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.