer an imminent threat, she still refused to see a therapist. No matter how hard she tried, Maria couldn’t convince her daughter to get help.

On April 16, 2019, Dafna Michaelson Jenet approached the podium inside the Colorado House of Representatives, pulled the microphone close to her mouth, and braced herself against the wooden plinth. For three years, the Commerce City Democrat had been trying unsuccessfully to pass legislation that would make mental health services more accessible to young people. Her third proposal, she believed, was her most balanced attempt yet.

The resulting Youth Mental Health Education and Suicide Prevention Act was personal to Michaelson Jenet. “This bill is for my son,” she said to those in the chamber. When he was nine years old, Michaelson Jenet’s son attempted suicide. He survived, and it became Michaelson Jenet’s mission to improve mental health treatment for children in Colorado. “It’s not only for my son. It’s for your sons. And for your daughters…. I don’t know about you, but I would give my child access to anything in the world—anything in the world—that would prevent his death.”

The bill wasn’t only born of Michaelson Jenet’s personal tragedy. Colorado was in a crisis: Between 2007 and 2020, the number of deaths by suicide among 10- to 19-year-olds in the state more than doubled. A provision of Michaelson Jenet’s legislation would lower the age of consent in Colorado, making it legal for children as young as 12 years old to access mental health services even if their parents opposed it. Research has shown minors often avoid mental health treatment because they don’t want their secrets shared with their parents. So, along with lowering the age of consent from 15 to 12, Michaelson Jenet’s bill would make it illegal for providers to disclose a minor’s information to their parents unless the teens granted their consent or were exhibiting severe symptoms, such as suicidal ideation. “Our children deserve confidentiality that may lead to saving their lives,” Michaelson Jenet said.

The Youth Mental Health Education and Suicide Prevention Act was signed into law by Governor Jared Polis on May 16, 2019. “With mental health, we have a fragmented set of programs, caregivers don’t know how to access the services that are available, and the programs are so limited that many don’t have access at all,” Jena Hausmann, the president and CEO of Children’s Hospital Colorado, said at the signing. “This bill is how we begin to change that.”

Dr. Christian Thurstone only found out standard procedures would be changing when his employer began preparing to meet the law’s mandates. As the director of Denver Health’s behavioral health sciences department, Thurstone oversees the adolescent psychiatry inpatient unit at the hospital, where children ages eight to 21 who are suffering severe mental health crises are treated.

Often, teenagers are admitted to an inpatient unit like the one at Denver Health under 72-hour stays, called mental health holds, or “M-1 holds.” This means an authorized health professional or law enforcement officer has determined that the child meets one of three criteria: suicidal behavior, homicidal behavior, or grave disability caused by mental illness. After three days, if the patient is no longer exhibiting those symptoms, state law forces facilities such as Denver Health to discharge the child or adolescent.

In the past, Thurstone appealed to guardians if he believed minors would benefit from a day or two longer in the unit so doctors could stabilize them further. Under Michaelson Jenet’s law, though, if patients ages 12 or older want to check themselves out, “we have to let them leave the hospital,” Thurstone says. “And that comes up weekly.”

On top of that, M-1 holds don’t take into account the five-day workweek. Recently, Denver Health’s emergency department admitted an adolescent on a 72-hour hold on a Friday. Thurstone didn’t see the teen until Saturday and was unable to reach the patient’s regular therapist. “Without their input, I made some medication changes that [the therapist later] questioned and, you know, didn’t think were a great idea,” Thurstone says. When the hold was over, Thurstone had to release the patient.

The Youth Mental Health Education and Suicide Prevention Act doesn’t explicitly state that an adolescent can refuse mental health treatment. However, the statute does require providers to procure a signed document from the minor indicating they are voluntarily seeking treatment. Some in the mental health community—notably the Colorado Psychological Association (CPA), a statewide professional organization—have interpreted that to mean children ages 12 and older can refuse services.

Dr. Julie Jacobs, a psychologist and the CPA’s legislative chair, paints a hypothetical picture of a child desperately needing care that both parents consent to.“Then the therapist puts this piece of paper in front of the kid and says, ‘Sign this thing [to indicate] you’re voluntarily here,’ and the kid says ‘no,’  ” Jacobs says. “Well, then, that therapist, if they’re managing risk, is potentially not going to see that kid.” That risk, Jacobs says, includes the possibility of therapists losing their licenses to practice in the state. (A spokesperson for the Colorado Department of Regulatory Agencies would neither confirm nor deny whether any providers were currently being investigated for violating the law.)

Despite these hurdles, Thurstone understands that Michaelson Jenet’s legislation has the potential to reap huge benefits. “I’ve done some focus groups of adolescents and then a big literature review about why adolescents do not seek treatment,” Thurstone says, “and the number one thing that adolescents say is confidentiality.… [The issues the statute is causing] are minor compared to the big steps forward that this bill created.”

Although some mental health professionals believe the legislation forces them into inaction, there are others—including the state’s largest school district—who argue they are trapped between conflicting laws.

Denver Public Schools (DPS) employs more than 360 school psychologists and school social workers, along with its teachers and principals. And, according to the federal Family Educational Rights and Privacy Act (FERPA), those school-based psychologists must alert parents or guardians when their children seek mental health services from DPS providers. (This does not apply to the 18 school-based clinics in the district operated by Denver Health.)

In other words, Colorado’s Youth Mental Health Education and Suicide Prevention Act says those ages 12 and older are entitled to confidentiality, and federal law says they aren’t. Conceivably, violating FERPA could expose the district to a lawsuit; not adhering to the state statute doesn’t carry a clear consequence. So for the time being, DPS has chosen not to change its procedures to meet the stipulations of the Colorado law.

Michaelson Jenet plans to begin the process of tightening loopholes in the statute by meeting with the CPA’s lobbyist in early 2022. She hopes to pass a so-called “cleanup bill” in the coming months that will include language specifying that Coloradans ages 12 and older cannot refuse mental health treatment when their parents and a therapist agree it’s in the youths’ best interest. “I think this is the first of a bunch of steps,” Jacobs, the CPA’s legislative chair, says, “but it’s a really good one.”

The confusion surrounding the interpretation of Colorado’s Youth Mental Health Education and Suicide Prevention Act is indicative of a larger problem, Michaelson Jenet adds. During her five years at the state Capitol, she says she has learned that if she doesn’t track her legislation after it’s been passed, there’s a possibility the law won’t fix what it was supposed to. So, in addition to the cleanup bill, Michaelson Jenet has proposed a separate measure to the Legislative Audit Committee, which she chairs, to establish a department whose sole job would be to track enacted laws and report back to the General Assembly. Michaelson Jenet believes she has the votes to get the legislation passed, but she also knows a bureaucratic overseer might not be enough. “Ultimately, until a law goes to court and a judge makes a ruling based on what they think the intent was,” Michaelson Jenet says, “you’re subject to interpretation.”

Waiting for the courts wouldn’t have worked for Maria, who, in the end, felt she had no choice but to take a drastic step: Maria lied and told Anabel that to get the emotional support dog she wanted, she was required to see a psychologist. “I’m not proud [about lying]. I don’t recommend it,” Maria says. “But I also don’t want my kid to start using drugs or die by suicide.”

Maria is optimistic that Michaelson Jenet’s cleanup bill will provide more options for parents like her. “I’m hopeful that I can have a voice, that I can be part of the treatment of my kid,” Maria says, “and execute my authority as a parent. Because we are here to protect our kids.”