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Involuntary Psychiatric Hospitalization

A life saving yet often aversive intervention

Involuntary Psychiatric Hospitalization: A life saving yet often aversive intervention

Lloyd I. Sederer, MD

The wake of too long a string of dark, violent and murderous attacks across our country has reignited debate regarding the use of involuntary hospitalization (and treatment) for people with serious mental illness. The media stories have usually focused on violence to others, though they often omit the more than 38,000 people annually who commit suicide—almost always suffering from an active mental disorder that leaves them hopeless, psychically agonized and too alone.

Some argue that people with mental illness are far more likely to be victims of crime than perpetrators. Others assert that missed opportunities to hospitalize and treat those who appear to be a growing public menace contribute to the tragic outcomes that can ensue. Still others claim that the loss of psychiatric hospital beds over the decades has contributed to today’s unsafe communities, and call for more money to restore what has been lost.

As these questions are debated, families, communities and clinicians experience every day the tragedy of ineffectively identified and treated mental illness. The greatest tragedies typically come at the end of a downward spiral that almost always is heralded by months of psychiatric deterioration and distancing from services and supports that could reverse an outcome that no one wants. Situations that end up in crisis predictably evoke responses aimed to ensure community safety, which include commitment and police intervention; when that happens a ‘nobody wins’ situation generally ensues.

When I have personally committed a patient of mine for what I believed to be a life threatening mental illness the result was that short term safety was achieved—but at an unwelcome price. I recall three people in particular—each one subsequently fired me as their doctor. Each time, moreover, my patient was traumatized by the experience of being taken forcibly, restrained and brought by ambulance or police cruiser to a psychiatric hospital where he or she was involuntarily admitted. In one instance, my patient later stalked me and was a threat to my safety. Here are their stories.

Orville Smith (name falsified) was 20 and had been arrested for going on a shooting spree in the middle of the night in a northern New England town. No one was around and his bullets were aimed at a Church steeple. The sheriff brought him to the rural hospital where I was on-call because of how bizarre his language and behavior appeared. I examined him in the company of the law officers. He was paranoid, psychotic (out of touch with reality) and dangerous since he had no insight into his behavior, nor any evident capacity to control it. Where I worked had no locked inpatient unit (this was in a small town a long time ago) so I arranged for this patient to be transported by a sheriff’s cruiser to the state psychiatric hospital a few hours away.

He spent several months hospitalized. I was not told about his discharge but he was discovered, without a weapon, casing my home. Again I examined him and he was psychotic; I arranged for him to return to the state hospital where he remained another few months. This time I was notified and I arranged to speak with him, accompanied by the sheriff. For reasons perhaps related to his clinical improvement, though he remained furious with me, he understood that his behavior would not be tolerated and he said he would leave me alone. I learned from the staff at the state hospital that he did not stay in treatment and I don’t know what came of him. I never quite felt safe until I moved out of that state.

George Packard (name falsified), a man in his 50’s, was my patient when I practiced at a community general hospital. He suffered from recurrent depressions that could be severe and accompanied by psychotic thinking; in the past, he had made a grave suicide attempt in which he cut his throat, surviving only by having been accidentally discovered. I had worked with him for over a year when he lost a part time job that meant a great deal to him. He failed to make his next appointment. I called him. He answered but hung up. I called again and got no answer. I left a message offering to meet in the next day or two but still got no call back. My mind imagined his next suicide attempt, thinking this one could be fatal. I went to the local police station, identified myself, pulled out the legal commitment paper I had completed, and asked the police to accompany me to his apartment. We knocked on the door. At first, he refused to open it. But the police were ready to enter using keys from the landlord and he relented. The apartment was a shambles; he looked horrible—unkempt, dehydrated, agitated and enraged that I had shown up, no less with the police. An ambulance brought him to a psychiatric hospital where he was involuntarily committed on the papers I had prepared.

Through his doctor at the hospital, I asked to visit. He did not want to see me. He told me, through this doctor, that I was fired, that he never wanted to see me again. But his depression improved and he moved on to another clinic and was alive a year later when I ran into his caregivers at a professional meeting. I never saw him again.

Susan Brooke (name falsified) was 45 when I saw her for evaluation. She was an accomplished professional who had the diagnosis of bipolar disorder. But her condition was unstable and treatment was not containing her mood swings, which impaired her ability to work and were highly disruptive at home and to her marriage. Her husband attended the evaluation and offered to be helpful in any ways he could. I arranged to see her again in a week but a few days later I received a call from her husband and sister saying she had become very ill: she had destroyed property in her home and was menacing to her family. I wrote out the necessary paperwork and by phone arranged for the town police in a semirural area outside a large city to meet me at her home, where family members would be waiting.

I arrived about 9:00 at night. Her husband and sister were there, as were the police. We huddled in the lights of parked cars. I knocked at the door to enter but the patient was screaming and threatening to me. I called for an ambulance and arranged for her admission to a private psychiatric hospital in the area. When the police went to the door she quieted considerably and went peaceably, but in restraints, with the ambulance personnel to the hospital where she was involuntarily admitted. A few days later her husband called me to thank me for my intervention and to say that his wife was doing better. He added that she never wanted to see me again.

Readers should know that I have treated a great many patients, many under my direct care and far more in the various clinical services I have overseen over decades of clinical practice. Three cases like this may seem like a lot (and there were others), but not if a doctor works with very ill patients and is disposed to being active and intervening when safety is at stake.

I am sure there are countless other stories like this. They are unsettling because there is no good answer when a person becomes potentially dangerous—to self or others—the condition legally needed to employ involuntary commitment. An intervention may be necessary but it may not be helpful—for more than the moment. People who are subject to loss of liberty, to the deeply unsettling experience of having the police intervene, of being transported in restraints, and of being put behind a locked hospital door never forget the experience. Some come to terms with it and a few even come to understand (even if they don’t forgive). But this is a traumatic experience and a normal response to it is to not want to put yourself back into an environment, like a mental health clinic or hospital, where that could happen again.

Would I do what I did again should circumstances reach crisis and life threatening proportions? I don’t know what other responsible thing there would be to do. Thus, good answers seem to lie with solutions that avoid the use of coercion and loss of liberty, whenever possible. These are solutions, I believe, that require that mental health interventions be made more humane while we also work to reengineer services to intervene earlier and more effectively in the course of a person’s illness.

We owe people with mental illness what has been called ‘patient centered’ care—not as a slogan but as a standard of practice. What this would look like would include open access to an appointment where, instead of waiting for days or weeks, people in crisis could come to a clinic the same day they want to be seen. There would be the ability for clinicians to meet with patients (and families) outside the four walls of a clinic, in settings more natural and less stigmatizing (this is particularly necessary for younger people). Special attention needs to be paid to what is needed to keep youth in school and adults in work, or on a path to work. Shared decision-making where patients are made partners in their care is an important way to engage and retain people in treatment. The use of medications needs to be highly judicious and attentive to managing the side effects that frequently discourage patients from taking them. We need to enlist the help of families who can serve as an early warning system for problems in their loved ones. Most often (though not always) families are the most important and enduring source of support for a person with a medical illness, including mental disorders (Opening Closed Doors: What I describe here is not new but it calls for changes that will take leadership and relentless persistence since change is hard, even when clearly needed.

We also owe people with mental illness and our communities an alternative to the demoralizing experience of a condition advancing to a severe, persistent and even dangerous state that makes involuntary commitment almost inescapable. This requires giving people with mental illness, their families and communities, and our mental health system the means to identify problems early, typically in adolescence, and new methods of engaging people with illness in effective treatments that also support their families. Some ways to change are described above and others that have seen success in other countries are being introduced in this country (Lieberman, Dixon, Goldman, Early Detection and Intervention in Schizophrenia: A New Therapeutic Model; JAMA August 21, 2013 Volume 310, Number 7). This is the kind of overhaul the mental health system needs. This is the kind of overhaul that could provide more effective care with dignity and probably save lives and money.

Humane, patient centered services and early intervention are paths out of coercion. Imagine their impact on people with mental illness, their families and communities, and doctors who may not need to find themselves in situations such as I have described. Achieving these goals would be something to be proud of.

Dr. Sederer is a psychiatrist and public health doctor. The views expressed here are entirely his own. The Family Guide to Mental Health Care (Foreword by Glenn Close), is Dr. Sederer’s most recent book. He takes no support from any pharmaceutical or device company.