It’s a Family Affair


I’m disturbed by a trend that I’ve seen in emergency departments across the state of South Carolina over the last four years that I’ve been doing telepsychiatry. It seems that many families, instead of talking amongst themselves when trouble arises and trying to work problems out, resort to going to the local probate court to take out an order of detention to have the offending family member committed for a mental health evaluation.

In South Carolina, as in many other states in the United States, a system exists whereby a person who is experiencing severe mental illness may be picked up by local authorities, taken to the nearest receiving facility, usually a hospital ED, and evaluated by a physician. If the person is found to be an imminent danger to themselves or to someone else, or if they are so mentally incapacitated that they are not able to make good decisions concerning their own self care, then they can be held for a specific time in the facility for observation or treatment as indicated. This is usually for seventy two hours. Now, if a psychiatrist like myself is called in to see them, either in person or on camera, and we decide after further evaluation that these dangerous conditions do exist and the person needs further mental health care, then we can either order (if on site and privileged at that facility) or recommend (if acting in a consulting capacity as I do in doing telepsychiatry) inpatient admission for further treatment.

Obviously, this system is in place to insure that people with severe mental illnesses such as bipolar disorder and schizophrenia get the care they need when an exacerbation occurs. It is also in place to make sure that people who are not truly mentally ill are not incarcerated against their will and held for no good medical reason or on a whim. You may have heard about families sending someone off to a psychiatric hospital (variously known as being sent “up the road” or to the “crazy house” or others) simply because they had an argument or felt they needed to be punished. This happened in my home state of Georgia when folks were sent to Milledgeville, the site of a huge mental health hospital that was in its heyday a small city unto itself, with tens of thousands of patients in residence. It also happened in my adopted home state of South Carolina, where its citizens would be sent to “Bull Street”, a notorious and fearful address in the heart of Columbia where you might be sent and kept for months if not years to walk the halcyon grounds and to be kept sedated and tranquilized after your family had “got shed of you for good”.

We think of those days as the Snake Pit times of mental health treatment, when people could be sent off by relatives who hated them or spouses who were jealous of them, when they were sedated and shackled and kept against their will for years, sometimes literally until they died in the facilities they had been sent to. I still hear stories to this day from patients who have a relative who died living at Bull Street. We like to think that these days are gone, that we have passed this era of inappropriate commitment and unnecessary treatment forever. Have we?

I have seen families send “patients” to the emergency departments in South Carolina and have heard too many stories about arguments between spouses and between parents and children that have lead to someone being labelled as “crazy”. When evaluated, of course, they are no more crazy that anyone else walking the street, and they certainly do not need to be committed against their will to a mental health facility for “treatment”. When I sometimes tell an angry and frightened parent that their acting-out latency age child does not need psychiatric admission but instead needs a more firm hand and more structured discipline from a loving adult who clearly shows who is in charge in the home, they look at me like I’m the crazy one. When I intimate that the family needs to step up and take charge in the care of an elderly adult who is showing the signs of deterioration related to an established diagnosis of dementia, they think I have lost my mind. Many modern families, I am very sorry to say, seem to be willing to lock someone up and throw away the key because it is the easiest, most expedient thing to do. The hard work of talking things through, problem solving, making amends, and living life with all of its trials and tribulations is foreign to them. It bothers me tremendously that someone would come in wanting to wield “the big stick” and in essence take away their right to self determination by exercising my power to incarcerate and “treat” when it is clearly not appropriate to do so.

In this age of what I have previously called “fast food medicine”, patients and families seem to be looking for the fastest, easiest way out of scrapes, arguments and episodes of illness. In mental health, some illnesses bring with them life sentences. Not the kind of sentence that means you spend the rest of your life walking the grounds behind a ten foot ivy covered wall, shuffling and drooling after your last Thorazine injection, but the kind of life sentence that requires supervision from caring professionals, attention by loving family members, and the understanding of society at large that the normal rough and tumble problems of life in the twenty first century do not always portend mental instability and illness.


This post was previously published on another of my blog sites in modified form two years ago. I hold that we have not made much substantial progress since then. 

10 thoughts on “It’s a Family Affair

  1. Sadly interesting.
    This reminds me the story of this Kennedy girl who was a little bit too “life-enjoying” for her family’s standards and was lobotomized. 😦


  2. Thank you. i lived in one state where the family wanted me to confirm that the well to-do grandpa needed mental help-lock up, because he’d take a drive after lunch and then park under his pecan tree and nap in his car by his cat fish pond. I told them that my grandpa took naps under Cottonwood trees, and he was as sharp as a whip. We moved to the Texas hill country where the rich grandpa parked his car under a giant oak.

    I asked the Texans if grandpa was okay. Of course he was, as he worked hard from the time he was about 8, he deserved some rest and respect. I told them about the other grandpa, and they said it was obvious the family wanted his money and property. I think the Texans were right in many ways.


  3. Having just navigated the mental health system in NYS (and having blogged about it even though my blog is more related to cancer advocacy), I find myself nodding at every one of your words. The flip side of this problem is what happens if the ED psychiatrist determines an involuntary hold is necessary. In NYS, 2 professionals must agree and the family member was asked to sign papers, too. The following morning, the doctor on the floor in the psychiatric unit was so dismissive and completely disregarded everything that was told to us when the admission was taking place. It was bad. You are so right….. The system is archaic, draconian. Too many are willing to throw up their arms in despair and give their problems to another. And on the other side of the coin, we have the caregivers who want to be sure they are partners, advocating for their loved ones with the hope that proper care might afford the patient their best shot at managing serious illnesses. The goal (in the case in which I am personally involved) is to see that the patient is able to live to what is determined to be their fullest capable potential. This requires much support and a coordinated team approach. And money. I applaud you for another beautifully written post and for shining a light into an area of health care that is so misunderstood and so stigmatized. You are a pioneer and a champion for those who need to be helped, not just medicated and shut up….

    Thank you barely scratches the surface….



  4. This reminds me of my years in inpatient child psych, when parents or teachers wanted kids hospitalized so we could “fix them” but weren’t willing to make changes in how the household ran or the type of attention and discipline used for teaching appropriate behavior. How I wish that I understood how and why this happens and what we could do about it…


  5. AnneMarie,

    I don’t know what to say.

    Keep up the advocacy and the good work that you are doing. It’s all important.

    Thanks for reading and taking the time to comment in such a personal way. I am very honored.



  6. What is the adequacy of your outpatient referral sources for families? Discipline and general parenting are not easy and for many are incredibly difficult. I agree that these problems are not appropriate for the emergency department. But they may be very appropriate for outpatient mental health services, whether the focus is on improving parenting, improving parent-child communication, and/or addressing individual mental health problems for the child.

    Services in my area are quite limited even though I live in a major city, even for families with good insurance. That is one of the reasons why families are willing to wait 4 months for an appointment to see me.


  7. Elizabeth,

    Services are severely limited in this area as well. If a patient or family need the services of a child psychiatrist, this is especially hard to come by. Many of us who were trained in general psychiatry are now child psychiatrists by default.



  8. Psychiatry is not the only discipline that provides mental health services and that is part of my larger point. Even so, there is a shortage of qualified and effect mental health practitioners for children and youth all around.

    I figured that services in your area are even more limited as that is my understanding of service availability and utlilization.

    I am not trying to criticize you or any other adult psychiatrist who is charged with serving children and adolescents without formal training in that area. Nor would I criticize any child/adolescent psychiatrist for not having expertise in parent training because that is more of the arena of child/adolescent psychology.

    And I also agree that an emergency department is not an appropriate venue for these services.

    My larger points are (1) parenting is really hard for a lot of people for many reasons. (2) it is understandable that families get desperate and use services inappropriately, and (3) where are they supposed to go for services?

    I am not asking you to fill these needs. But the fact remains that the needs remain. 20% of children and adolescents with diagnosable mental disorders receive ANY KIND of services.

    I used to work with rural families, many of whom did not have insurance and many of whom had restricted means. In private practice, I work with a different population; the families have insurance. (But my friend Nancy would point out, “Elizabeth is the only psychologist in Seattle who does testing who takes insurance!” This is not entirely, but mostly true. It is a different topic.) In any event, even families with means and knowledge to find appropriate services often cannot find them. I actually met my friend, Nancy because my practice had filled and I’d run out of referral options for psychologists who work with parents on discipline issues. I started poking around and making calls to people who looked well trained.

    It has to change and like many complex issues, the solution is not simple.


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