Posted by: thealienist | July 6, 2011

Involuntary Hospitalization: One Psychiatrist’s View

As I have been reading other psychiatrists’ blogs, I have seen heated discussions about involuntary hospitalization.  Many of these posts have focused on the legal aspects of commitment or have generalized from bad experiences to “all psychiatrists.”  I thought I might take a little time and tell the tale from my perspective.  I have also included some hints for patients wishing to avoid or obtain involuntary hospitalization.

There is little I dislike more than having to involuntarily hospitalize a patient.  I use it literally as the last resort.  I know that my chances of developing a therapeutic relationship with a patient are delayed, and perhaps prevented, by the use of power to compel hospitalization.  In addition, the process involved in involuntary commitment feels overly coercive — a mode in which I am not comfortable.  I do not think that I am the only psychiatrist who feels this way.  I suspect that many, if not most, of my colleagues feel similarly.

If this is true, then why do I involuntarily commit?  Because at times it is necessary.  When I am confronted with a depressed patient who is determined to kill himself or one who is psychotic and behaving in ways that are likely to lead to imminent self-harm or harm to others, I cannot in good conscience simply let them go.  This is true for both legal and moral reasons.

Legally, if I have a patient who is a threat to himself or others and this threat is due to a mental illness, I have a responsibility to act.  Some have objected that psychiatrists are not all that good at predicting who is likely to act on such impulses.  That is true in some cases but not in others.  If I have a patient who has just tried to overdose with a lethal dose of a sufficiently toxic medication under conditions designed to avoid detection and assure death, it does not take a fortune teller to see that this is patient is seriously suicidal.  Certainly this is the easiest case, but it is far from uncommon.  If this action occurs during the course of a mental illness, the patient deserves a chance at adequate treatment and may benefit from involuntary hospitalization.  On the other hand, if their intended or ongoing behavior is not associated with a mental illness, I still may have a need to act, though this may be a legal matter (i.e. a duty to warn).

Morally, I have a duty to my patients.  Those patients for whom I have had to seek involuntary hospitalization have been out of control.  This does not mean out of MY control, out of their spouse’s control, out of their parents’ control, or out of society’s control.  They were out of THEIR control.  They have been impulsive or based their actions on inaccurate or openly false assumptions.  They have not been able to conform their behavior to reasonable requests.  If they are going to make life-or-death decisions, I owe it to them to help them make sure that their decisions are based on an adequate understanding of the situation prompting their decision.   And lest anyone think that this is just self-justification, I have frequently seen patients who are grateful that they were prevented from harming themselves or others and are shocked that they ever could have contemplated such actions.

Still, I hate involuntary hospitalization.  It means that all other means of easing pain and making decisions has failed.  Sometimes they fail because the mental health provider failed.  Sometimes it failed because the patient could not comply with other alternatives.  Regardless, there are no winners, only those who hopefully will not suffer as much as otherwise.

If you have a mental illness and want to avoid involuntary hospitalization, it is pretty easy.  Here are a few simple steps:

1)  Work with your mental health provider.  If there is any less coercive way of assuring your safety and the safety of others, your provider will likely prefer it.

2)  If your provider seems to be concerned about your safety or the safety of others around you but you do not understand why, ask your provider what he is concerned about and why.  Perhaps there was a misunderstanding.  Perhaps he is seeing something that signals danger but that you were not aware of.

3)  Ask your provider what can be done outside of the hospital to monitor your safety and reduce risk.  If your provider is comfortable that your risk of self harm is reduced and that there are measures in place to ensure your safety, he will be less likely to feel forced into involuntary hospitalization.

4)  Ask about the appropriateness of other treatment options.  Sometimes, partial hospitalization or intensive outpatient care can be helpful while retaining more freedom.

5)  These steps will only work if you do them before you cause harm to yourself or others.

If you have a mental illness and WANT involuntary hospitalization, it is also pretty easy.  Just follow these steps:

1)  Pick a fight with the psychiatrist.  Call him names. Say you have a lawyer and you’ll get his license.  This works just as well with psychiatrists as it does with policemen during a traffic stop.

2)  Rather than show the psychiatrist that you can keep yourself and other safe, engage in a philosophical rant about how you have the right to kill yourself if you want to and that the philosophical basis for this right goes back to the Stoics.

3)  Be firm in your refusal to consider why anyone should be worried about you.  If you begin to show insight into how others feel about the need to protect you, the psychiatrist might lose heart and see if he can get you help outside the hospital.

4)  Refuse to comply with any request by the psychiatrist.  Remember, he is testing you.  He wants to let you go and is looking for a good reason to believe that you can look after yourself.  By not playing along or showing any self-control, you might convince him that you cannot be trusted to look out for your own interests.

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Responses

  1. You’re not a “policeman during a traffic stop.”
    You’re a psychiatrist…

    And the items you list (including ‘picking a fight’ with a psychiatrist)
    have nothing to do with an individual’s Constitutional rights and due process of law –

    http://discoverandrecover.wordpress.com/freedom/

    (scroll down to the ‘mental health freedom’ section).

    Last comment on your blog… I don’t need to read any more of your arrogance. Hopefully, you’ll leave the link, so readers can see what their rights are when it comes to your profession… A profession that has circumvented the Constitution for years… spitted on it, until it’s made people sick!

    Duane

    Like

    • Duane,

      You are correct that the listed behaviors are not listed in the Constitution and are not part of “due process.” I don’t know what that has to do with anything. The Constitutional protections and due process of the law are protected by the courts who ultimately rule as to whether the mental health caregiver has made a just decision from their evaluation.

      The behaviors I listed are part of the evaluation. I give patients every possibility to cooperate with me and avoid an unwanted hospitalization. If they cannot control their behavior sufficiently to get what they want, then neither of us get the satisfaction of making a treatment plan that avoids hospitalization. The activities were merely examples of the types of behaviors that show the inability to cooperate with an evaluator (of any type).

      Also, your assertion that my profession “has circumvented the Constitution for years” is not born out by the courts. I’m sure you can find some examples of misbehavior, but psychiatrists operate in close cooperation with the courts, especially with regard to involuntary hospitalization. To assert otherwise shows quite a bit of arrogance on your part (see your accusation of me above).

      Like

    • It’s not just the psychiatrist, it’s the state legislatures and federal courts that ENABLE them, by not only 1) handing individuals over to the mercy of such quacks, removing all constitutional protections from citizens declared “mentally ill,” and
      2) the federal courts, which remove all constitutional RECOURSE from the victims of shrinks who involuntarily commit people at the drop of a hat; essentially they say that the quacks are “private actors” and therefore cannot be held liable for breaching the Constitution.
      Thus, the People are caught in a “shell-game by proxy” by which the state escapes constitutional liability by assigning state power to NON-state entities, which are likewise thereby immune by virtue of BEING non-state entities.
      But this is all ok, because the victims are labeled “crazy.”

      The best alternative, is to NEVER ADMIT to having mental illness, or even subjecting yourself to a diagnosis thereof; once you do, it STICKS, and you’re at the mercy of any quack with a diploma.

      Like

      • Your post does not ring true. In my experience, when people feel that their psychiatric diagnosis is following them around, it is not the diagnosis, it is their behavior, which has not changed. This is why my post focuses on behavior, not diagnosis. Behave well, and you are well.

        Like

  2. You’re not a “policeman at a traffic stop.”….

    This is NOT about whether someone “picks a fight” with their psychiatrist…
    It’s about protecting people’s rights, including those who suffer deeply, and have emotional liability –

    http://discoverandrecover.wordpress.com/freedom/

    (Scroll down to the ‘mental health freedom’ section)

    And leave people alone!

    Duane

    Like

    • Duane,

      Your ability to be offended is remarkable. I have followed many of your posts in other blogs, so I am not optimistic that this will engage you in any productive conversation, but here goes …

      People who have sufficient self control to cooperate with those who have been empowered to make judgements about their behavior (this includes many people in society such as judges, police officers, bosses, psychiatrists, psychologists, etc.) will rarely be hospitalized against their will. Those who are unable to cooperate in their best interests (i.e. those who do not want to be hosptalized but still find the need to argue and antagonize those who are tasked with evaluating them) are instantly at a disadvantage because they do not exercise such self-control. They are more likely to be involuntarily hospitalized.

      Second, you ask me to leave people alone. I do. I don’t go out and chase them down. I don’t go out and drag people into treatment. They come to me. I suggest that leaving them alone (while it might please you — though this isn’t about you) would be inhumane and unethical.

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      • “People who have sufficient self control to cooperate with those who have been empowered to make judgements about their behavior (this includes many people in society such as judges, police officers, bosses, psychiatrists, psychologists, etc.) will rarely be hospitalized against their will.”

        The difference is, judges and police have LAWS that clearly exist to protect the rights of the individual, and are checked by an adversarial system in which the individual is assigned a suitable defense, and presumed innocent until proven guilty beyond a reasonable doubt in an nopen trial by jury of one’s peer, and in n which all constitutional protections are upheld.
        Here, they just get a quack who can pretty much twist anything you say against you, and holds your fate in his blood-stained hands without batting an eyelash, just by calling you “mental and dangerous;” and the judge will usually go by whatever he says.
        It’s a loophole in the Constitution, and you either know it or you’re a complete idiot.

        Like

  3. Last comment on your blog.
    I haven’t the time for your arrogance!

    Duane

    Like

  4. Actually, the best way to get committed (ie get a scarce hospital bed) is to detail an extensive, well thought out plan of action with which you intend to kill yourself and indicate that many steps in the plan have already been taken. For example, you could say, “I’ve been doctor surfing for precriptions for sleeping pills. If they write a prescription for 4, I easily change it to 40. I’ve been to about a half-dozen doctors and accumulated hundreds of sleeping pills. I’ve also read in books on suicide how to make overdosing even more effective and have taken steps towards that as well. This sort of thingwill get you a bed, guaranteed.

    Like

    • Anonymous,

      Certainly, that would be a great way to lay claim to the bed. However, to seal the deal, be careful that you are not too cooperative and show too much ability to benefit from outpatient care, otherwise the doc might still find a way to treat you voluntarily.

      Thanks for the post.

      Like

      • “Certainly, that would be a great way to lay claim to the bed. However, to seal the deal, be careful that you are not too cooperative and show too much ability to benefit from outpatient care”

        Yep, if you don’t dance like a monkey on a string, and jump through hoops and wag your tail like you’re told, then it’s the padded-cell hotel for you.

        Like

      • Learning how to deal with people effectively is not”dancing like a monkey on a string.” It is knowing how to handle interpersonal interactions and make sure that your interests are heard. People who are flexible in their interactions with others and can cooperate rather than fight are more likely to be seen as able to cope successfully in life.

        Like

    • “Actually, the best way to get committed (ie get a scarce hospital bed) is to detail an extensive, well thought out plan of action with which you intend to kill yourself and indicate that many steps in the plan have already been taken.”

      No. All you have to do is say that you’re having suicidal thoughts; and when they ask how you’d do it, just give an answer, like “I don’t know, I feel like I want to hang myself or something.”
      CLANG! You’re as committed as they want you to be.

      While we’re continually told to seek medical treatment if we have suicidal thoughts, we are NOT told that this is the dumbest thing youc an do if you want to keep your freedom, or your safety from being subjected to “treatment” which can include anything from coerced medication to frontal lobotomy, restraints etc. Basically you have NO rights.

      Like

      • I don’t know of anywhere where simple suicidal thoughts are sufficient for involuntary hospitalization. It usually requires suicidal thoughts, a plan with means to carry out the plan, and some reason to believe that the plan will be carried out (or a level of impulsivity that indicates dangerousness).

        I also wonder about your knowledge of psychiatric care. Frontal lobotomy? Really? Inclusion of that makes your posts sound a little too much like propaganda.

        Like

  5. Would you hospitalize Rob for not doing what you asked? That’s your clue to his dangerousness, that he doesn’t agree with you?

    Like

    • Good question. Let’s set up a little backstory…

      If Rob was brought to see me against his will due to behavior that endangered himself or others, I would give him every opportunity to explain his behavior and come up with a way to deal with it. If he were unable to cooperate with me to find a less restrictive way, then yes, I would be forced to hospitalize him.

      If Rob was brought to see me against his will due to behavior that endangered himself or others, and he worked with me to explain the behavior in a non-threatening way or to find a less restrictive way of dealing with the behaviors, then I would not hospitalize him.

      If Rob came to me voluntarily and expressed thoughts and wishes that would prove dangerous to himself or others, then we would hopefully be able to continue to work together to find an appropriate help for him that we could both agree on, whether it was hospitalization or outpatient treatment.

      If Rob was behaving dangerously but nobody noticed or cared and he did not see the need to seek treatment, then we would never meet. So no, in that case he would not get hospitalized.

      The long and the short of it is that if Rob wanted to not be hospitalized and he was able to accurately perceive his situation and control his actions, he would not get hospitalized against his will. If he is not perceiving reality correctly, so that he does not see the need for cooperation, or if he is unable to cooperate even though he sees the need for it, he will likely be hospitalized.

      (Sorry Rob that you were the subject of these speculations. Of course, this has nothing to do with you since I don’t know you except from you posts and have no reason to expect that any of the above would apply to you in any way.)

      Like

      • Translation: “I don’t play God. I AM God.”

        Like

      • It seems you have grossly misread my post. The purpose of the post was to show how patients can take responsibility for their mental health care and not leave it solely in the hands of another. I’m sorry you missed this point.

        Like

  6. I have been involuntarily committed once, about 7 years ago. I hated the experience and found it hard to forgive my therapist. My current opinion is that sometimes some people need help they don’t want. I have to note that the one thing I would never do if I was truly suicidal is admit it to a therapist or psychiatrist. Truth can’t survive powerlessness. If I thought the only power I had left was the power to take my own life then I wouldn’t say boo to the people who could stand in my way. I think people who pick fights with their psychiatrist are looking for help they can disavow.

    Like

    • Russell,

      Thank you for your story. I’m sure that there are many out there who have one like it.

      From my point of view, your story has at least one very important point. Involuntary hospitalization often is a lose-lose situation with regard to the therapeutic relationship. This is the main reason that I dislike it so much. This is also the reason that I try so hard to engage patients in their treatment. It helps avoid the powerlessness that one feels when things are so out of control.

      Your post also makes a good point about the many people who wind up killing themselves without telling anyone about it or seeking help. It seems tragic to me that people choose to take their lives in this way, but it happens all too frequently.

      Thanks again for your post. I’m sorry you had to go through an involuntary hospitalization, but I’m glad you are around to make this post. I hope you are currently living a full and contented life.

      Like

  7. I have been involuntarily institutionalized once after an attempt on my life. I have been working, or have worked, all the other options (CBT, ECT, Self Help Workbooks, medications, etc.) I now find myslef back in a very bad place and have thoughts or self harm or hurting others, but more of the former. I am, I believe, a rational thinker and WANT to adhere to social norms, but I can’t find a reason. I have been doing research today on a new plan and stumbled upon your blog thread unintentionally. I am going to see my shrink today, and I do NOT intend on being institutionalized again. At the same time, if I am not honest regarding my level of depression and my thoughts, how can I rationally expect him to adjust medications appropriately? I feel much more ‘well armed’ with your article, and will probably wing it this time, watching my words carefully. I’ll see what happens and repost the results. maybe you’ll have an idea or can point me towards an appropirate reference. Also, I think maybe Duane should come with me today.

    Like

    • Pat,

      I’m sorry that you are having such problems and are facing the frustration of feeling “back in a very bad place.” If one of my patients were in this situation, I would hope that they would be honest with me about what is happening to them and what (if any) hopes or goals they have for their future. I hope that you can show both your problem and your ability to consider solutions to your doc. If you can, I think that there would be little or no reason to hospitalize involuntarily. Best of luck at your visit. I hope your doc listens and has some good ideas on how you can get control of this problem.

      Let us know what happens (if you like).

      Like

  8. If you can argue for involuntary admission, you should first be subjected to it yourself, otherwise you are in no position to subject others.

    “I cannot in good conscience simply let them go.”

    Ah, yes, the conscience of the king– i.e. the unchecked authority to dictate the fates of others.
    The issue is, you should not HAVE the authority to do otherwise, beyond the power of a simple citizens’ arrest. Only the state has that authority, under the Constitution; and the Constitution likewise does NOT give states the liberty to assign state powers to non-state entities in order to dictate such matters at will.
    And ironically, despite the state’s doing so, such non-state entities (i.e. doctors and hospitals) are then allowed to duck responsibility to Constitutional protections, limiting victims of such “private actors” to state remedies– i.e. the state effectively circumvents the Constitution by breaching it.

    The only reason that this atrocity is allowed to persist, is that “mental illness” is a stigma against which society bears both a long-term historical hatred and conceit.

    Factually speaking, 8.3 million Americans each year have suicidal thoughts. However, only 36,000 of such incidents actually result in suicide; i.e. 1 out of 281 cases, or a rate of less than 0.4%. However any quack or shrink with a license, likewise has a license determine which 1 out of 281 people are involuntarily admitted — or, if they wish, COMMITTED– to a mental hospital, without any standard Constitutional protections.

    As mentioned above, such stigmas permit state mental-health codes to specifically target those with mental illness, suspending Constitutional protections for them by allowing a simple medical opinion to claim that they’re “dangerous,” and thus all due process and Constitutional protections go out the window– and a doctor can just as easily diagnose a person with mental illness on the spot, in order to take advantage of this “loophole–” similar to calling someone a “witch” in 17th-century Salem.

    This is not only a dangerous power to entrust with any non-state actor, but again it’s a power which should not be entrusted to non-state actors in the first place– and from which such non-state actors carry special immunity for such constitutional breaches.
    Again, this would never be tolerated against any groups not carrying such a stigma, and is little more than lynching.

    Such policies and practices will simply cause persons to hide such symptoms and related illnesses, and avoid seeking needed treatment in order to avoid the “Cuckoo’s Nest” syndrome of being stripped of all rights and dignity.

    Likewise, federal courts have upheld this “shell-game by proxy” of the state selling out constitutional rights to non-state actors who have no duty to uphold them.

    Like

    • The situation is not like you describe it, in general. Mental health providers can put someone in the hospital against their will, but only for a limited time. If the patient disagrees with the hospitalization, then the case is heard by a court. While it may be that in some places that the courts side with doctors too readily, that has not been the case in the areas I have practiced in. The State retains its constitutional powers in putting limits on restrictions of individual liberty.

      Like

    • I do not believe that this is an accurate description of the current medico legal situation. The law limits the powers and responsibilities of mental health providers and allows patients effective ways to challenge decisions they disagree with.

      Like

  9. The particularly disturbing part of this, however, is this:
    “If you have a mental illness and want to avoid involuntary hospitalization, it is pretty easy. Here are a few simple steps:”

    So if you have a mental illness, you have to TAKE STEPS to avoid being put away and subjected to “treatment” without any standard constitutional protections afforded prisoners.
    Because a person with a mental illness is a second-class citizen, and doctors and hospitals are above the law.

    Oh, and this is good:
    “If you have a mental illness and WANT involuntary hospitalization, it is also pretty easy. Just follow these steps:

    1) Pick a fight with the psychiatrist. Call him names. Say you have a lawyer and you’ll get his license. ”

    Yep, better not insult the king, if you want to keep your head!

    “Be firm in your refusal to consider why anyone should be worried about you.”

    Ah, the old Catch-22: if you DENY that you should be committed, then you NEED to be!
    This is the oldest trick in the book; or as the law puts it, if you disagree with the shrink then it proves that your “judgment is impaired so that you don’t understand the need for treatment”.
    Because you’ve got the stigma of the scarlet letter “M” on your forehead, and thus you can now be ruled a “danger” at any time by mere allegation.

    Again, this shows the arrogance that comes from such unchecked power– yep, you are the elite, they are the loonies who don’t know what’s good for them; and that stupid old Constitution is just a meaningless hindrance compared to your fancy degrees.
    No, if you have a mental illness and want to avoid involuntary hospitalization, frontal lobotomies, or whatever other arcane tortures they can STILL apply to you, by law in some states: AVOID THE STIGMA!

    The only way to be safe, is to be “sane” in the eyes of the law. If you need treatment, go under an assumed name and pay cash, use a fake ID, or whatever you need to avoid the stigma by which states will allow any quack to put you away just by calling you “dangerous.”

    Just as this article ADMITS– i.e. that you’ll be presumed guilty until PROVEN guilty, just on some quack’s say-so. And you won’t have the right to a psychological team in your defense, just in prosecution against you.

    Once you get that scarlet letter “M” for “mental,” you fall out of grace with society and lose all rights. God help them.

    Like

    • I’m not sure why you find this disturbing. If you find yourself dealing with a mental health professional, either you sought them out because you thought there was a problem or you were brought to them because you were behaving in a way that indicated to someone that there was a problem. Either way, there is a presumption that there is a problem that needs assessment. In that situation, your job is to advocate for yourself. Anything you can do to show that the behavior in question is normal, safe, and under control will be in your favor. Anything you do that shows the behavior to be out of control, dangerous, or based on poor insight or judgment will count against you. Taking responsibility for your own actions is a good start. Lying and hiding facts are unlikely to be helpful.

      Like


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