Are You Ready To Commit?

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One of the hardest things I have to do as a psychiatrist is to commit a patient for involuntary treatment.

As I have told you in many previous posts over the years, I see people who have anxiety attacks and depression and physical complaints and problems sleeping and all manner of relatively common, relatively easily assessed and addressed issues. That is the bread and butter, stock-in-trade life of the psychiatrist, just as treating diabetes and hypertension is old hat for an internist.

Sometimes my clinic work, and especially my emergency department work, require me to see someone, assess dangerousness or inability to care for self, or inability to make good decisions involving one’s own care, and then take a drastic step. I must decide to take away that person’s right to choose, that person’s freedom to get up and walk out of the office or the ED. I must make that decision because not making it might literally mean putting the person’s life in jeopardy.

At first glance, this parens patriae is a huge amount of power over other people, the ability to call the shots and hold you against your will just because I think that needs to be done. Obviously there is room for abuse here, just as there is the possibility of a vindictive family member going down to the local probate court and signing an affidavit stating that someone needs to be committed just because they are having a family dispute over money or land and one member is angry at the other. Not the best use of the system, but it happens.

I take the responsibility very, very seriously. If after listening to you and gathering corroborative information I find that there is reason to believe that you might harm yourself or someone else, or that you are just not able to safely take care of yourself for any number of reasons, I will move to commit you to a secure facility against your will.

“You can’t do that! I’m not going to go. I’m going to walk out of here and you can’t stop me!” says the now frightened patient, who was just threatening to blow his head off with a twelve gauge shotgun.

Well, yes, I can do that, and no, you’re not going anywhere, and yes, I can stop you.

This is a drastic step and one that is obviously taken much more often in the emergency department setting than in the community mental health center.

I have seen patients go from being in my face and hostile and threatening to kill me on the spot to blubbering wrecks when they find that I am done talking and ready to act to protect myself (and them) from their rage.

I have seen mothers weeping uncontrollably as I have recommended involuntary admission for a child whose constant cutting and drug abuse is out of their control.

I have seen alcoholics just this side of death try to argue with me about how they are no longer drunk, no longer going to shoot themselves, and no longer going to beat their wives if I’ll just let this one slide and send them home.

This decision to hold, to commit, to involuntarily detain is a very hard one indeed. I have to balance your right to freedom and to make our own decisions against the countless times I have seen others just like you, with the same stories, come to me and beg to be sent home too.

I have committed some of them, hearing them curse me as they were placed in the back of a police cruiser for transport, gone home and rested well that night, knowing that they would get the assessment and treament they needed in a safe, secure place.

I have let some folks go, only to find out that the next day or the next week or the next year they overdosed or shot themselves in the head or hanged themselves. Their choice, not mine. Doesn’t matter. It kills a little part of me anyway, every time it happens.

Risk assessment is a tedious, hard, nerve-wracking, necessary job.

Recommending the treatment that I believe you really need, in spite of all your lamentations and bargaining and pleading for me to do otherwise, sometimes feels like I’m sending my own mother to jail.

17 thoughts on “Are You Ready To Commit?

  1. My daughter and I watched the movie, Harvey this evening, starring Jimmie Stewart. The criteria for committment consisted of having a pulse-okay, I exaggerate. It prompted a good conversation about what it means to be a threat to oneself or others. Believing that your best friend is a 6′ 3.5 inch tall rabbit is not enough!

  2. Great movie! I love Stewart and never would have committed him, knowing that his real name was Mr. Smith, that he was going to Washington one day, and that he would one day tell me, “It’s a Wonderful Life!”

  3. P.S. Watching “It’s a Wonderful Life” is an annual holiday tradition for our family. I start crying by the first 30 seconds of the film when people are praying for George, without fail.

  4. Your last few paragraphs seem to indicate you commit for your own piece of mind, not your patients’. You are trying to prevent a little piece of you from dying, not your patient. Suicide rates are very high for folks after discharge from involuntary commitments, too, so involuntary commitments may not be as helpful/safe as you think. What they do surely do for many people, is create a very real traumatic experience and stop them from talking about their distress with mental health professionals in the future, which both may lead to more distress/death.

  5. Yippee! And you didn’t even know that I learned to do psychotherapy with a southern accent. (Yes, I am a native Northwesterner but I had a number of Southern clinical supervisors at UNC and U.F.) I didn’t realize it until I was a post-doc and some grad students asked to videotape me doing a mock parent interview as a training resource.

  6. Martin,

    No, that is not at all what I meant to convey.

    Everything I try to do as a doctor is with the patient in mind. That’s my duty as a professional. I am not actively trying to prevent “a little piece of me from dying”. I know that this will inevitably happen in the course of being a doctor, but to avoid it is not what drives my decision making or my therapeutic interventions.

    Involuntary commitments are certainly not perfect, and your point about suicides after the fact is well taken. A few days to weeks after discharge from any inpatient facility is always a high risk time for self harm in those prone to this.

    Lastly, the fact that pickup orders, probate court orders, commitment papers, police cars, handcuffs and all the other pieces of the system are traumatic goes without saying. I would implore you, as I do all my patients and family members who are distressed by this state of affairs, to advocate, actively and loudly, with local, state and federal officials to change the laws governing our current process.

    Greg

  7. It’s always difficult to discuss involuntary psychiatric admissions; there are so many issues involved. The first and foremost is protection: sometimes it is necessary to protect a person from herself or himself, or to protect that person from other people (because they are vulnerable due to inability to take care of themselves) or to protect other people from this person (because they are liable to hurt someone from within a psychotic state). Is that paternalistic? It most certainly is! Is it a bad thing? Usually not. Can the power to do so be abused? Yes, of course. Is it frequently abused? Not very frequently in the US these days, thank God.

    It is sometimes very easy to decide to admit someone against their expressed will. The decision is based on clinical observation and interview and medical history, all evaluated against the decades of clinical experience of the doctors making the decision. Sometimes the decision is more difficult. When I have been asked for my professional input on such a decision, I have always come down on the side of protection, protection of this person and of those around him or her, if I had doubts.

    The process of being involuntarily detained is horrible. In many states, and it seems that Dr. Smith works in one such, the order is carried out by law enforcement, which is traumatic and humiliating. People are often treated very badly with “one-size-fits-all” policies that have been crafted with worst-case scenarios in mind.

    I am against strip-searching psychiatric patients in emergency departments. I am against taking away their clothes and possessions (except those items that might be used to hurt themselves or others). I am against having them guarded by security guards in lonely, empty rooms for hours or days until a psychiatric bed opens up.

    But if I had to choose between putting my best friend or dearest family member through all that and them hurting themselves or being hurt or hurting someone else while not being able to make sensible decisions, I would do it in heartbeat because I love them and I want them to be safe.

  8. Dear Retired APRN,

    Thank you very much for that comment. I don’t expect that everyone who reads my blog and comments will agree with me (that would be very boring indeed and we would all just give up and go watch a movie if that were the case), but your comments are spot on in my opinion.

    Please see also my comment from yesterday at the Shrink Rap blog:

    http://psychiatrist-blog.blogspot.com/2013/06/shrinky-stuff-around-web.html

    Thanks again for reading and commenting. I hope you come back often!

    Greg

  9. Martin said, “What they do surely do for many people, is create a very real traumatic experience and stop them from talking about their distress with mental health professionals in the future, which both may lead to more distress/death.”
    This has been my experience. I have been seeing mental health providers for years. My last appointment was 5 months ago, and it led to an involuntary 72 hour hold because I disclosed to the psychologist that I had been having thoughts of harming others, even thought I didn’t have the means, the intent or even a plan. Indeed, I was released after the 72 hours was up because I was deemed to not be any threat.
    Nevertheless, under duty-to-warn laws, the provider notified the people she thought were the subject of my thoughts, which, because they are co-workers, led to me losing my job. The unfortunate part of this is that I have given up seeking treatment because I no longer feel I can be honest with the provider, unless I want to risk being re-committed. And since I’m now unemployed, and potentially unemployable, I’m at a much higher risk of “distress/death” (to use Martin’s words), than I ever have been.

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