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. 

Court Is In Session

iStock_000001647199_SmallGood morning.

I’ve had family members call me before and ask about how to handle a pretty common situation. Their daughter or mother or husband have stopped taking their psychiatric medication, or they are drinking heavily again, or they are responding to voices or other hallucinations to the detriment of their day to day functioning. What to do? How to help?

If the family member or other person so afflicted is willing and able to go voluntarily to their local physician, counselor or mental health system, that’s a good start. Oftentimes seeing someone, ironing out any issues with adherence to a pre-existing treatment plan or getting new prescriptions written rights the ship and nothing more is needed. That is the best case scenario.

If the person gets to the facility and a clinician feels that they are not able to help on an outpatient basis, they might recommend that family take the next step and proceed to the local emergency department for further evaluation. Now, if the patient is willing to do this, no problem. If not, mental health center clinicians or other providers have the option to fill out what is usually known as Part I of a commitment form, authorizing the involuntary transport of the person to the ED. There, the ED physician and possibly a psychiatrist or telepsychiatrist gets involved and the evaluation moves forward.

Another way this can happen is that the family or other concerned person may go to the local probate court and petition for an involuntary pickup order that will force the person to be transported to the ED for the evaluation. When faced with this possibility while working in the clinics, I would almost always want the family members themselves to do this, versus someone from the mental health center, as the family usually had a much more intimate knowledge of how the patient was functioning and if an involuntary admission was likely to be needed. Oddly, even if they were worried sick about their loved ones or in some cases even being abused by them, family members would be hesitant about doing this, fearing the wrath of the detained patient or having extreme feelings of guilt about “having him put away”. With gentle encouragement, they would usually go to the court and proceed.

South Carolina utilizes two models for civil commitment, a police powers model and a parens patriae model. Both require a commitment hearing in a probate court in the county where the person is located. The police powers model allows for immediate detention, as I referred to above.

Under the police powers model, a probate judge, after receiving an affidavit from a family member or another party concerned about a person’s welfare, may issue a detention order that allows police to pick up the alleged mentally ill person and take him to a local mental health center or emergency room for evaluation, as I outlined above. After evaluation, the person may be immediately detained in a psychiatric hospital if the certain criteria are met.

There is a written affidavit sworn by a witness (the family member alluded to above is ideal in my opinion) stating their concern that the person is mentally ill and that because of that, the person is likely to cause serious harm to himself or others if not immediately hospitalized; the specific type of serious harm thought probable (what is the person likely to do if not treated); and the factual basis for this belief (what has the petitioner actually seen the person do, such as taking out a gun, loading it, and making a threat to shoot himself).

Also, certification by a licensed physician may come into play here. This written statement by the doctor must say that the person is mentally ill and that because of his mental illness, he is likely to harm himself through neglect, inability to care for himself, personal injury, or otherwise, or to harm others if not immediately hospitalized. (We take care of our own, so to speak, if they cannot take good care of themselves) The certification must contain the grounds for the opinion.

Read more about this process in the state of South Carolina, and how probate court judges play a vital role in it, here.

So, we’ve looked at several ways that a person may end up in the local emergency department. I see patients in two dozen EDs around the state. Some are very good at handling mental health emergencies and evaluations. Some are not so good.

Next, we’ll  take a look inside, pulling back the curtain of the ED bay, opening the door of the holding room and feeling just what it is like to be held against one’s will in a hustling, bustling hospital ED.

I think it might surprise you.