involuntary commitment

[karl71]

Hey all - I'm a 4th year student debating whether to go into Psych or not. One of the things that I did not enjoy during my psych rotations was all the involuntary commitments. I live in a state/county where involuntary commitments are very easy to obtain and very common. On my last inpatient rotation, at least 75% of our census was involuntary. I know that this is something only to be used for people that are dangerous to themselves or others, and I agree it is often necessary to do this. But it does not change the fact that I felt uncomfortable with the process at times. Having to keep patients in a locked down unit without being able to see the light of day, breath fresh air, forced to eat crappy hospital food, and having to be around some of the other violent patients is not pleasant. I felt bad for the pts who were doing better, but just didn't have a bed open for them yet and had to endure more days and weeks more in this environment.

I also felt frustrated having to constantly bicker with pt's who were not full treated or stabilized but would ask every day, many times a day, "when am I being discharged"?

The pts that really were super ill, and the ones that were there voluntarily were awesome, and I loved working with them. Unfortunately this was the minority of pts.

Just wondering what some of you that have been in this field for a long time think. Do you ever kind of get to a point where you see the long-term picture and are able to sluff this kind of frustration off? Thanks.

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[michaelrack]

Involuntary committments are often a big part of residency, and sometimes part of working in a community mental health center. Most patients in state psych hospitals are committed.

It is a small part of private practice psychiatry.

 

[chameleonknight]

Involuntary committments are often a big part of residency, and sometimes part of working in a community mental health center. Most patients in state psych hospitals are committed.

It is a small part of private practice psychiatry.

Indeed, when rotating through private hospitals, about 90% of the inpatients were voluntary. In state hospitals, you can pretty much flip that.

 

[BabyPsychDoc]

Voluntary inpatients in public facilities are either remarkably intelligent (thus managing to preserve insight into their illness), have borderline pathology, or have a host of social issues (eg, homelessness). The former ones are reasonably uncommon, and the latter ones are being discharged as soon as reasonably possible. Therefore, you are bound to work mostly with involuntary inpatients.

As an outpatient psychiatrist, you would still have to keep involuntary commitment as a part of your arsenal (eg, suicidal patients).

I would say it is normal that you feel uncomfortable with the idea at present, but you seem understand the necessity of it, and if you do decide on training in psychiatry, you will become more accustomed to it (like surgeons get accustomed to gory bits of their profession)

 

[whopper]

I never had a problem with the involuntary commitment process. When you think about it, I think any reasonable person would believe that someone mentally ill to the point where they wanted to harm themself or others is in need of involuntary commitment. History is filled with cases where mentally ill people on that level of illness have harmed innocent people.

I did however have a problem with ER doctors claiming the patient was suicidal to dump that person to psychiatry, then that person ends up getting involuntarily committed when that person was not suicidal. That often times was cleared up after a few days, and yes, in those cases I was ticked off-not at the commitment process, but by the doctors who abused their power (ER doctors in this case, not psychiatrists--though yes of course there's anyone in any field who's going to abuse their power).

As bothersome as it is, any field of medicine in the hospital will have their fair share of dumping to other departments. Its called turfing. If you do medicine, you'll be ticked with the surgeons who want to bring their patient to the medical floor who are still actively bleeding (yes it happens), or the ER doctor who dumps someone to the medical floor who is not appropriate for inpatient, or as a resident, getting beeped to deal with a non-teaching patient, and when you clarify they are non-teaching the nurses will lie and claim the patient is a teaching patient because they'd rather dump the job on a lowly resident instead of dealing with a disgruntled attending.

Think about why its bothering you. It could be you don't agree with the process itself. While I do agree with the process, I'm not here to convert you on this thread (if you want to start a debate about it on a different thread, then I'd debate you on it).

It could also be that you were bothered by something that really affects all of us in a hospital--turfing.
It could've been that the doctors you worked with weren't doing their jobs right--either in commiting patients or teaching you about the process to make you feel more comfortable with it.

It could be that you don't fully understand the process, and if you knew more, you'd feel more comfortable about it. I was in that position as a PGY-1. It could be that your personality just doesn't like commiting people which is fine, just like some doctors don't like cutting people open, etc.

But in any case, you will have to commit patients in psychiatry. You have to face that fact. Even in outpatient where involuntary commitment happens the least, you will from time to time (about every few months) have to commit someone or at least call emergency services to have that person evaluated by a crisis center for commitment. You do need to weigh how this will affect your decision on picking a residency.

 

[karl71]

Thanks everyone for your answers, very helpful. During this past rotation I just completed, I was able to see the need for involunatry commitments and was starting to feel very comfortable with the whole process. I think what has thrown me for a loop is the fact that the nearby state hospital recently shut down. We are now getting a lot of chronic patients that would have been at the state hospital, that are now staying for months, and even some for up to a year, on our lockdown unit(that is supposed to be a short-term/acute unit). Just the thought of no fresh air, not seeing the light of day, and eating crappy hospital food for an entire year is unsettling to me. All of the pts I'm referring to were in a situation where they were not currently a danger to themselves or others, but just had no place to go, would have destabilized if allowed to go back on the streets, and had to stick around. Basically placement issues.

So perhaps this was a situational thing given the recent state hospital closure. To be honest, when I did a simillar rotation a year ago before the state hospital closed, there were far less of these situations.

Anyway, thanks again for the thoughts.

 

[OldPsychDoc]

.... All of the pts I'm referring to were in a situation where they were not currently a danger to themselves or others, but just had no place to go, would have destabilized if allowed to go back on the streets, and had to stick around. Basically placement issues.

So perhaps this was a situational thing given the recent state hospital closure. To be honest, when I did a simillar rotation a year ago before the state hospital closed, there were far less of these situations.

Anyway, thanks again for the thoughts.

Cross-reference this to the "personal challenges as a psychiatrist" thread...

 

[Wednesday]

I think it's interesting that I prefer the involuntary pts to the voluntary ones who are there as a result of personality disorders/homelessness/post drunken SI. At least the involuntary ones presumably really need to be there. I see two more themes in your post--patients who do not appreciate you (a lot of this in psych) and limited resources (also a lot in psych given the short shrift mental illness gets). Not to discourage you, but psych might be frustrating for you in the long run. Just something to think about.

 

[kugel]

With a slightly different point of view...
I'm GLAD that you were bothered by all the involuntary patients. If you thought, "This case isn't clear what I should do, but who cares? I'll just slap a hold on him and throw him into the inpt unit and they can figure it out from there," THAT would worry me.

Involuntary commitment revokes a person's guaranteed civil rights (in the US) even though there is no arrest, no guaranteed access to legal counsel (in many states), no arraignment within 24 hrs, etc. This is a serious business and much of our profession treats it too casually (IMHO).

I'm not saying it isn't necessary. It is. I do it every single day at my job. And I'm grateful (nearly) every day that it is available to keep the pt and others safe while trying to arrange help that is desperately needed. But that doesn't mean that it shouldn't give one pause.

 

[Faebinder]

I'm one of those whom are almost convinced that voluntary admissions in psychiatry should just be disband. What's the point? If the patient has enough insight to come in voluntarily then he/she can go to the day programs instead. Every now and then, a relatively rare case comes by that puts doubt in this opinion.

 

[whopper]

Involuntary commitment revokes a person's guaranteed civil rights (in the US) even though there is no arrest, no guaranteed access to legal counsel (in many states), no arraignment within 24 hrs, etc. This is a serious business and much of our profession treats it too casually (IMHO).

When a medstudent or resident is working in a crisis center, and working under an attending who commits a patient without explaining the entire process to his students, it can make that student feel uncomfortable.

I've been in that boat a few times. You get the occasional attending who just wants to get out of the crisis center half an hour early and doesn't really explain the process.

I think any person who is a believer in the Bill of Rights would be justifiably uncomfortable with an attending who performed in this manner.

 

[nancysinatra]

When a medstudent or resident is working in a crisis center, and working under an attending who commits a patient without explaining the entire process to his students, it can make that student feel uncomfortable.

I've been in that boat a few times. You get the occasional attending who just wants to get out of the crisis center half an hour early and doesn't really explain the process.

I think any person who is a believer in the Bill of Rights would be justifiably uncomfortable with an attending who performed in this manner.

This is why I think that turfing to psych is completely different from the turfing that goes on between other specialties. Late night transfers from outside hospitals are also very problematic, I find. We get patients where we almost have to take them, sometimes on the flimsiest of excuses, because once they've arrived where else can they go? (And the story over the phone is always stronger than the real story when the patient comes in.) Even voluntary admission to a psych ward comes with restrictions, since the unit is locked. When you have half the evidence you need and actually commit the patient, knowing they might not have a mental illness in the end, I feel that's very questionable practice. Maybe there's a reason why we do this, but so far no one has told me what it is.

What about the cases of fleeting psychiatric symptoms secondary to a GMC? Can we commit people based on that, ethically and legally? Do people, for example, who are hyperthyroid, who might be acting manic--do they meet the legal definition of having a "mental illness?" The only explanation I can get from anyone is how important it is to "protect" patients. Well, if it were me, I'd want my rights protected as well as my safety. I would say, from what I've seen so far, most patients on the psych ward are not in imminent danger of death. Most are at some danger, yes, but not absolute imminent danger. I feel like sometimes we are taking our obligation to protect patients to the point where we extend it to committing people who haven't been proven to be mentally ill even though a mental illness is required for commitment. Definitely, in my experience so far, we get better training in how to protect people's lives than in how to protect their rights, even though depriving people of their rights is a big part of our job.

Another thing is that as a resident I am often asked to fill out commitment forms on patients I barely know. I trust the statements I get from fellow residents and attendings, but these are legal forms and I do not like repeating second hand information that way--if it's wrong, it's perjury, and the perjury stops with me. Unlike some attending, whose license is on the line, in the case of a perjury conviction, I'll be the one who gets to go to jail. But I feel like the signing of commitment papers gets treated just like the signing of medical orders, and I'm expected to put down on that form whatever the attending says.

 

[whopper]

Late night transfers from outside hospitals are also very problematic, I find. We get patients where we almost have to take them, sometimes on the flimsiest of excuses, because once they've arrived where else can they go?

Out of the worst dumps we got were from other hospitals. THE WORST was a guy who attempted suicide by jumping out of a window, he broke both his legs, the ER doctor medically cleared him without doing anything to treat the person's broken legs, and wrote on the physical exam that everything was normal.

When he got to us, yep, both legs were broken, We called up the other hospital to talk to the ER doctor, who by then was no longer on duty.

There is a big disconnect between hospitals in this regard. Had it been an ER doctor in our own hospital, the department heads would've gotten together and discussed this case. There probably would've been some repercussions on the ER doc. Since it was from another hospital, I don't think anything happened between our hospital and the other one other than the phone call.

I can say however that the patient was extremely upset, and demanded to know the ER doctor who cleared him. He said he was going to sue that doctor. We happily provided him with the documents the ER doctor wrote saying the person was medically cleared and that his physical exam was completely within normal limits.

 

[Regnvejr]

.....Another thing is that as a resident I am often asked to fill out commitment forms on patients I barely know. I trust the statements I get from fellow residents and attendings,.....

Huge no-no. On those forms, the only thing to put down is what you personally witness. If you can not testify that you personally heard the patient express the info or witnessed behavior, then don't write it down. The one determining the patient being in danger or a danger is also the one filing the hold. Nobody else can.

 

[kugel]

Another thing is that as a resident I am often asked to fill out commitment forms on patients I barely know. I trust the statements I get from fellow residents and attendings, but these are legal forms and I do not like repeating second hand information that way--if it's wrong, it's perjury, and the perjury stops with me. Unlike some attending, whose license is on the line, in the case of a perjury conviction, I'll be the one who gets to go to jail. But I feel like the signing of commitment papers gets treated just like the signing of medical orders, and I'm expected to put down on that form whatever the attending says.

This is an excellent question for your hospital's Risk Mgt Attorney. Try to make sure that the question is framed as a question, and not as an accusation against the attending. Something like, "As part of my education, I'd like to understand better the laws regarding commitment and just how I can better protect the medical center (and myself) while safely treating the patients. Just what happens if someone determines that the information I received and recorded on the commitment papers turned out to be wrong - even an outright lie? What if it's from people who have a (hidden) grudge against the patient? What if it's from another medical professional?"

The Risk Mgt Attorney is chock full of expert opinions on such matters. I recommend that you do NOT trust statements from your attendings on what is legal and what is not. 90% of every statement about medico-legal issues I've even heard from a doctor are (at best) incomplete or exaggerated - and at worst, utterly and completely wrong.

Can you imagine getting opinions about which antibiotic to use for community-acquired pneumonia in a 60yo alcoholic smoker from the hospital attorney? Why not? He's been practicing law in a medical environment for over 20 years. And he hasn't killed a pt. yet, so he must be right.

Same logic as trusting your attending on legal issues.

In our residency, we got our lecture about how the commitment process works and how to complete the paperwork from the Hearing Officer who oversees the commitment proceedings - so he knows exactly what he expects and what he considers "legal" in these proceedings. He even warned us about "trick" questions that the defense attorneys sometimes ask. That was ideal.

 

[whopper]

If I ever put information on a petition for commitment that was not observed first hand, I would cite the source of information. I would also report that this information was not witnessed by myself.

E.g. "per his case manager, he was manic and screaming at his neighbors without provocation."

or "according to his ER intake record, he was screaming and making threatening body language"

If any of the previous people did not give specific examples (which often happens) I will admit to it...

E.g. according to his ER intake record, he was screaming and making threatening body language (no specific examples were given).

Here was a typical type of commitment petition I'd write where there was no actual data witnessed by myself, but there was enough data to justify the petition.

"Mr. X was brought in by police for reportedly causing a public disturbance. According to the police, he had walked an intersection and was trying to direct traffic even though the traffic light was operating correctly. The police further stated when they asked him to leave the intersection, he appeared "off". The police did not give any more specific examples of this behavior. They brought him to the ER. While in the ER, he was reported to have been agitated to the point where the ER doctor gave him emergency medication which has rendered him unconscious. The ER records do not describe his specific behavior while agitated. He was then transferred to the crisis unit.

I have had Mr. X in the crisis unit for 4 hrs, and he is still unconscious. Based on the reports from the police and ER staff, in my medical opinion, he should be considered for involuntary commitment. There is a significant likelihood that I will not be able to perform a mental status of this person while awake or at least heavily sedated because of the medication he was given within the time allowed by NJ law.

 

[Regnvejr]

Always remember that when you rely on 2nd-hand info, it might be tainted. "Son said he was suicidal," you admit, find out he is fine, but when he goes home, son ran with the money and the car. You NEVER know what others motives are, so unless you witness it yourself, it didn't happen.

Police sticks holds on people all the time, and when you get the story, nothing was wrong, but it was just an easy way for the officer to get that person out of the way and out of their hair.

Holds are placed for lots of reasons, but unless you witness the problem yourself, you better not fill that form.

 

[Regnvejr]

..Here was a typical type of commitment petition I'd write where there was no actual data witnessed by myself, but there was enough data to justify the petition.

"Mr. X was brought in by police for reportedly causing a public disturbance. According to the police, he had walked an intersection and was trying to direct traffic even though the traffic light was operating correctly. The police further stated when they asked him to leave the intersection, he appeared "off". The police did not give any more specific examples of this behavior. They brought him to the ER. While in the ER, he was reported to have been agitated to the point where the ER doctor gave him emergency medication which has rendered him unconscious. The ER records do not describe his specific behavior while agitated. He was then transferred to the crisis unit.

I have had Mr. X in the crisis unit for 4 hrs, and he is still unconscious. Based on the reports from the police and ER staff, in my medical opinion, he should be considered for involuntary commitment. There is a significant likelihood that I will not be able to perform a mental status of this person while awake or at least heavily sedated because of the medication he was given within the time allowed by NJ law.

I don't think it would hold up. Police or ER physician should have filed. You can wait till he is no longer unconscious, but if he wakes up clearheaded, you don't have cause to file. And I don't think you can file till he wakes up. Now, if there are clear signs of selfharm or similar, then no problem, but at least where I have worked, unless the ER physician or the police filed, then a hold wont be valid.

 

[kugel]

In Whopper's hypothetical case, I might focus the reasons for continued detention of the patient on his current mental status (which I can observe):

"According to the reports, he was a Danger to Self and Others in the community and the ER. Currently, he is clearly Gravely Disabled in that he cannot possibly find/utilize food or shelter, nor can he voluntarily accept continued care, in his current unconscious state. Although this will likely change within hours, he cannot safely be discharged in this condition, so needs to continue involuntary care at this time."


In cases where the reports indicate egregious, flagrant dangerous behavior, but I cannot observe that in the couple of hours in the PES and the pt has been calm/cooperative with me, then it goes something like this:

"Although the patient denies all the reports of his recent behavior, there is nothing to suggest that the reports were false or exaggerated. There is nothing about the situation outside the hospital that has changed, so the behavior is likely to recur immediately if the patient is discharged at this time. In order to be even consider this patient for safe discharge, he will need at least 24 hrs of observation without any SI/HI or suggestions of dangerous behavior." And my plan for that time includes further collateral information from the original and other witnesses and seeking any info about inciting or perpetuating factors that might be addressed before discharge.

 

[whopper]

I don't think it would hold up. Police or ER physician should have filed. You can wait till he is no longer unconscious, but if he wakes up clearheaded, you don't have cause to file.

Yes they should have reported what specifically happened. Often times they do not, and by the time the person is in the crisis center and I'm finally ready to see them, the police and the ER staff that were around that could've reported the person's dangerous behavior are off duty. Sometimes I actually have contacted the police or previous ER doctor and asked them what happened, and I often get an answer to the effect of "hey you're the doctor, you figure it out." Without those people being able to help me anymore.

If a person was actually directing traffic to the point where the police had to take them to the hospital, and given PRN medication that knocked them out, that's pretty much all we could go on.

Obtaining collateral information in cases like this within just a few hours of time, especially if its after 5pm, and on a weekend can be extremely difficult. Want to call up his outpatient doctor? What are the odds the doctor is available 24/7? Often times when the treatment team does get in touch with collateral information, the data supported they should have been committed.

Of course the police and the hospital could've over-reacted, and I've seen that. However if you let a person go after the above extreme incidents without collateral information showing the person can be safe and at least observed 24 hrs of stable behavior, you're more likely than not going to discharge someone who's involuntarily commitable...and could do something dangerous within a very short period of time.

 

[nancysinatra]

These suggestions are really helpful. I've been wording most of my forms so as to say that the patient "was reported to..." Hopefully that protects me in the case of an incorrect report if the patient feels they were illegally committed and sues.

As far as attendings and residents, it's not their legal opinion I trust (goodness no!)--but just their assessment of the patient prior to coming inpatient, in the ER for example. So I can write "was reported to..." with some confidence.

Where I'm less sure when to believe things is with the police. They never seem to leave written reports, so what I hear isn't even second hand--it's 3rd or 4th hand. It's not that I distrust them, it's just that they have an agenda, which is to keep order out there. Their view of things might not always be factually accurate. And the police wouldn't know who is medically ill, who may have overdosed on illicit drugs, and who is psychiatrically ill. From what I understand of the law, we should be distinguishing between these things BEFORE committing people. However, late at night on call I am under great pressure to decide quickly, and it's then that I notice how little information I actually have, and how impossible a real workup of anything would be. Just like on any service we defer the non-life threatening stuff til the primary team comes in the morning. But the difference is, we have to put people on the psych floor in the meantime, sometimes involuntarily.

Of course, I can't trust the patients almost at all. I have hardly ever met a patient who AGREED with whatever was said of them in a police statement. They always deny it.

I like the idea of asking the Risk Mgmt attorney. They'd probably clear my questions up really quickly!

Whopper, that is unbelievable about the broken legs. Do you recall what kind of fractures they were? That patient could have been at great risk being transferred like that!

 

[whopper]

Do you recall what kind of fractures they were?

No. The second the x-rays confirmed they were broken, we were able to transfer him off the psych unit. I wasn't caring at that point because my focus on was getting him off the unit, and was ticked with the medical & surgical staff on the other units refusing to allow us to transfer the guy. Further, the patient wasn't even my patient. He was being treated by a (at that time) senior resident who was too chicken to do anything because he knew the patient was going to sue, and didn't want his name on the chart. He was arguing that it was "unethical" for him to treat the patient.

The guy was obviously confusing ethics and legal risk. It was legally risky for him to treat the patient, but it was at the same time unethical for him to not treat him because of fear of being attached to a malpractice suit.

I told that resident several times (And he was my senior, but the staff actually thought he was my junior because whenever something extreme happened, he couldn't handle it and the staff tried to get me to solve the problem) that if there was going to be a lawsuit, he was covered since he was not an attending, that he didn't make the error, and that in fact by his refusing to treat the patient he was at even greater risk. He still didn't do anything. This is after about 20 minutes of me telling him to grow a pair and take responsibility. It got to the point where I raised my voice to almost yelling (if not yelling) at him on the unit. I never raised my voice to that level, even with agitated patients. I specifically told him that if I was forced into treating the guy because he refused to do so, I would cite in the chart everything that happened, including mention of his refusal to treat.

I called up my chief, told her what was going on, and called the attending and demanded he step in. I then proceeded to treat the guy and wrote in the chart that this guy was not supposed to be under my care, but because of the other resident's lack of action, and because this was an emergency situation and that I had to step in. I specifically named that resident, and stated that I demanded he treat the patient.

After the incident, I called up the program director and complained. My chief (who was on top of this situation when she became aware of it) did let the department head know. I was majorly ticked off, though I was told by the the chief and department head that I did the right thing.

During that time I did ask staff to monitor the guy and to make sure he wasn't going into shock because I figured a broken bone could also mean cut arteries. His vitals remained stable, and he showed no gross signs of shock, and his feet still have good capillary refill--though during the few hours it took to resolve this situation he was in extreme pain and was very angry. The medical & surgical floors refused to touch him until they actually got word from the radiologist. I walked to the radiology dept, told the radiologists what was going on (they were attendings, I was a 3rd year resident) and told them the nature of the emergency, and that they needed to do the X-ray STAT.

In short an MAJOR error on the order of malpractice was committed, and a chicken resident refused to touch the patient that clearly was his responsibility. The dept did tell me they took disciplinary action against him though I didn't see anything happen to him that I was aware of (of course programs aren't supposed to tell the residents what's going on with individual residents). He graduated just the same.

 

[kugel]

Huge no-no. On those forms, the only thing to put down is what you personally witness. If you can not testify that you personally heard the patient express the info or witnessed behavior, then don't write it down. The one determining the patient being in danger or a danger is also the one filing the hold. Nobody else can.

Actually, this varies from jurisdiction to jurisdiction.
Know the law where you are practicing.
In CA, the laws are vague enough and contradictory enough that each county has its own interpretation and policies about psychiatric holds - and these sometimes differ quite dramatically b/w counties.

In CA, the code specifically states that the person writing the hold should take into account info from people who are likely to have information pertinent to the case.

 

[whopper]

True.

I read about the CA a few years ago in psychiatric journal (I think it was Current Psychiatry), and remember it mentioned what you wrote-That in CA, there is leeway to allow for collateral information to be a valid source of evidence for commitment (if I am interpreting you correctly.) Where I did residency (NJ), I would write down collateral information, but cite what I witnessed vs what was obtained through collateral data. It could turn out later that the source was erroneous. By separating yourself from the erroneous information, that could protect you.

I would (in NJ) cite the sources of information to further strengthen your decision to involuntarily commit. Often times crisis psychiatrists are not in a position to have enough time to find out what's going on within the time allowed. In NJ which had a 24 hr limit before a doctor had to discharge or involuntarily commit someone, it was often not enough time to figure it all out. Unless you had enough data to say they were safe, the doctors there virtually all the time in those circumstances wrote for an involuntary commitment. The judges in those cases (from the cases I've seen that have gone to court) always agreed with the doctor's decision in those circumstances.

I've only seen 1 case where I sat in court and witnessed a judge strongly question a doctor's recommendation to involuntarily commit the patient. In that particular case the judge still held the involuntary commitment, but scolded the doctor saying that the doctor should've done a better job within the time to collect more data and present his case better. She said she would only allow the commitment to go on another 2 weeks because she was more willing to err on the side of his professional judgment and did not trust her own ability to say the person was safe to go into the community from a psychiatric standoint. She then said if still saw the patient there after 2 weeks, she demanded a much better job in the presentation of the case to commit.

In that particular case, the doctor IMHO was extremely lazy, and really wasn't on top of the data concerning the case. If you asked this doctor what was going on with one of his patients, usually he did not know. I also noticed he had a habit after that case of strategically keeping his patients in inpatient as long as possible, then discharge the day before court so he could avoid having to testify in front of judge.

Since I've been working in a 10 unit facility (each holding 28 patients) in Ohio, I've heard of actually quite a few cases where the judge let the person go against the doctor's recommendation. I haven't sat in those cases, but you hear about them because the court is in the facility.

 

[kugel]

I've only seen 1 case where I sat in court and witnessed a judge strongly question a doctor's recommendation to involuntarily commit the patient.

Where I've worked, the judge (or assigned magistrate) did not simply rubber stamp the doctors' decisions. And I respect them so much more for it. If you build an adversarial system (like court), then it doesn't protect anyone unless the conflict is taken seriously. Where I trained in Albuquerque, the magistrate took his job of keeping us honest very seriously. And I learned to have my (crap) together before going in. Nothing like having to defend your case to a sharp opposing attorney to teach you to know your case.
And when I had a case in which Adult Protective Services dropped off a woman without an acute psychiatric disorder but then would not return my calls or make any efforts to assist the patient with discharge plans, I had the state's attorney subpoena the APS worker to the commitment hearing. All of the sudden, phone calls and assistance fell from the sky. APS put her in emergency adult foster care (as they should have done from the beginning) in less than 24 hrs (before having to appear at the hearing).

 

[whopper]

I agree.

The doctor I mentioned above was complacent. He was rarely challenged, and the shortage of psychiatrists allowed for that because he was not easily replaceable by the hospital system.

However when he finally encountered someone telling him boldly that he did not do a good job, and that the judge expected better, well he didn't really rise to the occasion and do better. Instead he just discharged everyone right before the court date.

In hindsight, I was surprised with my current experience that the judge kept the person in another 2 weeks. The burden rests on the doctor to prove the person is commitable. If not, then the procedure is usually to discharge. In Ohio, several of the judges would've said something to the effect of "you didn't prove the case, the person now has to go." Even if the person was still in need of psychiatric services--> which would then prompt the hospital administrators to go after the psychiatrist and criticize him/her for not presenting the case well enough (which IMHO was valid and justified).

For the most part, the defense attorneys for the patients go through the motions, though on a few occasions the lawyer cross examining me did every single possible thing to get their client off, even use some court room histrionics. As uncomfortable as that is, the system IMHO is actually better when its done that way so long as the cross examining lawyer doesn't intentionally confuse or misdirect the judge or jury.

After one of the most brutal cross examinations I've experienced so far, I approached the lawyer, shook his hand and said "If I'm even in trouble, I got to remember you." The guy took his job seriously and asked the questions I'd love to see a lazy psychiatrist get nailed on. Yeah it was brutal, but it was fair. I just had to go to the bathroom for about 10 minutes to massage my neck and lower by BP.

 

[Efficacious]

I never had a problem with the involuntary commitment process. When you think about it, I think any reasonable person would believe that someone mentally ill to the point where they wanted to harm themself or others is in need of involuntary commitment.

In a libertarian sense, everyone has the right to commit suicide and should not be burdened with a more difficult life, something which they seek to escape.

Psychiatry on this point has likely and arguably caused more problems than found solutions. A person's quality of life that leads one to becoming suicidal is only going to be exacerbated by involuntary commitment and thus it makes their situation worse.

Medicine rightfully should be concerned with the best interests of the patient but if that patient does not want to live and in the foreseeable future he thinks his life will only get worse, and a reasonable person would be inclined to agree, then by all means, let him kill himself. Unless you are concerned about your decreasing paycheck which is not merely a conflict of interest, but also something that may alter your best judgment and preclude you from exercising any vested "authority" you may have over that person.

 

[erg923]

A person's quality of life that leads one to becoming suicidal is only going to be exacerbated by involuntary commitment and thus it makes their situation worse.

The treatment/outcome literature on this topic does not support this statement. In fact, it seems to be quite the opposite on average.

1. Katsakou C, Priebe S. Outcomes of involuntary hospital admission – a review. Acta Psychiatr Scand 2006; 114: 232 –41.[CrossRef][Medline]5
2. Houston KG, Mariotto M. Outcomes for psychiatric patients following first admission: relationships with voluntary and involuntary treatment and ethnicity. Psychol Rep 2001; 88: 1012 –4.[Medline]6
3. Katsakou C, Priebe S. Patient's experiences of involuntary hospital admission and treatment: a review of qualitative studies. Epidemiol Psichiatr Soc 2007; 16: 172 –8.[Medline]12
4. Farnham FR, James DV. Patients' attitudes to psychiatric hospital admission. Lancet 2000; 355: 594.[Medline]13

 

[Efficacious]

The treatment/outcome literature on this topic does not support this statement. In fact, it seems to be quite the opposite on average.

Of course it doesn't. All of medicine and especially psychiatry is about the bottom line, the numbers on the page, and the # of Franklin's in your wallet.

We have an NIH and NIMH which provides grants to scientists to replicate data that reflects the position of the medical establishment and we have psychiatrists that testify about patient's mental conditions who are not qualified to do so and are receiving kickbacks for every commitment they sustain for a given hospital. It's all about money, and no I don't expect your worthless literature to reflect the truth.

Your profession was slicing scalps open and pouring in salt to release demons from patients (not to mention torturing them if not blatantly killing them) in the Middle Ages and to think you have come a long way or somehow improved is fallacious and as dangerous or more dangerous than the patients you so readily commit illegally, unethically, and unconstitutionally.

 

[erg923]

Of course it doesn't. All of medicine and especially psychiatry is about the bottom line, the numbers on the page, and the # of Franklin's in your wallet.

We have an NIH and NIMH which provides grants to scientists to replicate data that reflects the position of the medical establishment and we have psychiatrists that testify about patient's mental conditions who are not qualified to do so and are receiving kickbacks for every commitment they sustain for a given hospital. It's all about money, and no I don't expect your worthless literature to reflect the truth.

Your profession was slicing scalps open and pouring in salt to release demons from patients (not to mention torturing them if not blatantly killing them) in the Middle Ages and to think you have come a long way or somehow improved is fallacious and as dangerous or more dangerous than the patients you so readily commit illegally, unethically, and unconstitutionally.

blah blah ....get real pal.
PS: GO TALK TO THE TARASOFFS. THEN COME BACK TO US....

 

[Efficacious]

....get real pal

Typical medical blowhard. I don't need to "get real". Your profession needs to "get real" and get a life and stop ruining everyone else's.

Your medications cause obesity, diabetes, depression, suicide, high blood pressure, and many of them result in death. I have read the studies on your medications which cause unexplained deaths in many patients prior to being marketed to the general public.

Not only that, I also understand where psychiatry developed: Nazi Germany in the 1930s. The original eugenicists were psychiatrists and many of the psychiatrists were Nazis who actively participated in the genocide of the "undesirables" as you call them. Your whole profession is a scam and you are killing people. You know it, I know it, God knows it and you can laugh all you want. Psychiatry is going to fall when the people wake up.

PS: Why don't you go cry about it to a moderator and get me banned or something. I know that's what your itching to do because not only do you oppose the Constitution and civil rights and civil liberties for your patients you also are against the First Amendment. So go cry about it.

 

[erg923]

Relax pal, no one is crying here. Im not gonna ban you, but I probably shouldnt feed the troll either.

I think it interesting that you think psychaitry wasnt around before the nazis though..... That sounds suspiciously....dare i say...scientology-like

 

[Efficacious]

Im not gonna ban you, but I probably shouldnt feed the troll either.

I think it interesting that you think psychaitry wasnt around before the nazis though..... That sounds suspiciously....dare i say...scientology-like

I didn't say that. I said it developed in Nazi Germany in the 1930s. Because of poo your profession has stirred men like Dr. Peter Breggin and Dr. John Breeding have had to clean up the mess.

Tell me, how do you feel about ECT? On second thought, I really don't give a poop. Maybe you can look into it and determine how it causes brain damage every time it's used, the irreparable memory loss, and death caused from it. But once again, your deflection of and impermeability to truth will keep you blind.

I also know about your Axis 5 code. I'm sure you will deny that too and play idiot.

EDIT: I still don't give a poop.

 

[erg923]

I also know about your Axis 5 code. I'm sure you will deny that too and play idiot.

Fantastic. I wasnt aware anyone was trying the multiaxial system secret though.....

ps: The moderators will ban you for using inappopriate language however. This is professional forum son, be respectful of your peers.

 

[Efficacious]

Fantastic. I wasnt aware anyone was trying the multiaxial system secret though.....

ps: The moderators will ban you for using inappopriate language however. This is professional forum son, be respectful of your peers.

Don't pretend like you don't know. Axis 5 is a code for involuntary commitment laws. Your Axis 5 is all it takes to be committed because it is a code between the law enforcement and the psychiatrists. Nothing else is required but a 20 or lower on Axis 5.

 

[Regnvejr]

Sounds like Scientology wannabe or some disgruntled Axis II predominate. All mouth and no facts.

 

[Efficacious]

This is professional forum son, be respectful of your peers.

So professional you would skip over the essential article adjective. Yes, very professional.

 

[Efficacious]

Sounds like Scientology wannabe or some disgruntled Axis II predominate. All mouth and no facts.

No, I'm a conspiracy theorist. Fact is stranger than fiction. Especially the medical establishment's fiction.

 

[Regnvejr]

Don't pretend like you don't know. Axis 5 is a code for involuntary commitment laws. Your Axis 5 is all it takes to be committed because it is a code between the law enforcement and the psychiatrists. Nothing else is required but a 20 or lower on Axis 5.

Now, that's downright dingy.

 

[erg923]

So professional you would skip over the essential article adjective. Yes, very professional.

Good catch my angry, disgruntled friend. My typing could use some work.. But really its cause my wife is yelling at me reminding me that its saturday night and to get off this board. Night.

 

[erg923]

Don't pretend like you don't know. Axis 5 is a code for involuntary commitment laws. Your Axis 5 is all it takes to be committed because it is a code between the law enforcement and the psychiatrists. Nothing else is required but a 20 or lower on Axis 5.

This is filled with alot of errors, but I still think your giving the police too much credit here. They don't know squat about what we do, nor, in my experience do they really care.

 

[Efficacious]

This is filled with alot of errors, but I still think your giving the police too much credit here. They don't know squat about what we do, nor, in my experience do they really care.

Okay. Well this has been interesting. I hope I haven't said too much to offend. I'm going now, hopefully to start fresh tomorrow.

 

[whopper]

illegally, unethically, and unconstitutionally.

Illegal and unconstitutional? No. (Ethics are subjectively debatable.)

The current medical-legal climate of psychiatry are based on legislation or challenges to the state that have been examined by the Supreme Court of the United States, and they have rendered judgments with the "establishment" following those laws.

So if that's the case how can it be illegal and/or unconstitutional?

 

[Encephalopathy]

Don't pretend like you don't know. Axis 5 is a code for involuntary commitment laws. Your Axis 5 is all it takes to be committed because it is a code between the law enforcement and the psychiatrists. Nothing else is required but a 20 or lower on Axis 5.

Haha, sounds like this guy was on a hold one time and someone explained to him it was because the doctor gave him a GAF of 20.

To the OP, I agree it's tough to have to work with someone on a hold when you don't think they need to be on one. Don't let it dissuade you from psych, though. Once you become the resident/attending, you'll be able to apply and lift holds more appropriately, based on your own assessment. And you can be sure that the people on holds really need to be on them.

 

[whopper]

Your Axis 5 is all it takes to be committed because it is a code between the law enforcement and the psychiatrists. Nothing else is required but a 20 or lower on Axis 5.

Not really except in cases where law enforcement or the doctor are acting out of line.

I've mentioned this in the past. Have doctors made mistakes? Yes. However the power that the state requires upon psychiatrists--to petition for involuntary commitment and hold patients until the commitment hearing is imposed upon us by law. If the law told us to not hold anyone, I would not hold anyone (though I do think the current laws are appropriate).

This is similar to the police and state having the power to hold someone in jail until that person goes to trial, though there are differences (such as commitment is for treatment, while jail is for people to be tried before a judge to possibly then go to prison).

And just like the police, doctors can make bad decisions and inappropriately hold somebody until the judge can review the case. Even then the judge can make a wrong decision and keep a person committed. Is there police brutality? Yes. Are there judges that make mistakes? Yes. Are there doctors that may inappropriately hold someone...yes. However the system not being perfect is not justification to end the system--such as getting rid of the police, getting rid of the court system or getting rid of the responsibility of doctors to hold patients they feel may be dangerous due to mental illness. The answer is to make the current system better by trying to find errors that can be fixed.

How often does unfair holds happen? Rarely. The legal system is filled with checks and balances. Patients have the right to communicate outside the hospital to call their friends, families, lawyer, the media, their local politicians to help them if they feel they are being unfairly held. In most states, it is required by law to offer the patient written information on how to make contact with patient advocates who will examine if they've been unfairly treated, and patient advocates are often times in crisis centers where involuntary commitment process starts to examine the process. In most states, the petition for commitment has to be reviewed by another doctor who then has to write a report saying he/she agrees with the previous doctor or the hold ends, and then ultimately it will go to a judge for review.

From my own anectdotal experience, if unfair holds happened, it was because an ER doctor exagerrated the person's presentation to dump that person in our court. It wasn't the psychiatrist who did this, it was the psychiatrist who cleared up the story so the person could be discharged.

If the case does eventually get to the judge, and the judge finds wrondoing on the part of the doctor--it will not look good for that doctor, and it will give the patient ammo should that patient want to sue.

Add in on top of that, several organizations such as NAMI actively investigate and make sure patient's rights are being respected, the state will at random times send in actors into mental health institutions posing as patients or employees to make sure everyone is following the rules etc....

While our system is not perfect, it has plenty of checks and balances in place. These added checks and balances that were not in place decades ago (before the 70s) are the result of the law, judges and patient advocates examining the system and finding areas where improvement was needed.

Doctors just aren't supposed to write a GAF=20 on a piece of paper...period. They have to justify why on that paper the person needs to be held such as descriptions of why the person is dangerous to him/herself, others or unable to care for him/herself on their own due to mental illness. Otherwise there will be people in the system that during the check and balance process will see this and question the hold and may take action to end it.

If one actually examines how the system works, to complain to us (on this board) or to attack psychiatry as a whole for the commitment of psychiatric patients is the wrong way to look at it. If you don't want a psychiatrist, then don't go to one. For any cases where people are treated against their will, it only be done if someone reported you as dangerous to yourself, others or unable to care for yourself in the community on your own due to a mental illness or your parent demanded you get treated for a mental illness..in which case you can only be held, or in the case of a minor if the parent demands medication and the doctor agrees.

If you want this process to end, instead of griping to psychiatrists--who are on a board and really can't help you, you need to try to get your politiicans to change the law and get the Supreme Court to overturn most of its mental health decisions. Given some of the complaints I've seen, it would seem to me that several people who don't like us psychiatrists would want people who are mentally ill and dangerous to be out in the community. I don't think I'd see any politician or Supreme Court Justice backing that.

IMHO, there are areas that do need improvement, but I wouldn't want to waste my time arguing these areas with someone who really doesn't understand the system, but is angry with it based on reasons that aren't true. In that case, I'd rather just try to explain to the person that their misconceptions are misconceptions.

In a libertarian sense, everyone has the right to commit suicide and should not be burdened with a more difficult life, something which they seek to escape.

If that's your opinion, then so be it. However the law certainly has stated what we doctors are supposed to do in such as case. If you want people to be able to freely commit suicide, and that doctors should have no responsibility to step in, then don't argue with us, take this up with your politicians. If they took away the legal impositions to force us doctors to not commit a patient, it'd actually make our lives easier. I wouldn't agree with it, but my caseload would certainly be a lot easier.

 

[Faebinder]

If that's your opinion, then so be it. However the law certainly has stated what we doctors are supposed to do in such as case. If you want people to be able to freely commit suicide, and that doctors should have no responsibility to step in, then don't argue with us, take this up with your politicians. If they took away the legal impositions to force us doctors to not commit a patient, it'd actually make our lives easier. I wouldn't agree with it, but my caseload would certainly be a lot easier.

Well said....

Quit attacking psychiatrists and go change the laws and take away our responsibility when people go kill themselves.

 

[whopper]

If that's your opinion, then so be it. However the law certainly has stated what we doctors are supposed to do in such as case. If you want people to be able to freely commit suicide, and that doctors should have no responsibility to step in, then don't argue with us, take this up with your politicians. If they took away the legal impositions to force us doctors to not commit a patient, it'd actually make our lives easier. I wouldn't agree with it, but my caseload would certainly be a lot easier.

Aw geez, noticing my grammar errors in hindsight...

If they took away the legal impositions to force us doctors to not commit a patient

Should be..."If they took away the legal impositions to force us doctors to hold a patient for review for involuntarily commitment."

Sorry, but I think everyone got the point.

Suicide is one of the biggest areas where psychiatrists are sued for malpractice, and the area that gives us a lot of headache when trying to figure if the person is safe. If the law was changed so that anyone could freely commit suicide, then our jobs would be a heck of a lot easier.

So by all means-to all those who don't want us to have the power to hold for petition for involuntary commitment, knock yourself out. I wouldn't agree with it, but I would obey the law.