It’s a Family Affair

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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. 

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.