Posted by: Kate | August 6, 2008

Lock ’em Up, Throw Away the Key

So, Monday-through-Tuesday was quite interesting.*  Every one of those tidbits of conversation would have made a complete blog post on its own, and might, yet.  Interestingly, only one out of that whole messy group was actually hospitalized; can you guess which one?

It’s a capricious thing, our mental health system.  I would guess that 90% of the time, things work out to the mutual satisfaction of myself and the patient.  We spend a while talking, and the ones who want to go home (even if they started out thinking otherwise), go home, and the ones who need to be in the hospital, end up there.  I would confidently say that 100% of the people whom I believe need to be hospitalized, are admitted.  Even if they only stay there for a few hours, that’s out of my control.  There are people I don’t think can safely go home alone for the night, and they don’t.  (How come I suddenly hear a faint echoed “So there, nyah”?)

Sometimes, conflict happens.  That other 10% rears its ugly head.

Some people want to just go home – maybe to finish the job, or maybe to just hurt in silence – and they don’t like it when someone else intervenes.  That’s rare, though.  Usually, I’m able to explain things enough that they at least stop arguing with me.  They may still be unhappy about the decision, but I’m able to convince them that I can’t authorize any different choice.

Other times, I hear objections from people who believe that they want to be in a psychiatric hospital but who don’t meet admissions criteria.  Because there are criteria.  Hospitals are not like hotels, with a bed for anyone with (or without) the ability to pay for it.  They’re also not a catch-all for any possible disorder, able to treat substance abuse and concurrent medical disorders and developmental disabilities.  They’re not a place to just get away for a while, and they’re not asylums from abusive relationships.  Places exist to address all of those needs, but not psychiatric facilities.  Usually some brief education and appropriate referrals will clear that up.

The other thing that hospitals are not, is someplace to send someone based on what-ifs.  This is the most frequent point of contention: when, regardless of what the patient wants, some third party wants them to be hospitalized because of what could happen.  I can’t hospitalize based on your concerns that your mother, friend, boyfriend, neighbor, or cashier at WalMart might someday, perhaps, maybe, in the future, become suicidal, homicidal, psychotic, or otherwise unpleasant.  Even if they have been that way in the past.  Even if you think it’s likely to happen soon.  I can’t work with what-ifs.  I can only work with right-this-seconds.

If someone is suicidal now, even just having thoughts about it, then I can facilitate a hospital admission, and will devote however many hours of my life are necessary to do so.  If they have been suicidal within the past 40 days, and between your testimony and their actions in the Emergency Department I can build a reasonable case to prove it, then I can facilitate a hospital admission.  Even against their will.

But I cannot, ever, at all, facilitate a hospital admission for your brother based on, “Well, no, he hasn’t actually said that he’s suicidal or done anything to himself, but he’s acting weird and he sleeps a lot and I’m really worried about him.”  I appreciate your concerns and your care, truly I do.  But making someone go to the hospital when they don’t want to is a basic violation of their civil rights.

It varies by state, and it happens that New Hampshire is particularly interested in protecting one’s civil rights around health and well-being, or the lack thereof.  This means that you have the right to, for instance, avoid the dentist for five years and then show up with a mouthful of cavities and the need for two separate oral surgeries and general anesthesia to address it all.  (Just a for-instance, not that this has ever actually happened.  Um.)  It also means you have the right not to go to therapy, or take antidepressants, antipsychotics, or antianxiety medications if you don’t want to.  Any exceptions to this have to happen via a court process.  So, an abusive guy can be forced to take anger management classes, or someone under the age of 18 or older but with a legal guardian can be forced to go to the dentist.  But there has to be a legal process in place, so that those rights are taken away in an incremental and careful process.

This includes mental health care.  You can, most of the time, just say no.  Even if the rest of us all really, really think you’d be happier and healthier if you were in therapy.  You are allowed to be crazy.  You can sleep on the sidewalk, scream at the little blue hippos flying around your head, not bathe for long enough that your clothes whimper when you enter the room, laugh inappropriately at funerals, and watch Weekend at Bernie’s in the nude.

You just aren’t allowed to be dangerous.  You can’t threaten or attempt suicide or homicide, and you can’t allow your physical wellbeing to be damaged or threatened (for instance, people who don’t heat their homes in the winter because they don’t notice it’s cold, or who cut their arms until they’re infected, or who get so wrapped up in their own psychosis that they forget to take their insulin).  When your actions reach a certain level of dangerousness, then someone else – me, or your family, or a neighbor, really anyone – can step in and take away your right to decline treatment.

It’s a big deal, a drastic course of action. It’s not a decision to be made flippantly or impulsively. So I don’t. Even if you really, really want me to.

Sometimes, after I have spent hours with a patient and their family, I will decide that this is not – at least, not yet – a circumstance that allows for us to involuntarily commit that person to a psych ward. Sometimes everyone accepts this with grace and gratitude. And sometimes the family will get all snotty and say, “What, so, we have to wait until he actually kills himself before you’ll do something?”

So far, I have refrained from jabbing anyone in the eye for the presumption that my work – listening to everyone, taking in all this information, gathering together ten years of schooling and intensive professional experience, protecting people’s civil rights, trying to communicate the whys and wherefores to everyone involved – is not doing something.

*For those new to the story, I do risk assessments for the local emergency rooms.  Basically, if someone shows up at the hospital with suicidal thoughts, depression, anxiety, psychosis, or a number of other options, I’m asked to sit with them for a while and decide whether they’re safe to go home, or if they need to be admitted to a psychiatric hospital.



  1. We unfortunately have first-hand experience with just what you’re talking about. Two members of my husband’s family have ended up in the ER for psychiatric problems – one ended up involuntarily committed for 48 hours for a suicide attempt she still says was an accident, the other was sent home but ended up jailed 2 days later for assault during a manic phase.

    I appreciate that there are people like you on the front line to help patients and their family and friends get the help they need, whatever form it come in.

  2. This makes me want to look into our laws here just to see how they differ or are similar.

  3. I’m going to guess the 8pm “I don’t need AA” commenter.

    It’s sad when you know a person who could truly use help (junkies, etc.), but there’s nothing anyone but them can do about it. We have a friend who has been a heroin user/abuser for years on and off. We just hope we’re not attending his funeral any time soon.

  4. I’m guessing the woman with the baby who took the OD and then wanted a refill. She seemed pretty volatile.
    This makes me think of the times when there is a school shooting and the media keep asking, “Weren’t there signs that this might happen?” It’s like you said, though. In this country we cannot lock everyone up because of the what-ifs or the might be. In some way we’re all walking what-ifs, after-all.

  5. What a wonderful website you have!

    I had to comment on the previous comment by Erin:
    I do agree that we cannot lock up everyone, however in this day and age of civil rights for everyone and their pooch, there is a veritable breaking point wherein the law needs to switch. All too often the instigators are getting away with literal murder in being slapped with puny sentences.

    Here in Canada for example, a few weeks ago a man boarded a bus with a hunting knife (of course unbeknownst to all. He proceeded to share a small break on the journey with a 22 year old youth and later on would switch seats to sit next to him only to proceed to murder him.

    The assailant is now in custody and of course the insanity plea is being pursued. Even more ironic is that this man will be supported by taxpayers while he provides absolutely nothing to the society which he has successfully removed himself from.

    I have worked in ER, Cardiology and ICU and can say with sad comfort that we do not properly screen for repeat offenders. There are all too many people who present with some kind of emotional challenges, and we all too often focus in on the amelioration of immediate concerns and physical matters without probing into potential outcomes of the seemingly lesser emotional problems.

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