Tuesday, May 28, 2013

Involuntary Psych Hospitalization: Tell Me Your Story!

We haven't written about involuntary psychiatric treatment on Shrink Rap for a while because it gets our readers really stirred up.  Now I'm going to try to stir you up.
 
ClinkShrink and I are talking about writing a book on the different perspectives of involuntary hospitalization -- we'd like to put both sides of the argument on the page and look at issues related to patients' rights as well as families, members of the law enforcement and legal systems, and the doctors, nurses and hospital staff.  Roy is involved in his techy projects and won't be in on this, though we will continue to get his input and to eat pizza and crabcakes with him.

We're at the point where we need a "sample" chapter to illustrate what it is we are trying to write.  This isn't going to be a real chapter in the book (I don't think), but just "here's the idea."  Because the actual chapters will entail a great deal of interviewing and reviewing medical records and speaking with people and their families, I'm looking for an easier way to begin the process, and truthfully, the idea was inspired by our Shrink Rap readers who have written in over the years with stories about how they were damaged by what occurred during their involuntary hospital stays.   It got us thinking that there have to be better ways, while at the same time, it seems that it's shameful that our society leaves terribly psychotic people living on the streets and eating from the garbage because there is no way to treat them.  Maybe if treatment were nicer?

So I need your help.  I need someone with a really good, detailed story to be the subject of my sample chapter.  Will you tell us your story in the comment section, or email it to us at Shrinkrapblog at g mail dot com?  The comment section might be nice because it would allow for others to dialogue.  We don't need your name, but please don't write as Anonymous because I won't be able to the stories straight, a nickname is fine, and you can sign in to Google as "anonymous" as long as you sign the entry with some name that distinguishes you from the others.  Also, I might want to speak with you later, so if that's not acceptable, then maybe you don't want to participate. 

 For the sake of the sample chapter, I would like to hear from people who feel they've been treated badly.  The "so glad they committed me, it saved my life" is for another chapter.  If you're a psychiatrist and you have a patient who feels they've been unduly traumatized by an inpatient admission, please see if they want to participate, and the same goes for family members.  Obviously, books are about stories, and the stories need to be compelling.  

Years ago, we did a poll, and I was struck by the fact that two-thirds of those who had been involuntarily hospitalized said they would not want to be hospitalized again, even if they were a danger to themselves or others. 
 
In advance, thank you so much.

Thank you in advance.

73 comments:

Anonymous said...

And you didn't need material for a book in 2011 so you wrote:

Dinah said...


Rob:
I'm not outraged because I believe most people leave the hospital in a better state than they arrived in and the hospitals I've worked in are nothing like prisons. It just doesn't strike me as the end of the world-- basketweaving and stupid charting issues aside-- if someone ends up spending a few days in a hospital. If they kill themselves or someone else, it is the end of someone's world. The majority of people I've treated who've been hospitalized felt it was helpful, and those who didn't have been motivated to make changes so that it doesn't happen again. Mostly people just come out and move on with their lives, and that is good.
I do believe that people who feel they were mistreated should complain. 
If you'd like me to lose sleep because someone is forcing Jared Loughner to take medications, it's probably not going to happen.

Okay, this horse is very dead. Time for a new topic. Unless of course I can inspired Clink to blog on the differences between hospitals and prisons, since she spends time in both.
July 09, 2011
Dinah said...
Ah, the Shrink Rappers are growing tired of the whole debate on Involuntary Hospitalization (at least my co-bloggers seem less than enthralled).
I am going to refer interested parties over to the Alienist's blog-- he even has directions on how to get yourself involuntarily committed. 

Looks like things are a bit heated over there:
http://thealienist.wordpress.com/2011/07/06/involuntary-hospitalization-one-psychiatrists-view/
July 10, 2011

Dinah said...

I still feel that I personally would rather spend a few days in a psychiatric hospital than die or worse, kill another person. However, the comments and the discussion about this from back then did make me aware that there are others that don't share my opinion and that people who feel strongly about this issue move into camps, patient rights vs. treatment advocacy, and that they shut each other out. I also learned from the stories that people wrote in back then, that really unpalatable things sometimes happen that shouldn't and there is room to change to a kinder, gentler, system that is more respectful to patients.
For one thing, commenters inspired me to write about how strip searches should stop.

So anon, thanks for pointing me back to my own words and to the Alienist who seems to have returned to the blogosphere. If you can find me some of the stories in the comment section of the >1800 shrink rap posts, maybe I could use some of them! We have literally 10's of thousands of comments, so getting back to them is hard.

Joel Hassman, MD said...

Really, you were struck by the 2/3 comments rejecting inpatient care knowing what they know now?

Umm, wish I could write the truth to what that means most of the time, but, you don't like my opinion about certain topics. But, it is what it is, and the role of Non Axis 1 factors has to be considered, even though DSM 5 is now ignoring it outright.

As Hawkeye said so well in that M*A*S*H episode, "let's hope it is a long and healthy hate."

Hope Pandora's Box can be quickly shut before to much is out.

Anonymous said...

Hi Dinah,

You might want to contact Will Hall who wrote this blog entry which discusses involuntary commitment. He would be able provide an excellent prospective as an an ex patient and current MH therapist.

http://www.madinamerica.com/2013/04/time-for-a-new-understanding-of-suicidal-feelings/

""I was locked up at San Francisco General Hospital’s psychiatric emergency ward because confinement was considered necessary to protect me from suicide. But when I was forcibly tied down, locked in an isolation cell, threatened with being strip-searched, kept behind barred hospital windows for months and subjected to degrading treatment, it was the hospital that I needed protection from – not my own feelings.""

http://www.madinamerica.com/author/whall/

AA

PS - Here is recent video of a talk he gave at Grand Rounds, OHSU Department of Psychiatry – Oregon Health And Sciences University

http://tinyurl.com/nhukwkz






jessa said...

I guess I'll refer you to my entire blog, as this is what my blog is about. The major story of psych hospitalization in our culture is of people getting better and being glad for the treatment. The main opposing story is of overt abuse. My story could be considered psychological abuse and is much more subtle and more akin to racism than to slavery and lynching. Possibly important to note: I wasn't always involuntary, but the treatment was the same regardless (I'm in the same ward and the phrase "voluntary until you ask to leave" isn't just a joke).

madewithawesome.blogspot.com (or click on my username)

Eliza said...

You might also want to read about Jaakko Seikkula's Open Dialogue approach for acute psychosis in Finland which has reduced the need for involuntary hospitalization.

Anon8 said...

Noble intention, but I don't believe you are capable of seeing the other side and I fear your book will bear that out. Hasn't the 10s of thousands of comments showed you that yet?

Anonymous said...

$$$$$$$$$$$=noble????????????

Joel Hassman, MD said...

Other side? Frankly, Dinah, this post will bring out the real dark side of what drives the disruptions on psychiatric units, and that is basically people who don't have boundaries, quickly get tired of the false illusion of hotel stay diversions, and at least for some, the painful realization upon family/significant other visits to the unit that the behaviors driving the involuntary committment in the first place will not be tolerated further upon discharge.

It is amazing, sheerly amazing that for every one person who has a positive reply about an involuntary stay, there are literally a score or more of brutal descriptions of incarceration-type experiences that I truly believe that was the writer's experience.

Except one little detail always omitted by such writer of outrage: what did you do to get involuntarily committed, eh? You didn't just meekly say "I wanna die", or, "I'll kill that bi--h!", or, "voices are telling me to dance naked on the street".

No, let's have a moment of brutal, honest candor here, dissenters of the process. You were disruptive, for a decent period of time, and were abusive and refusing to accept redirection. And you all think that people who do the involuntary committment process just do it in a heartbeat. Well, for the psychotic ones, I believe that is what they saw at the time of admission. But, I really know that a sizeable percentage who write here and at other sites, they know what was going on when committed. You just didn't want, nor accepted, redirection.

And alienating loved ones was a very poor choice.

So, continue to write away how outrageous this process is. As I wrote above in my first comment here, let's hope it is a long and healthy hate. All those bastards who did terrible things gave you the chance to bitch about it for years at threads like this!

Wow, and there it is!!!

Sarebear said...

I've never been admitted, although I've come the closest I've ever come, a couple times this year.

However, once I had the records from my suicide attempt in the mid-90's and read what they said, I was mad, upset, and other things that my sister's lying kept me from getting admitted and getting the help I was desperately needing.

She pretty much said that she would give me s upport, etc. (one could get more support from a stretched out bra or pantyhose with more runs in them than material left) and from wh at I read in the records, THAT was the deciding factor. Although the fact that I seemed so happy may have had something to do with it (I was happy I was finally going to be getting help, or so I thought; naive, see? painfully so . . . the system crushed me with a big boot and basically said it didn't care.

I have the records and, with identifying information removed, would be happy to have them used in your project in any way you see useful, if you would find it so. If not, no hurt or offense or anything taken.

I was so . . . naive about the matter. I'm still naive about alot (being in court the other day made that abundantly clear, although things were really off even the judge admitted so).

Dinah said...

Admittedly, I worked a long day, after a very long week, and I have not read all the links yet, but I will.

AA, Jessa,Eliza: Thank you!

Anon8: I'm sort of thinking that the 10s of thousands of comments mean someone is interested dialogue.

Anon: I absolutely promise you that the per hour rate for being a psychiatrist is many, many, many times higher than the per hour rate for writing a book. If we end up writing this, I will cut back on my clinical time to write and have a lower income. Part of what I'm struggling with, but I love writing.

Sarebear: thank you for your story and I'm sorry you are having a rough time. Most people come in voluntarily, and there are many more stories of people who want to be admitted but get turned away.

Joel: I love being a psychiatrist. I like my patients, I find psychiatry to be incredibly rewarding and my patients are gracious and appreciative people whom I feel honored that I can work with people in this capacity. While I understand your frustrations with 'the system,' I don't relate to your feelings towards the people you work with. 'refusal to accept redirection?' Ugh, can I barf now?

But if for every person who is grateful for their involuntary hospitalization, there are a score who are angry, as you suggest, perhaps it's worth looking at how they are treated and trying to figure out if there are ways to leave some of these people less traumatized.

Liz said...

joel: "Other side? Frankly, Dinah, this post will bring out the real dark side of what drives the disruptions on psychiatric units, and that is basically people who don't have boundaries, quickly get tired of the false illusion of hotel stay diversions, and at least for some, the painful realization upon family/significant other visits to the unit that the behaviors driving the involuntary committment in the first place will not be tolerated further upon discharge."

are you for real? you mean that when i was admitted due to a suicide attempt, if i would have just realized that my suicidal depression would no longer be tolerated upon discharge that would have made all the difference?

i don't know you, obviously, but you don't know the people about whom you write, either. it's clear from what you say that you know a heck of a lot less than you think you do.

in fact, dinah- perhaps you should interview joel. at least from this comment, he seems like just the sort of doctor that drives people away from psychiatry in the first place. it makes sense that people's hatred of hospitalization would confuse you, because i don't think you would treat people the way some doctors do-- as though the mentally ill are worthless trash. if you interview joel, i think you would understand a little bit better where frustrated psych patients are coming from....

if you ever want to talk about my experiences, i'd be more than happy to, but i don't have the clear cut horrific stories some do... as always, it is a bit more complicated. i have had doctors treat me like shit and doctors who were wonderful. but it was dialectical behavior therapy that has made all the difference.

it is thanks to dbt that i haven't commented in a while-- i've been busy completing my first year of graduate school (and caring for the new baby). i'm so thankful and glad i had SOME treatment providers who offered treatment rather than judgment, in particular the psychologist who facilitated my dbt group.

good luck on your book, dinah. unfortunately, i think those who would most benefit will likely write it off, as it will be somewhat based on the experiences of "crazy people". regardless, a noble effort.

Anonymous said...

Joel,

As Dinah well knows, I am definitely in frequent disagreement with her. But the contrast between her and you regarding attitude about patients is like night and day.

I hope to goodness for your patients' sake that the attitude you display on blogs is totally different that what you show to your patients.

Anyway, I have told this story about someone I know regarding involuntary hospitalization but it bears repeating since you seem to assume the worst about patients. This person had been compliant for years taking heavy duty medications.

Unfortunately, a med she was on was making her sick to her stomach. When her psychiatrist refused to changed her medication and blamed in on her "mental illness", she became admittedly belligerent as I think many people would in that situation. The guy in response involuntarily committed her to the hospital who finally did switch her meds at a lot greater cost.

And for those of you who think a few days is harmless, she was quite traumatized for having the nerve to want to switch from a med that was making her sick.

By the way, I found out that scenario is quite common which no one should be shocked about. I mean, anyone with an "MI" label is not credible and yes, I am being sarcastic.

To be honest, I am tired of brutality being justified. I mean, if someone was raped, no one would dream about the other side needing to be provided. Sorry, I know that may sound too direct but I had to say make this point

AA

Anonymous said...

In hindsight I am glad I was hospitalized however the experience itself was humiliating and frightening. I share my story in the hopes it may give some in mental health food for thought.

I sought treatment at my EAP for depression. Over time, it grew worse and worse and yes, I became suicidal. My therapist asked if I would be willing to go into inpatient treatment and I agreed. However, she also started involuntary commitment so when I arrived at the hospital I was handcuffed and placed in leg irons. The closest hospital (where I was directed to go) didn't have a psychiatric unit. All my belongings were taken and I waited in a locked room for hours until the sherriff came to transport me. I wasn't allowed to phone any family members during this time (or my work who was expecting me back post appointment.) When the sherriff arrived I was led through the waiting area in handcuffs and chains and put in the back of a police car where I got to listen to the deputies describe their hate for the "crazies" during the 45 minute ride to a different hospital. Upon arrival there I was strip searched and placed in isolation.

I was terrified throughout this whole process. I didn't understand why I was being treated as a criminal when I agreed I needed help and I wanted help. I am also a survivor of sexual assault and being strip searched was horrible. Not once did anyone explain what was going on or speak directly to me. I felt as though I had no value. I only learned why I was transferred to a different hospital later. I didn't even realize at that time I was involuntarily committed - I thought wow, this is what everyone who has a psychiatric problem has to go through.

If someone had talked to me, explained things to me or even once really evaluated me beyond a piece of paper saying I was a danger to myself a lot of this stress could have been mitigated.

On a side note -
Dr. Hassman, I agree with many of your comments and your general philosophy that you can't medicate life. However, your most recent comment on this blog took me aback. I don't think that amount of venom was warranted, nor do I think that anyone is "bitching." That doesn't mean however that the involuntary commitment process can't be improved. It can. There will always be patients who need to be restrained and I understand that. There is a need for safety of health care personnel. The tough question is how do we balance the needs of the patients so they're not further traumatized? I don't have an answer. Maybe though this type of discussion will help someone find one.

I don't hold any hate for anyone - if I did, I wouldn't really be healthy would I? Yet I can't deny it was a degrading and scary event in my life.



Thanks,
BYH

Dinah - I will talk to you further if you like just let me know and I can email you more information.

Dinah said...

BYH -- shoot me an email, if you will. What state are you in? In Maryland, you can't be admitted involuntarily if you agree to be voluntarily admitted. It's also hard to understand how if the counselor was that worried about you that you were allowed to transport yourself to the hospital. I would like more details.

I'm sure we won't come up with an answer that helps everyone.

Anonymous said...

Dinah, I'll shoot you an email too but wanted to publicly say that I was transported from the counselor's office to the first hospital by city police (as opposed to the sherriff's office who came later.) My counselor said she didn't feel comfortable letting me go alone and I agreed. This being a small town, she knew the officer and it felt more like him doing her a favor by giving me a ride than anything else. I sat up front with him, no handcuffs, he walked with me to the desk and wished me well. I guess maybe I was extraordinarily naive but I didn't think that meant involuntary commitment.

I sometimes wonder if anyone knew I had agreed to go - and no one really talked to me at the first hospital other than you'll need to wait here until we can get you to the other hospital.

BYH

roblindeman said...

Amazing that no respondents so far have mentioned the terms "Liberty", "Freedom", "Civil", or "Due process".

These are your inalienable rights, folks! Ignore them and they will go away.

Anonymous said...

I just think that because you never seem to understand the commentors who disagree with you, Dinah, your book will end up being warped and one sided. Sorry. That's what I've seen from all posts and comments on this topic (and some others). I believe you try, genuinely, sometimes, but you don't get it and aren't capable of it.

Anonymous said...

Maybe you are "warped" and one sided? Something to think about. Perhaps you can only ever see your perspective. (For anon above).

Dinah said...

Ugh, please either contribute to the post with a story, or don't. If you think my intentions are bad, then certainly don't contribute.

Joel Hassman, MD said...

You just want stories from the patient's point of view, or from a physician's as well?

Had a wonderful (not) experience while I worked at a state facility 2 years ago. Seems as though certain counties and their well known hospitals in our state feel that state inpatient units are to house people who don't "fit the needs of the county". Sad and quite the backward trend of how psychiatry was not to be used since the 60s, hmm?

Your call.

Anonymous said...

Dina, no interest in people trying to get their love ones commited. I am sure it feels like forced treatment to patient and wholly unsatisfactory to the loved one. Anyways, I have one. Montgomery co. Md. If your interested.

Dinah said...

I had in mind a book with a lot of interviews, observation, research. At this point, there is an someone who is a proposal and someone who is vaguely interested but wants to see a sample chapter. I'm thinking that meeting/interviewing/verifying/tagging along/ whatever -- too much work to do without knowing there is a publisher first, so I'm thinking about a sample chapter to show the concept/writing sample. So far, it's just a thought, I have not actually started writing.

So the answer to the "just patients" question is Just for now. First/sample chapter I want to be of someone who was involuntarily hospitalized and feels damaged by it. I sent an email to the youtube guy AA mentioned but have not heard back. I liked his story because he felt wronged and he's successful and credible. I'm learning good stuff from the things people are writing in and emailing me with. If there is a book, later chapters will be on other perspectives, including doctors. We're a long way from there.

Anonymous said...

Saks has a good book on forced treatment.

Eliza said...

You might also want to include something about how the family members are treated. When my father was involuntarily hospitalised because of behaviour resulting from his Alzheimer's I couldn't not believe how disrespectful the psychiatrist was not only to my father but to me. His manner didn't improve much even when he found out that I was a psychologist. I had my dad transfered to a specialist facility and within 24 hours they had him eating, taking his meds, clean, hair cut, and wearing clean clothes.

If you are going to write about this subject you need to include something about the social construction of mental illness, racism and other prejudices which influence people's treatment.

Re voluntary vs. involuntary - there is no such thing as voluntary hospitalization when involuntary hospitalization is the the offing. I've had patients told they are going to get "a rest" on the ward and of course there is not much that is restful in these places. When I'm waiting to see a patient on the ward I sometimes sit and close my eyes and just listen to the sounds of crying, yelling, keys jangling, doors slamming to remind myself of that.

roblindeman said...

Anonymous May 29, do you mean Saks, or Szasz? The latter certainly wrote books on the subject of involuntary "hospitalization". Several actually. Not sure who Saks is.

Dinah said...

Clink bought Saks' book. Elyn Saks is an attorney who has schizophrenia. Quite the woman.

I love inspiring and resilient people, and it helps us all get away from any idea that diagnosis determines prognosis.

Anonymous said...

Sorry, should have been more specific. Elyn Saks' book Refusing Care: Forced Treatment and the Rights of the Mentally Ill.

She addresses arguments in favor and against forced treatment. Also, her Ted Talk is good - she was held against her will because she "couldn't do her law school homework." She points out if that were the standard for committing someone it would mean much of the country should be hospitalized.

Anyway, my thoughts are very much in line with the arguments opposing forced treatment. I think sometimes psychiatry fails to consider what the patient would want if the patient was competent to make decisions (substituted judgment)- I have never wavered in what I would want and that is no forced psychiatric treatment. I have always been oriented X 4 and my wishes to be let go should have been respected. They made a bad situation considerably worse.

It is unfortunate, that the psychiatric advance directive does not protect me against force. The advance directive tells me to list in order of preference which type of forced treatment I would want (chemical, seclusion, physical restraints). How about none of the above?

I didn't see another psychiatrist for years after that experience. The one I have now knows and respects my thoughts on this subject, and has stated he would not ever do that to me. I wouldn't go back if he did.

Kristen (not my real name)

Dinah said...

Clink downloaded the Elyn Saks book a while ago, I don't know if she read it yet.

So Kristen, your post brings up several thoughts, and I know I'll get ripped by everyone for this but so it goes.

-- There is a standard that you need to be dangerous to be involuntarily committed. So while I dont' know Ms. Saks, haven't heard the details, read the book, or listened to the TED talk, I will tell you that every psychiatrist who reads this thinks there was something more going on then she couldn't do law school homework. That may have been an indication that she wasn't focusing well or her usual bright self, but it's not a commitable reason. One might wonder if while she was wasn't doing law school homework she was disoriented and walking into the highway, or doing things that constitute being a danger. I know no details here and I do understand that miscommunications occur, so maybe that was it and it was a huge mistake (they happen).

I believe in advanced directives. But, you don't forced care now or in any of the circumstances where it may have happened before, and maybe that's reasonable. But if you started to believe that your lovely friends or children were plotting against you, that there were cameras inside you as proof, that people were poisoning you, and the only option you saw was to kill them in self defense and you told this to your doc. I realize you probably never that sick. But if you did get that sick, and you have a 'no forced care' under any circumstances directive, how do you feel when you've killed innocent people (and I really don't mean 'you' but any person). No one asks to get THAT sick, and there are hospitals full of psychotic murderers. You don't have to answer this.

You do make a wonderful point, however, that disrespectful care leads people who need care away from treatment and discourages people from getting future care.

ClinkShrink said...

Wow, Dinah you really need to listen to this Ted Talk!

http://youtu.be/f6CILJA110Y

Pseudo-Kristen is right, it's pretty fantastic.

I had downloaded her book because lately I've been a bit preoccupied with the idea of advanced directives and some of the implications if they really had 'teeth,' but that's an idea for another day and blog post. Dinah has patiently listened to my backchannel ramblings and far-out thoughts on the issue, which aren't fully formed enough yet to put out into public domain. But that's why I downloaded the book. I haven't gotten to it yet, but it definitely just bumped up to next on my waiting list.

ClinkShrink said...

One quibble: I've always disliked the term 'high functioning X' because it never seemed accurate. It implied there was a known average or mean level of functioning for a given diagnosis and that's just not true. In my pre-blog days I've worked with and known people who had experienced mania with psychosis and fully recovered, or enough that no one knew they had ever been sick, so that wasn't a new idea for me. Post-blog, I see from our readers that it's not necessarily a good term from a clinical standpoint either, since implies a negative prognosis.

Joel Hassman, MD said...

Dinah, you are too nice a person in allowing some of these commenters to get away with the skewed impressions they sell to unspoken/unwritten readers who read at these sites.

You and I have worked inpatient units in our careers, and while it is rather easy and obvious when we take in people who are psychotic or profoundly manic and in need of redirection, why aren't you saying something to address the characterological and frank addiction crowd who are just being difficult and disruptive in the community and need us to house them until they get their crap together?

I don't know what percentage they are involving involuntary admissions, but if I took a guess, it would be close to 50%. And I really don't understand why blogs let these people get the pass they get away with in giving the impression they were "so horribly mistreated and rudely managed, and how staff were so insensitive to their needs".

Like if they gave their significant others and families and other support systems more a chance to redirect and encourage more responsible behaviors and choices, being hospitalized wouldn't happen in the first place!

I asked in a comment earlier for someone or more to note what played a role in their being admitted involuntarily. I haven't read anyone being willing to share some personal details that show candor and brutal honesty to note the situations. If I missed something, sorry. But, people who have struggles with interpersonal skills need to step back and start to ask the tough questions of, "why is everyone else NOT getting me!"

It could be there is just a profound mood or thought disorder that the average person can't understand.

But, it could also be you don't know how to work with people. And when you are on an inpatient psych unit, staffed by more than not who are trying desperately to help you, and yet you probably aren't interested in helping yourself by starting to accept other people's perspectives about what they see in you, well, swimming upstream is exhausting real fast.

My advice for your book, if it is about solely sales, or about helping people, is to decide whether you will examine ALL the reasons why people are forced into inpatient care. It ain't only about Axis 1, in my opinion.

And I know you know that!

Hey, did you catch my Bulworth series this week at my blog? Doubt it was a pleasant read. Good luck with your book.

Joel H.

Dinah said...

Joel,
It has been many years since I've been on an inpatient unit. The vast majority of patients were there voluntarily. Some people were admitted involuntarily to play it safe, watched for a couple of days, then allowed to sign themselves out. Even if the staff did not agree they should leave, very few were held to the 72 hours notice. I got through my pgy=2 year without ever attending a civil commitment hearing.

Misbehaving drug addicts? Involuntarily? I have no memory of this. What I remember is drug addicts insisting they were suicidal so they could get voluntarily admitted. It was a ploy for food and shelter. We'd leave them in the ER, hoping they'd get sick of it, or want a cigarette, declare themselves not suicidal, and leave. If it went on long enough, they got admitted for "3 hots and a cot." The hospital ended up making a special quicky-unit for them to get them detoxed and hooked into addiction treatment.

Yes, some of the stories reflect that people were in a really bad place and there was a misunderstanding and they were wrongly committed. If more was going on, I don't believe they were lying. I believe they don't see their behavior as others around them do, that there is a lack of self-awareness or insight, that may or may not be part and parcel of an illness or an addiction. I don't believe that there is much to be gained by hammering at people that they behaved badly, this is something that requires a longer, ongoing, therapeutic relationship with someone who is kind to you, listens, and whom you trust.

If our research shows that everyone on a psychiatry unit is well treated and that all we have here are crazy people who misinterpret the words of others or who are restrained, etc, because there is no other means to keep everyone safe, then there is probably no book in it.

You and I see things very differently.

Anonymous said...

I think Joel's point, from a family's member perspective is that the person being hospitalized is either unwilling or unable to accept why it is occurring in the first place so of course it always seems intrusive. Adderrall addicts that become psychotic, benzo addicts w depressive issues, etc. Generally they see no problem with their rx drugs (docs, take some blame here) because they are given perscriptions but their behavior at home gets totally out of control (of course not in their opinion). Joel, I agree w you. If more docs were like you there would be less diagnosis.

Je suis said...

Dr. Hassman

Years ago, I spent some time in an involuntary voluntary commitment. By that I mean I was given a choice, with this statement:

"we can force you you know".

I'll never forget those words, and the subsequent loss of self-determination that accompanied them. All this because I became depressed, and started thinking about how I could end that feeling. I realized that there was something going on, and made the decision to call a professional for help. That was the help I received - a forced hospitalization. I did not have a particularly bad time there, overall, but the loss of freedom, and the feeling that your fate was in the hands of a stranger, without your having any say in the matter, was - and is - an unsettling, even traumatic, experience. Contrary to your expressed rhetoric, I did meekly say "I think I want to die" when talking with the councilor - that was all it took. I wanted someone to talk to, to sort out these feelings with, that was all; but what I got was something else. Something that turned me away from ever seeking help again. Something that destroyed all trust and belief in psychiatry. A forced hospitalization. A marginalization. A negation of personal independence.

So, for your brutal, honest candor: I was not disruptive, in fact, no one who knew me had any idea what was going on until the hospitalization. I did not alienate my loved ones, but the hospitalization shocked and frightened them, and afterward they didn't seem to know how to act around me for a long time - so if there was any alienation going on, it was the commitment that was the direct cause. Again, no one had any idea what I was experiencing. And yes, the process did just happen in a heartbeat, based on one conversation. No disruption, except for my life, and no abusive behavior, despite your projecting it onto every person who has been involuntarily committed.

Ultimately, I am in the same place I was before the 'help" I received, with the addition that I will never seek out psychiatric help again. Because of attitudes like yours. Because you've already
prejudged people like me. Because it's possible that you are wrong, but you won't ever see that.

I never said that the people that who "did this to me" were "bastards", or anything else for that matter, nor do I spend a lot of time 'bitching' about it on threads - once in a while a particularly unreasonable post catches my eye, and I respond.
Your vitriol certainly got my attention.

As for your suggestion that those people that initiated the commitment are the reason that I am still here: no, they are not. They made no difference whatsoever. I still struggle to this day with the feelings, and
there are times when I wish I had just gone ahead and done what I was contemplating. They did me no favors, gave me no lifeline, offered me no hope. I am the only reason that I am still here, and its entirely possible that I will falter and lose the fight one day.
I accept that. I find that to be a better outcome that another useless encounter with your vaunted psychiatry.

So, yes, there it is.

Joel Hassman, MD said...

Hopefully, my last comment here at this thread:

To Je Suis, I appreciate your reply, glad someone was willing to note some detail, but, maybe for the sake of space writing on your part, I don't really understand the chain of events if merely saying "I think I want to die".

I think I have written repeatedly that I do not say EVERYONE who is involuntarily committed has it happen for personality/addiction issues, and maybe I have been fortunate in my career, but for the few times, about 8-10 in 20 years mind you, I have had to do Emergency Petitions as an outpatient psychiatrist, most have come back to at least note they had to go in, some actually thanking me. Colleagues, get this: in the past 5 years, I have had about 3 patients that I felt met the need to be petitioned be discharged FROM THE ER without even a call to me to clarify my position to send them for psychiatric assessment to consider hospitalization. Pretty bold for a doc meeting a patient for 1 hour to dismiss what a colleague is concerned about, knowing the patient for much longer than that ER doc!

I find it disappointing to read people write they will never seek out treatment again because of a negative experience. One should be cautious and hesitant, but, to take a reflexive extreme position and refute care interventions entirely, well, that is a statement to me.

As to Dinah's reply just above, I agree, you and I do see things quite differently. I am sorry to hear you never went to a commitment hearing in your entire PG-2Y time.

For the sake of space here, I will just note this, and I will think about making it a post at my site: having had to continue a 72 hour stay for a sincerely suicidal elderly patient, who ended up needing and benefitting from ECT treatment, and had most in her family be supportive and appreciative of the efforts myself and the Attending provided in her care, I was not pleased I and the hospital were basically sued for retaining her by one of her children, after her discharge!

I learned a lot from the experience, thankfully the judge dismissed the claim as seen as frivilous by her lawyer child. Started to reinforce my tombstone epitaph of "no good deed went unpunished".

My work both at a community hospital and at a state facility has given me much recent understanding of what goes on these days involving involuntary commitment. I stand by what I have written above. And to me, much of what I have read at this thread, the comment 2 above as a noted exception, and appreciated mind you, doesn't really dissuade me from thinking differently.

I had a schizophrenic patient about 12 years ago hug me after coming out of the hospital for a 2 week stay, because this person realized the persistent suicidal thinking would have lead to their death. This person came out realizing the need to live was better.

Gee, how else could this have been handled to get the same outcome? Maybe readers can offer alternatives to hospitalization to prevent suicidal deaths. That will be an interesting read, if comments have validity.

Thanks for being allowed to participate, have a nice weekend and June.

Je suis said...

To Joel Hassman, M.D.

Please allow me to clarify; When I stated that I was hospitalized for saying merely "I think I want to die", that is an approximation. I don't recall the exact wording of the statement. I do recall that I was having some issues, with suicidal ideation, and wanted someone to talk to about it. Talk to, not be forced into a temporary prison, which is what involuntary hospitalization feels like. This is why I will not
seek such assistance again; I will not risk a second occurrence of that episode. It leaves a mark; now you are stigmatized, with an involuntary hospitalization on your record. Yes, it's protected information, but go ahead and try for, say, a government job or security clearance and you'll find out just how protected you really are. Hint: not so much.

Now, as for your 'care interventions", let me explain a bit as to why the word care is a misnomer. You see, I work in a hospital, one in which people are
held or committed frequently. It is not a psychiatric "care" facility in and of itself, but a local hospital with a trauma center. We get quite a bit of
"psych patients", some legitimate, some not so much. let me give a few examples of conversations I have been involved in or overheard.

1) In talking with a nurse I know, one who does PRN work as a second job at a psychiatric facility, upon receiving a patient who had attempted suicide: she stated that she wished these suicides could "just get it right" and not bother her, that she'd like to "show them how to do it", and that she's "tired of dealing with them".
This sentiment was echoed by several nurses nearby. So much for care. Do you really think this attitude doesn't come through when actually dealing with the patient? Because I can tell you that it does.

2) An ER nurse that I frequently chatted with informed me that when she gets a suicide attempt via ingestion, where she has to pump the stomach (or help to, I'm not "up' on the details of stomach pumping), she then removes the
tube and has the patient swallow the activated charcoal that is given. Note that she removes the tube before giving the charcoal; she said that she could just pour it down the tube but that she makes them swallow it as a kind of revenge, presumably for their effrontery in making the attempt in the first place. Is this the care you mentioned?

3) I was in the room when a conversation took place between the nursing supervisor and a social worker regarding a patient that had been placed on a 72 hour hold by the ER physician. The social worker wanted clarification as to why the patient was on a hold since he did not meet the criteria. The nursing supervisor explained that it was just how the ER did things, that the patient had argued with the physician and made him angry, and so the physician initiated the hold - which sounds to me more like a retaliation than a case of medical need - and that it doesn't matter anyway, as they can just reverse the hold after a couple of days and the patient can go home, no harm done. She stated :"what's a few days, anyway?" Of course, a few days is a big medical expense, since most of the money is made in the first few days, but then that has no bearing on the issue, does it? After all, the only one harmed by it is the patient, who get saddled with the cost of an unnecessary hospitalization, and we all know how little that matters. That's the state of psychiatric care, at least in my experience.

Care, indeed. No thank you.

styles said...

"Dinah, this post will bring out the real dark side of what drives the disruptions on psychiatric units, and that is basically people who don't have boundaries..."

When I read Joel's comment, I thought that this was the pot calling the kettle black. I actually was surprised he was so harsh about this, because he generally doesn't self-censor on this blog. His own sense of boundaries is usually way off. I kind of wonder if he's talking about himself in some way.
He may not have a poor sense of boundaries in other areas of life, but on this blog I typically think of Joel as being one of the more disruptive commenters and brings out some of the strongest negative feelings from the blog owners and other commenters.

Anonymous said...

Dinah & ClinkShrink,

I think you would both like her book on forced treatment. I was afraid when I bought it that it would have too much legal jargon, but she includes stories to represent each side. I think she represents both sides very well.

Dinah, I hope people do not rip you for your response. I will not. You are right, there was a lot more going on with Elyn than not being able to do her law school homework. She was also psychotic. I thought it was funny that inability to do law school homework was given as a reason to hold her against her will. It's been a while since I read her books and watched the TED Talk, I need to go back and read/listen again.

In my state, in addition to danger to self or others, they can also hold someone against their will for being gravely disabled.

For me the issue is not so much does the person qualify for forced treatment, I can agree that I did qualify. The problem was I left the hospital even more despondent, and feeling completely alone in my darkness. For me the important issue is will it help or harm a particular individual.

My subsequent therapist and psychiatrist have been able to work with me without doing to me what the first one did, and they have been the ones who have been able to help. There have been times, probably many times, they could have had me committed, but they did not. It is for this reason that I was finally able to trust them enough to receive the help I needed. Interestingly, Elyn Saks' physician could have hospitalized her when she threatened to trash his office. If I remember correctly, he didn't do it. She was able to build a trusting relationship with him, despite struggles with psychosis.

You asked what if I started believing friends or children were plotting against me, that there were cameras inside me as proof, that people were poisoning me, and the only option I saw was to kill them in self defense and I told this to a doc. I cannot see myself ever telling a psychiatrist that. Psychosis has not ever led to me having homicidal thoughts, or caused me to hurt people or animals so I just don't see that happening. If I had homicidal thoughts or if I had lashed out at someone, perhaps I would feel differently about things. The times I've been psychotic I withdrew from people, I didn't plot their murders or lash out at them. For whatever reason, it has just never manifested itself that way with me, not matter how scared I've been. If I ever cause harm to someone, I would need to be locked up.

I believe had my first experience with a psychiatrist gone differently I might have been able to confide the stuff going on in my head a lot sooner and received help much more quickly. Unfortunately, all it did was make me too afraid to talk for a long time.

I don't pretend to know the answers for other people. What I know is what has not worked for me, what has helped me and what has hurt. I know others feel differently, and that's fine. There experiences are theirs, their lives are their own. I am not them, and they are not me.

Thankfully, I finally have a therapist and psychiatrist who are able to recognize me as an individual and treat me accordingly.

Pseudo-Kristen

ClinkShrink said...

In the Ted Talk, Elyn Saks mentioned she was also standing on top of a building shouting thought-disordered delusions in addition to not being able to do her law school homework. Nevertheless, she's an impressive example of recovery and determination.

I see the patients where there were bad outcomes. The first episode of psychosis, or the first-ever violence associated with a psychotic person who had never been violent before. I don't have any doubt that any of these people would rather have been involuntarily admitted before the crimes that lead them to my hospital (or prison, as the case may be). But hindsight is 100% accurate and 0% useful.

Dinah said...

Standing on top of a building yelling thought disordered things (depending on how close to the ledge or the nature of the top of the building) seems like reason to certify to me. I think inability to do law school homework is an example of not functioning, and isn't it wonderful that Elyn Saks eventually was able to do her law school homework and become someone who contributed so much to the world!

So Pseudo-Kristen: I guess I believe that advance directives need to be more specific. Which hosptials are okay. Which medicines are and are not okay. If you have the same course of symptoms, no hospitalization, but "if it become clear that I may injure or kill others, even though this has never happened, then please prevent this?" Mothers kill their children, and personally I'd rather spend time anywhere under any condition for any length of time before I killed my kids.

I think part of the problem with the miscommunication aspect is that depressed people often feel suicidal, this is just part of the deal. When a patient I know says they are suicidal, I virtually never consider committing them (20 years of private practice = 0 civil committments). It's in an ER, or when people see someone they don't know who has no real way to assess safety, or when the patient says "I am going to do this, it's not just dark thoughts, the gun is ready, I won't call you and I won't promise not to do it." That's when people get committed for being suicidal. Mostly, people get committed for being psychotic and disorganized. In the ER, I once committed someone who was found walking on a major highway naked, even though the evaluating social worker insisted the patient had an outpatient evaluation set for the next day. I wasn't so sure the patient would live to the next day.

Anonymous said...

Dinah,

Perhaps what I should have said is that I do not ever want to be forcibly treated based upon a hypothetical. I don't want to be forcibly treated for something that theoretically "could" happen but has not happened. If I violate a law, that changes things considerably. Then, we are no longer speaking about what is hypothetical, we are talking about something real. I expect at that point that there would (and should) be limits to my behavior.

The problem with forcibly treating based upon hypothetical situations is that there is no way for me to defend myself against what I could do but haven't done. There are a thousand and one things I could do. I could rob a bank. I could commit credit card fraud. I could fly to a foreign land and try to sell one of my kidneys. The what-ifs are limited only by our imagination and creativity. The fact is I have not done any of those things. If I do, then I would agree that I should be detained against my will. But, only then.

Pseudo-Kristen

Dinah said...

Pseudo-Kristen,
Of course you are right and no one wants to hold people who might do something, especially if those things are hard to carry out, don't endanger someone, and come from a rationale place.

Many people want to kill themselves and just do it without involving the mental health system.

If someone walks into an ER and says "I am feeling very suicidal and will likely kill myself when I leave here," What is the doc supposed to do?

And if you want to not be treated by force for a hypothetical, what is a treating psychiatrist to do if a mother says she is terribly depressed, very suicidal, thinks it would be awful to leave her children and Satan is commanding her to take them to a better place. It's a hypothetical, she may never well act on it. By your theory-- we wait and see, and then the kids are dead and mom likely goes to jail forever, not a hospital, and the psychiatrist gets sued. A week in a psych hospital might prevent that (or it might not).

jesse said...

This is a fascinating thread and Dinah should be congratulated for considering writing a book on such a topic. Despite being quite kind and considerate she has been tarred and feathered here and the “living room” has all but disappeared. So I have kept my head down and refrained from comment. Recently there have been a few responses (such as Pseudo-Kristen) that have been thoughtful and reaching out rather than polemic, so here are a few observations.

As has been pointed out the criteria for involuntary hospitalization is danger to self or others. Simply stating “I’m thinking of killing myself” does not in itself meet those criteria. The last time I certified anyone (decades ago) was a man who had pulled the electrical outlets and live wires out of the receptacles in his apartment (wooden structure!) because he thought the devil was speaking to him through them. I had gone there and saw it.

Elyn Saks is quite verbal and her TED interview impressive. Yet there is a strange disconnect between the description she gives of how her psychosis was affecting her and her having mentioned the notation on her chart (as a reason for admission) that she could not do her homework. Was this the only reason she was admitted? Had the doctor noted many of her symptoms but then added the observation about her homework as an example of her inability to function at her usual level, something he felt obliged to note?

Had she been cooperative, or had she become threatening and belligerent? In my experience staff are generally kind people and I know of many staff members who were seriously hurt by patients.

So here are a few comments: First, like Elyn Saks, virtually all of the commenters who discuss their forced hospitalizations do not tell us what they were doing, in full and in detail, that led the physicians in the hospital to sign the certification. This seems to be a kind of lacuna, and it is very striking. “A danger to oneself or others.” How did they get to the emergency room? What happened? Does the person standing on the ledge of the building have to jump to establish the proof needed of self danger?

Second, there are very few comments on how they were affecting other people. How frightened their friends or relatives were. The efforts that had been made to help them, for hours on end, with those caregivers worn out and fearful of the worst. Rarely an indication that the professionals might have been trying to do their best and it was the patient who had misunderstood them.

Third, there is a frequent use of the plural “you.” “You psychiatrists don’t get it.” “Your vaunted profession.” Rarely a realization that there are many kind people in the helping professions and that one cranky, unkind, thoughtless professional does not represent all. Imagine writing “I went into a restaurant and the waiter was nasty. You waiters are so thoughtless and mean.” You northerners, you blacks, you Jews...

Finally, the alternative to the forced hospitalization is frequently jail, not freedom. It is well known that jails are filled with many people who certainly are not getting the best treatment there. Jails are not deigned to be hospitals. Once I had a patient who had slammed the door in a store and screamed at the clerk. When the police arrived he was lying down in the center of a reasonably busy street, waiting to be run over. Instead of bringing him to an emergency room he was taken to jail. Years later I saw him begging in Baltimore, homeless.

ClinkShrink said...

"It is well known that jails are filled with many people who certainly are not getting the best treatment there."

Oh Jesse, I can't believe you just said that in front of ClinkShrink. Those are fighting words.

"...you northerners, you blacks, you Jews...you correctional psychiatrists..."

We all know the standard of care is worse in correctional facilities than the community, right?

Correctional psychiatrists are the ones who are actually providing care for the people who can't afford your fee-for-service private practice rates. (Assuming a private practitioner was actually willing to treat my forensic patients, which they're not.)

Have you actually seen the treatment records of people in free society practice? I do, regularly, when doing pretrial evaluations. I see people getting bizarre combinations of meds, being diagnosed with conditions that have no documented basis, being given inadequate followup. And these are people with insurance.

I wouldn't put such a high rating on the community standard of care. And that's care given after two to four months waiting for an appointment.

OK, I'm off my soapbox now.

Anonymous said...

Another comment: both my voluntary hospitalisations for severe depression with no psychosis were voluntary purely because of the threat of involuntary hospitalisation. The hospital psychiatrists, both times, stated, "you don't want to be involuntary. That is worse then you can imagine." So exactly how voluntary that makes them, I'm not really sure, but even the doctors at this top five private ivy league nyc hospital were aware of the discrepancy. Dinah, you just aren't willing to see reality.

Je suis said...

Dinah
Although I haven't addressed you directly thus far, I do want to thank you for the opportunity to express some of the issues I've had regarding the way my experiences with psychiatric care were handled. I keep coming back to this blog just to see what's new, mostly because it seems open to the fact that not everyone sees everything the same, and allows for differing points of view. So, thank you - to all of you who are responsible for the blog.

ClinkShrink
Your comments about the community standard of care - priceless! As the comedian said: "it's funny because it's true!" -
except its not funny at all; it's sad. I have a lot of respect for you for calling it out, as well as for providing psychiatric care in a correctional facility. If I had met someone like you on my first encounter with the byzantine system called psychiatric care, i might now feel differently about it. Then again, if I had been born wealthy, beautiful, and brilliant, things would be different - but that's not the case; things are what they are. C'est la vie.

Jesse
I can only answer for myself, of course, but here you go: how did I get to the emergency room? I didn't. I was having some rather troubling thoughts involving suicidal ideation, and decided to seek help. I made a call to a local facility, who put me in touch with someone I thought I could talk to about this issue - my first mistake. I went to the appointment and explained about the depressive symptoms I had been experiencing, along with recurring idea that I might have to take action in order to stop it. Yes, that would be thoughts of suicide.
Thoughts, not actions. I was there to seek help before it got out of hand. I had no plan, just a vague idea involving cutting and bleeding - I know, not really very effective, but this is what kept popping into my head. So I explained this to the counselor, and that I wanted someone to talk to about it, maybe to help me understand what is happening and why I keep having these thoughts. They were not there all the time, but would just "appear" at random intervals, without rhyme or reason. What I got was an involuntary hospitalization. I say involuntary because, even though I was given the choice, a choice presented with coercion ("we can make you if you don't agree") is not a choice at all. Most agreements are not binding if coercion is involved, yet somehow this one is. Ever wonder why that is?

Now, how frightened were my friends and relatives? Not at all, they had no idea. No one had any idea, I kept it all hidden, quite successfully. Until the hospitalization "outed" me, of course. So I have psychiatry to thank for that, as well. I would have preferred to keep it quiet, I tried to via making an appointment that no one knew about so as to handle it with a minimum of disruption, all to have it blow up in my face thanks to this hospitalization that I neither needed or wanted. Now that family members were aware, due to the machinations of psychiatry, they became concerned; and things became awkward for some time after that. So, thanks for that, psychiatry. one more reason to stay far away from "help".

So, "a danger to oneself or others"
is the criteria, and you want to know what it takes to establish that criteria? So do I. because I did not meet it, and that's according to the psychiatrist that released me from there after a relatively brief stay. Yet it happened, and the damage done was significant enough that I will not
ever risk going through it again. I still suffer with the same symptoms, sometimes even worse, and still have similar ideations, which I suppose goes to show just how useless the hospitalization was, since I'm still here years later with little difference in the outcome - except that someone got paid a large amount for a useless hospital stay, one that was not wanted or needed, and someone else, namely me, lost any faith they might have had in the mental health system.

Anonymous said...

Dinah & ClinkShrink,

I appreciate you debating this very emotionally charged subject without getting angry at me for having a different opinion.

I find my line moving just a little, in regard to the threat to others. I agree if someone says they are going to kill someone (even if it's at that point hypothetical)there should be intervention. I would imagine that making a threat to kill someone would also be illegal, but I could be wrong. (I'm thinking of the teens who have plotted to kill their classmates as an example).

So, in the case of plan to murder others, yes I would say detain against their will. I think in these discussions I am coming from a place of concern that the line to commit will be loosened, and we will make it about psychosis (even when the person has not been violent against other people and/or violated no laws). That's scary to me, because I know had that line been different I might not have received the treatment I needed. Threats and force would have possibly meant I received treatment sooner, but the minute I was forced to be there I would have said what I needed to say and then I would have been gone. I would not be seeing a psychiatrist and taking medication today had this been done by force. I would have run. We don't have enough money to hunt down people in hiding from forced treatment, and I think the loosening of the commitment criteria will only lead to more anger against psychiatry which really helps no one and only feeds the anti-psychiatry crowd.

ClinkShrink,

Your examples make me admittedly uncomfortable. I would of course never want to harm anyone, and I would imagine many of your patients never thought in a million years they would be in the situation they are in. But, I have real concerns about the lowering the bar of commitment. I just don't want force used against me for something I could do but have never planned to do and am extremely unlikely to do.

I keep coming back to the issue of what would a person who is competent want. I take back something I said yesterday that it should be about if the intervention helps a person. Even that is problematic because when I look at cancer treatment, for example, we do not all want the same things. Although it seems dumb to me, some people will forsake chemotherapy for a treatable cancer and instead opt for some sort of quackery instead. As much as I disagree with their decisions, if they are competent to say what they would want in these cases, it remains their decision to make, regardless of the outcome.

I want the same scenario as the cancer patient. I want to say, as someone who is presently competent to make decisions, that this form of intervention was not life saving for me, it was harmful to me personally and drove me further from care. I want to be able to opt out of all forced treatment in case of psychiatric emergency (with the exception being if I have violated the rights of others i.e. broken laws, hurt them, or made a specific threat against them). I also want to protect the rights of those who feel differently and would want different things. I think we can have both.

I think the way out of this is an enforceable advance directive so that people who are competent can have their personal wishes respected in case of emergency.

Thanks for the very interesting discussion.

Pseudo-Kristen

ClinkShrink said...

Thanks Pseudo-Kristen, our thinking just converged. Time for me to put up my blog post.

jesse said...

@je suis: when you wrote : "So I have psychiatry to thank for that" I think what you really meant was that you went to a counselor (apparently not a psychiatrist) who did not know how to help you, so then you were brought to an ER where two people signed an involuntary admission form. Perhaps those people were not psychiatrists, either. What you describe certainly would make all of us regular Shrink Rap contributors cringe. I have never done what you are describing and I doubt any of my collegues have either. Many times patients have brought up the most disturbing thoughts and discussing them has been a relief. No hospitalization ensued at all. I do not doubt that you were treated that way, but do question whether it is an inditement of our profession or of those particular practitioners.

One issue that Dinah might explore in her book would be whether there is a better outcome (particularly in terms of the experience for the patient) when psychiatrists are involved, psychologists, or other levels of training. It may be, but there may be factors we have not considered.

I think our field is difficult to practice well and cookbook responses are often unhelpful or even harmful.

Dinah said...

So I'm not much for forced care, either. And suicidal thoughts are part of depression -- we simply can't hospitalize everyone who has these thoughts...no beds, no desire, no reason to. But there are misunderstandings, nervous counselors, and there are people who present to the emergency room saying they are suicidal. And there apparently are people (or one person) who would tell a psychiatrist they are thinking about killing people, and then did. It's not the norm to say you're going to kill people, though in East Baltimore, it is the norm to say you might if they mess with you first, but that's life in a tough 'hood, not psychiatric illness.

We are never going to get it exactly right, especially with people we don't have a relationship with. How do we capture those who come for help who really would kill themselves and not over capture? How do we create a system that allows for forced treatment (at least for an assessment). Given that some miscommnications will happen (and hopefully those people will be quickly released), what if we got the system a bit kinder so that being hospitalized was not so traumatic, at least not for so many people? Our readers describe awful scenarios. My patients who have had coerced admissions have not described such trauma, but perhaps that is because Clink and I are in a city where the main psych hospitals are ranked #1 and #8 in the country.

jesse said...

Thinking further about the situation je suis described, the most important factor on the part of the counselor, psychiatrist, psychologist, social worker, and so onis experience. It is more common that less experienced professionals become themselves anxious and afraid when working with patients who bring up suicidal thoughts than more experienced professionals would. There cannot be just one factor, but I bet this is the most important one.

Joel Hassman, MD said...

"My patients who have had coerced admissions have not described such trauma, but perhaps that is because Clink and I are in a city where the main psych hospitals are ranked #1 and #8 in the country."

What does that have to do with the price of eggs in China? If you are referring to Hopkins and Sheppard Pratt, not exactly the pillars of respect among psychiatrists I know both here in Baltimore and in travels elsewhere, and with Hopkins, along with Harvard and Stanford, those unholy three we can thank for indoctrinating us with the biochemical model and better living through chemistry.

Units are only as good as the philosophy and standards of care set by the treatment process, not by blind allegiance to mangled care and a name that is not so pristine as of 2013.

Didn't Jesse seem to echo my early comment of what were some specifics to the cause of hospitalization, now one person has answered, but, come on, who fights commitment the loudest and hardest? All of you psychiatrists know what I am asking about!

I don't think this is an honest debate overall, and I know people at this thread think I am so rude in my rebuttals and hypotheses.

Yeah, well until proven otherwise, truth hurts, and I don't have time to do the political dance these days. As Dinah notes in her next post tonight, if you want help by coming into an ER, you don't call all the shots. You ain't a customer. Frankly, let's really put it out there, if you want to die, you don't encourage others to find you or shove the attempt in their faces, and you don't ask people who took a vow to help and support life to just rotely accept your version trumps our training.

Better to have the patient hate you for the rest of his/her life, and it be a long and healthy hate, than have family/significant others/friends look at you and ask "why did you not try to stop them?"

most people with Axis 1 disorders have not given me distaining looks of death when they finally left the inpatient unit. That's my experience at community and state facilities in the past 5 plus years at least. Agree or not, it is what it is from my point of view.

Doesn't this dance with some people get old here?

Je suis said...

Jesse
I suppose I should have written that I have mental health care to thank for that, then; as the entire situation falls under the blanket of the mental health care system. But really, that's splitting hairs; the layman doesn't really know the difference between counselor, therapist ,psychologist, or psychiatrist; no, they just know that a *mental health professional* did whatever it was that was done to them. And don't forget, you see a psychiatrist within 72 hours, but I was not released after that first meeting; no, the psychiatrist waited a few more days before initiating a release.
Why? I don't know, possibly something they were told by the counselor, but even after meeting with me several times, and learning of my concerns, it still took time, despite my affirmations that I was not at that time planning anything drastic, and that I had come for someone to talk with. This is not someone in imminent danger, but someone trying to prevent the situation from deteriorating. I did not fit the criteria, yet there I was.

I have an idea: perhaps, if the fault was the counselors, or other undertrained/overzealous mental health workers who are not psychiatrists, then it follows that only psychiatrists should be able to initiate and approve a hold or hospitalization. No one else. Maybe then these kind of issues would be resolved without the unnecessary detainment and
negative feelings generated thereby.

jesse said...

@je suis, psychiatrists can also be poorly trained, inexperienced, have poor judgment, and so on. There is no guaranteed way to prevent what happened to you, and all of us have heard stories of bad judgment from doctors, lawyers, you name it, no profession is exempt. What can be done, if at all possible, is to try to get a referral from someone you know and trust with experience when choosing a professional. It is not garanteed, but it is a good start.

Sarebear said...

What Joel says here "Frankly, let's really put it out there, if you want to die, you don't encourage others to find you or shove the attempt in their faces, and you don't ask people who took a vow to help and support life to just rotely accept your version trumps our training."

is quite distressing to me. If I truly wanted to die I'd just do it, right, and not tell anyone or get help? My therapist has helped me understand (sometimes, I still struggle with this) that even a person who truly wants to die, will have second thoughts, have urges to connect with someone on it, or whatnot . . . that doesn't mean that I'm playing around. See, my mean older sister that was in charge of the house when my parents were gone, and us to some extent though we were all adults, she told me something as I was being wheeled out on gurney out the door to the ambulance after my suicide attempt "If you wanted to die, you'd not have called 911". She didn't take me seriously at all, and so much of me wants to prove to her and everyone else, especially hearing a psychiatrist saying that if one is serious you won't tell your shrink etc. . . . to prove it and do it and keep it all secret until I'm DEAD.

I don't expect people to not voice their opinions, even ones that head this way and distress me, however, I am wanting to point out that this comment affects me negatively in a dangerous way.

Which I've just done. I do understand that the way I've taken it may not be the way it was meant, but it is how it hit ME.

Sara

Anonymous said...

Jesse,

I think you're right about the importance of an experienced mental health professional. I don't think that can be stressed enough. The psychiatrist I have now is in his 60's, has been in practice a long time, and is a very calm, positive person. My therapist is a little younger, mid 50's but she too has been in practice a long time, and is super calm. My first therapist, on the other hand, was inexperienced and neurotic. I know he was well-intentioned with the whole hospital thing, but an anxious patient seeing an anxious, inexperienced therapist probably isn't the best combo. I think it only escalates things.

Pseudo-Kristen

EasternShoreMD said...

Dinah, Thank you for opening this discussion. Book or no book, I hope this helps to increase our level of consciousness about how people at the other end of a power differential are treated.

I happen to work with Dr. Hassman (no comment) - and hope that I/we and other psychiatrists can increase our ability to put ourselves in our clients'/patients' shoes.

(Who am I to judge someone's symptoms and behaviors in a manner that suggests they have an easy alternative choice? I consider reference to Axis II pathology, for e.g., something that requires more wisdom and skillful treatment than Solomon could even provide, not as a red letter A on their breast that they have somehow earned.) I think everyone EVERYONE makes the best decisions he or she can with the resources they have at any given time. May we clinicians have more resources to our hearts and empathy!!

I have "strong-armed" 2 patients involuntarily into the hospital in my career. They were both gracious enough to thank me afterwards and affirmed that they were really intent on suicide, helping assuage my guilt about having abused a power trip. But I am lucky not to be the one making such a hard call most of the time.

I wish we treated all inpatients, but particularly those there against their own desires or insights, as persons deserving great compassion and understanding. This is not a deserved "time out" for bad behavior. And they wouldn't even be there if they had half the blessings of those who are in the roles of treating and confining them. Inpatient units are too often horribly long, boring, chaotic, unfamiliar, sunlight-deprived time outs even if that were the case.

The other side-line of this discussion Dr. Hassman often raises relates to patients who are "drug-seeking." There has to be a better perspective than assuming that if a patient "gets himself" committed or is "drug-seeking" that he or she is just some bad child obstinately insisting on getting his/her own way.

I have to maintain that it is my job to be compassionate and to make sense of my patients' choices (why do their choices make perfect sense for them given who they are, how their body works, what alternatives they have experience with, and what they've gone through?), and from that place help them see why other options might work for them better. If I come from the "Doctor Knows Best" MDeity position, I am the pot calling the kettle black. I am abusing my power differential because it is easier for me than to exercise MY own self-control and higher consciousness.

Enough ramblings.
Thanks for the discussion,
Brenda C Scribner, MD, in Maryland

Hum said...

@EasternShoreMD,

Would you consider allowing yourself to be cloned? The world needs more sane shrinks. We have some but we need a lot more.

Humdedum

Je suis said...

@Jesse
You're right, of course, about inexperience and bad judgement existing across all professions; however, the majority of those professions cannot take away my freedom, remove me from my life and livelihood, my possessions and relations, like psychiatry can; even if only temporarily. Further, with most of the other professions, I can discontinue contact with the professional if I feel that the relationship is not working to my benefit; not so with an involuntary commitment, where one is essentially stuck with the
individual who initiated the commitment. The committed have no say in the matter.

As far as professionals go, I would also like to mention that
a psychiatrist commits people based on the standard of dangerousness, yet in a court case in California, the APA testified that a psychiatrist has no better judgement of an individuals dangerousness that the average person. So, even within the profession there is an ambiguity
regarding dangerousness. Perhaps this is why there is so much animosity regarding this issue;
maybe the profession as a whole needs to get its house in order?

Star said...

I was recently admitted to a local hospital in the St. Louis area. I had been out of a different psych ward for about a month, and expressed to my shrink at the time that I was still having near-constant suicidal thoughts. Her immediate (and only) response was I must go to the hospital: I could go voluntarily or she would have me admitted.

I went “voluntarily.” A friend was kind enough to pick me up and drive me to the ER so I wouldn't have to take an ambulance. I went to a different hospital than I'd been to before because I was mad about the (incorrect) BPD diagnosis I'd gotten by a shrink who spent less than 30 minutes with me over 6 days.

I was admitted through the ER. They wanded me and then had me change into a gown (privately, in a bathroom). They took my belongings (clothes, etc.) and wanded me again. My things were searched thoroughly and I didn't see them again until discharge.

Upon admission to the psych unit, a brusque nurse had me fill out some of those standard depression rating scales. Then she abruptly came in and said it was time for my "skin check."

She took me to my room (I had no roommate) and told me to disrobe. I protested, crying. She said "standard procedure" is to inspect all over for cuts, scars, tattoos and other marks. I volunteered to show my self harm scars and healing cuts (including one with stitches). She said I had no choice, I must undress. She said I could not keep my bra because it has a wire (though the ER said otherwise), and immediately started to undo my gown and bra for me (without my consent or even saying what she was going to do). I cried. She acted like she was inspecting a cadaver - I wasn't real or human.

She took many photos of my scars and the stitched cut on my arms. She wouldn't tell me why "it's standard procedure." She scolded me for weeping and for self injuring. All while I stood naked in front of her.

During that visit, I had a male doctor walk into my room unannounced while I was dressing from a shower. A psych NP told me my symptoms and side effects were not true, and that I had to wait all weekend to see the shrink before my meds might get changed.

Every shift change, my new nurse would come to me, wherever I was, and demand (then and there) that I show them my stitched wound. I was not given the opportunity to go somewhere private, or have my medical concerns kept private from other patients. This happened more than once while I was sitting with other patients. It was mortifying.

I was not permitted to refuse to have my vitals taken at night (they did rounds at about 3am, and I never could get back to sleep). I was forced to have blood and urine taken. I had no rights.

After two days, on Sunday, I requested to sign myself out AMA. I had follow up care already with my GP on Monday, therapist on Tuesday, and group therapy on Wednesday. The nurse laughed at me, saying it wouldn't happen. She would have to call the shrink (who hadn't seen/examined me) and he would have me flipped to involuntary and I would have to stay for another 3 business days. When I protested, offering to contract for safety, stating again my support system, she said it wouldn't happen. She said I was still suicidal (which I had not reported since admission). She said "you're a cutter! You have stitches!" as reasons I should be held involuntarily. She said that since I was crying now, but "had been fine 10 minutes ago" was proof I couldn't leave. She “asked” if I really wanted her to call the doctor. I said no. I wept and had a (long) panic attack alone in my room for about an hour. I was never checked on.

The shrink did rounds around 7pm Monday evening. He discharged me right away, without asking how I'm doing, if I'm "feeling safe" or even seeing the meds I was on (let alone change them). On the plus side, I suppose, he didn't discharge me with a BPD diagnosis.

Anonymous said...

Star, I am unaware of a law which permits forced photography of patients. This is most likely their hospital policy to protect themselves in case patients try to blame additional wounds on staff, and it was probably stuck in the informed consent somewhere. However, if at the point it happened you said no and they did it anyway, well, I might pursue that one. Might be worth reporting to JCAHO that you clearly verbalized no and they forced you anyway. Let them defend it. I think they might have trouble doing so.

When I was in the psych hospital under an emergency detention they were going to photograph me, and I said no. They said it was their policy to do that and basically told me that I had to do it. I asked if they could legally force me to be photographed. The nurse disappeared to ask and when she came back that was the last I ever heard about forced photography.

They can't just do whatever they want to involuntary patients. If you agree to photography, then that's fine. If you don't agree and they force it, then I would be interested in hearing them defend forced photography. It's not done to keep you safe, it's done to keep them safe.

Anonymous said...

I was voluntarily involuntarily committed and since discharge (2 years ago)... well let me put it this way - I will not see any psychiatrist ever again and I keep some savings on a separate bank account so if I ever feel I'm in danger of being forcibly treated (degraded, humiliated & tortured?) I intend to take a taxi to the nearest airport and GTFO the country. Haven't seen a GP since either... just can't make myself to. God forbid I ever have an accident... I'd run as fast as I could broken legs and all. Don't like medical professionals, don't trust them, don't want to see them.

Star said...

Anon on June 6:

I have really seriously considered making complaints about the hospital. I truly was not allowed to refuse anything - the photos, seeing the hospitalist and nutritionist (? I'm not diabetic, have no food allergies...), or even having my vitals taken.

I argued about the photos (they also took one of my face, ostensibly for my chart so the nurses would know who I am), and was overruled. I fought having vitals taken my first night, to the point where the tech was yelling at me that I had no choice.

I understand the reasoning behind the photos. I understand the reasoning behind forcing all psych patients to wear hospital gowns (two, one forward, one backward) all the time. I understand being wanded in the ER, and even why my bra was taken away. I agree with you - it's all about protecting the hospital & staff from lawsuits. Their safety can be maintained with less intrusion. Wounds could be documented in the notes without photos - and based on talking courteously to the patient. I was there for help, after all (whether or not it was my choice - which, in theory, it was).

I have been disappointed that I did not get contacted by the hospital to give feedback on my stay. The care from the staff was lacking. I have not complained either to the hospital or JCAHO; I am still mulling it over. I admit to worrying that I would be brushed off as another crazy psych patient.

bonzeblayk said...

Oh dear.

I'd love to help you out, Dinah, but my narrative just rolls on and on… it runs a lot longer than a chapter!

It's hard to know where to start; I think I'll just drop you into the latter part of my "tayrot" Facebook Photo Album - My CPL 330.20 Discharge Order p2.

A travail of 15 years as an insanity acquitee, with 4 1/2 years spent institutionalized midway through - and 15 months of that behind double razor wire? Wow.

But the ironies just kill me… just like the screwed-up timeline produced by a forensic psychiatrist, where events spanning six weeks were carelessly expanded to 444 weeks, a necessary hospitalization got stretched out far beyond any rationally justifiable proportion…

And that's just it: that's my entire history of criminal charges, spanning six weeks back in 1997. That's it. Period. I have never been convicted of a crime.

And almost all of the horror stories about me that wound up in my "Core History", which the clinicians dwelt upon in their reports… were well-crafted tales, "good stories", a legend, if you don't mind me resorting to the language of spooks?

"… if you dangle a history rife with inventions of violent behaviors before them? … They bite."

My "tayrot" Photo Album is intended to provide something like an overview and timeline for the story… I believe it gets the essence across?

I have to kick myself: I originated the kernel of The Plot… in a strictly moronic (NSFW) movie plot? Please don't laugh too hard at this?… I am turning it all into ART:

B.A.R.BLAYK - QUADRILOGY!

sigh OK, my karaoke may be merely artful, but at least I strive to be entertaining! (And I think I deserve some credit for retaining my sense of humor, no?)

Yes, it's a very long story… it sounds unreal: it's all too true.

thanks… and good luck to you and Clink with the book!

Sincerely,
- bonzie anne

bonzeblayk said...

OOPS

… that should read "six weeks were carelessly expanded to 320 weeks" … not "444 weeks"!

… it's "only" a factor of 53 off, rather than 86!

Sorry! My bad… ;-)

Sincerely…
- bonzie anne

PS: Since you appear to be the kind of folks who like to verify things, here's the link to my FBI rap sheet as provided by the Census Bureau

"… additional information is needed to determine your eligibility for employment. Therefore, we request that you supply two letters of character reference along with a detailed explanation of your following arrests."

"Oh Lord!" - I thought on reading this - "… that's a book! A very long one!"

It's not yet written, but as you can see - I'm working on the paraphernalia.

Anonymous said...

Dinah,
Do you want stories about involuntary 'voluntary' hospitalisations? The classic, "Do you want to sign in as a voluntary patient, or do I need to make it involuntary?"
And do you want stories from Australia?
Bec

Dinah said...

I've never been to Australia, this would be a great excuse to go!'
But no, I only want truly involuntary patients, and I'm limiting it to the US, but thank you for asking.

Thank you everyone who contributed!

robert said...

Six months ago, while seeing my VA psychologist, I disclosed that I was having trouble with thoughts about harming coworkers and myself. I never stated intent, I had no plan, and I had no means. I just wanted to talk about. Still, I was admitted for a 72 hour hold. I also happen to work at this VA hospital. Because of duty-to-warn laws, the mental health provider contacted the people I had mentioned in the session, people who also are co-workers at the same hospital.

While nowhere near as bad as some of the places I've heard about, the ward is still a dreary, drab and depressing place. I couldn't sleep. They abruptly changed my meds (then changed them back upon discharge).
I wasn't held in leg irons or placed in handcuffs, but I did lose my freedom, my privacy, my job, and my desire to continue treatment.

I was discharged after the 72 hour hold expired. The attending physician made it very clear that she didn't believe I had ever been a threat. Upon discharge, I was investigated by the agency for possible criminal misconduct, which they found none. Even though the investigator stated that he believed 'this whole thing was overblown', I was still terminated, for 'expressing inappropriate thoughts'.

I do not feel grateful or thankful to the psychologist or to the admitting physician who I believe was hasty and glib in his 'assessment' as to whether I was actually a threat. Quite the contrary, even though I need help, and I know it, I don't see the point in resuming treatment. I have lost trust in the therapeutic process, because for me, it has essentially ruined my life. What's the point in going to treatment if I don't trust the process, if I don't feel I can speak with candor about what's really bothering me?

For me, the involuntary hold process has been very damaging, and has provided no discernible benefit. I didn't need a 'safe' environment, I needed a professional I could trust, one who would have more appropriately considered whether I really was a threat. Nobody in this process except for the admitting has ever considered me a threat. I'm now unemployed, and probably unemployable. I gained nothing.

Just to be clear, I'm not saying I believe this is all that common, just that in my case, it was inappropriate and has created incalculable damage.

Dinah - I applaud your desire to write about this, and look forward to reading whatever may come from this. I'm happy to provide more information if you want, but I suspect you have plenty already.

Regards,

robert said...

Six months ago, while seeing my VA psychologist, I disclosed that I was having trouble with thoughts about harming coworkers and myself. I never stated intent, I had no plan, and I had no means. I just wanted to talk about. Still, I was admitted for a 72 hour hold. I also happen to work at this VA hospital. Because of duty-to-warn laws, the mental health provider contacted the people I had mentioned in the session, people who also are co-workers at the same hospital.

While nowhere near as bad as some of the places I've heard about, the ward is still a dreary, drab and depressing place. I couldn't sleep. They abruptly changed my meds (then changed them back upon discharge).
I wasn't held in leg irons or placed in handcuffs, but I did lose my freedom, my privacy, my job, and my desire to continue treatment.

I was discharged after the 72 hour hold expired. The attending physician made it very clear that she didn't believe I had ever been a threat. Upon discharge, I was investigated by the agency for possible criminal misconduct, which they found none. Even though the investigator stated that he believed 'this whole thing was overblown', I was still terminated, for 'expressing inappropriate thoughts'.

I do not feel grateful or thankful to the psychologist or to the admitting physician who I believe was hasty and glib in his 'assessment' as to whether I was actually a threat. Quite the contrary, even though I need help, and I know it, I don't see the point in resuming treatment. I have lost trust in the therapeutic process, because for me, it has essentially ruined my life. What's the point in going to treatment if I don't trust the process, if I don't feel I can speak with candor about what's really bothering me?

For me, the involuntary hold process has been very damaging, and has provided no discernible benefit. I didn't need a 'safe' environment, I needed a professional I could trust, one who would have more appropriately considered whether I really was a threat. Nobody in this process except for the admitting has ever considered me a threat. I'm now unemployed, and probably unemployable. I gained nothing.

Just to be clear, I'm not saying I believe this is all that common, just that in my case, it was inappropriate and has created incalculable damage.

Dinah - I applaud your desire to write about this, and look forward to reading whatever may come from this. I'm happy to provide more information if you want, but I suspect you have plenty already.

Regards,

Dinah said...

Thanks Robert. I hope something good comes of the work. Please shoot me an email at shrinkrapblog at gmail dot com when you have a chance.

Dinah said...

Thank you, all. Now I'm looking for stories about how involuntary hospitalization proved to be helpful. If you have such stories, please post them here:

http://www.psychiatrist-blog.blogspot.com/2013/08/involuntary-psychiatric-hospitalization.html

Anonymous said...

I was being threatened by someone (long story). I reached out to my sister for help. She talked me into going to the emergency room so that they could "give me something to calm down". Before I knew it I was being sent to another hospital for "observation" whether I liked it or not. They put me in a ward for people with "chronic schizophrenia" even though I had no medical history of schizophrenia or any other mental illness. It was completely traumatizing. I didn't sleep for days because of the people I was around. They gave me medication with terrible side effects. They were most concerned with collecting data (i.e. how much I slept, ate, blood pressure, etc.). They released me when my insurance ran out. My sister was happy about the whole thing. Did I mention that she has been feuding with me for over 10 years and likes to brag about getting revenge on people? It was a huge mistake trusting her.