Friday, July 08, 2011


There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

  • The psychiatrist doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a psychiatrist to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
  • There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the psychiatrist/ER staff to give them each enough attention.
  • There are other risk factors which leave the psychiatrist feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
  • The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
  • The psychiatrist has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
  • The psychiatrist has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
  • A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
  • The patient refuses to commit to a safety plan.
  • The psychiatrist is evil and loves power.  (I had to throw that in here)
This is our 1,500th post.  Thank you for helping me procrastinate.


jesse said...

Wonderful post! You address the fact that there is always an intersection between at least two people in these instances. We try to use our best judgment, but it cannot be perfect, and need not be. The person who takes the action needs to be able to explain why he did. Rarely is there no reason except for the words.

aek said...

1500! Congratulations!

Now wiping the smile off my face and pondering your likelies list: "The psychiatrist doesn't believe that the patient has no intention of acting on them.
There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having.
There are other risk factors which leave the psychiatrist feeling worried
The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.
The psychiatrist has his or her reasons for being predisposed to being overly cautious
The psychiatrist has his own baggage All sorts of factors influence how a shrink thinks.
A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
The patient refuses to commit to a safety plan.
The psychiatrist is evil and loves power."

I don't read anything in this list that squares with evidence-based medicine. It appears to be arbitrary, intuitive possibly, capricious and utilitarian (time conserving in the face of workload or external threat). It may also be punitive and retaliatory. It makes me shudder, quite frankly.

And when I consider the differences between psychiatric hospitalization and imprisonment, I don't find any comforting significant differences. Both deny basic civil liberties, are based on token reward systems for staff benefit and control, and they both create and promote powerlessness and helplessness conditions. Moreover, they are bereft of comfort, reassurance and essential family/sig other presence.

Housing patients with all sorts of mental illnesses together and forcing them to interact with one another as "peers" is entirely unfounded - it has no basis in science. All patients with cancer are not hospitalized and treated this way, nor are patients with endocrine diagnoses or cardiovascular diagnoses or kidney diagnoses, etc.

Part I

aek said...

Part II - final

And what is this intensive treatment and management you speak of (wry grin)? Inpatient psychotherapy doesn't exist, for the most part, and there are no classes for patients to learn about specific medications and management. H#@*, too many psychiatrists are so busy practicing "psychopharmacology" to the dereliction of practicing medicine, that they don't do baseline metabolic and lipid screening before prescribing meds which cause derangements of those. Forget about lab monitoring. Better to see a pharmacist than a psychiatrist for medication safety.

I react strongly to this because I've seen patients suffer, harmed and be traumatized as a result of the subjectivity and capriciousness of involuntary treatment. One thing I learned along the way in investigating a sentinel event or two is that there are no standards of nursing care and practice for patients with psychiatric diagnoses hospitalized on non-behavioral health units (med-surg, OB-gyn, critical care, etc). I also learned that no psychiatrist would ever darken those same units to see patients because - horrors! - they weren't "medically cleared".

A mental health crisis is a crisis, no matter the setting where care is delivered. The bottom line is that people in unbearable distress do not receive care which helps them to regulate, tolerate and decrease the distress. Instead, they are "contained, evaluated, monitored and medicated".

I looked briefly in the pub(med), but couldn't find a single study which looked at patients' outcomes around involuntary hospitalization. Does it decrease suicide attempts and suicides? unknown Does it lead to improved distress tolerance? unknown Does it lead to increased rates of remissions? unknown Does it lead to higher rates of treatment compliance? unknown Does it lead to better quality of life/well-being? unknown Does it lead to more medication burden? unknown, but I have a guess
/rant (discard if the living room soilage and aroma is too foul)

rob lindeman said...

Oh My God!

This litany of arbitrariness and subjectivity serves as justification for depriving innocent citizens of their liberty?!

Say it aint so!

Wv- blyro. Brand of fountain pen used exclusively for incarceration of those innocent of crimes

Sunny CA said...

Gee. I come here to procrastinate on doing all the things I need to do! It never occurred to me that you do the same thing.

Thanks. Interesting post. It was well worth putting off the dishes and other tasks.

Anonymous said...

This was a great post. Didn't sound judgmental or as if you were disregarding patient perspective, which sometimes your posts do. You made a bunch of valid points. Appreciated.

Anonymous said...

I wonder why the term is different in other countries, ... I'm in Australia we call it "Scheduling," in England it's known as "sectioning" ... committed seems to be the word in the states ... interesting

rob lindeman said...

What, is invocation of the Deity no longer permitted in the comments section?

Dinah, the list is capricious, arbitrary, and subjective. Please tell us you take deprivation of innocent people's liberty more seriously than this!

Anonymous said...

Perhaps I have noted here before that patients are at very high risk of suicide in the year following their discharge. I am sure there are all sorts of reasons. To be on the safe side, how about everyone has to stay in hospital a year beyond the proposed date of discharge? Hmm, they had better build bigger wards in a hurry, as well as expand the psycho-geriatric units--we're all going to die in there if the world wants to keep up perfectly safe and if we do not want to cause excess worry for our doctors.

Dinah said...

Rob: People are wrongly arrested all the time for crimes they didn't commit and are kept in jail for months to years. Why doesn't that bother you? Poor OJ, Poor Caley...all found innocent by the due process system you love, but not until they've served and served.

Generally, those who get hospitalized because of the 'mis-communications' listed above are released with in 1-3 days, once all is clarified. Often the next day.

Evidence-based medicine has not been particularly useful to me when the going gets rough.

What we do know is that people attempt suicide impulsively, and that if the moment is interrupted they often go on with their lives. Getting them through that 'moment' and doing something that helps shift the gears, may enable them to go on with their lives for decades. Apparently Rob thinks we should let every heartsick teenager kill themselves over a breakup? (and yes, these kids do end up in the hospital, at least the ones who don't die)

The hospitals I've seen look nothing like prisons. I will leave this one to Clink since she's been in both.

Hospitals do allow for quicker treatment, especially with regards to meds. You can check levels daily, observe for side effects and move the doses faster if they are tolerated, be certain the patient is actually getting what you want them to take. In outpatient world, people just don't get labs done when I ask them to (over and over again), and things move more slowly.

Until the recent posts here, I had no realization that involuntary commitment was such a concern--- my patients who've been through it were troubled and got themselves out fairly quickly ("I suddenly realized that if I wouldn't take the pills, I'd be there on my birhtday, so I swallowed them and they let me out the next day").

The BIG problem we see in psychiatry is that there are no beds for those who WANT them (and the vast majority of patients are voluntary, asking for beds, coming to the ER saying "admit me!" but if they don't say they're dangerous, they can't get that true in the lobby of the prison, too, that people are there asking to come in???

Dinah said...

I meant Casey, not Caley. Oy.

rob lindeman said...

Dinah, unconstitutionaldeprivation of liberty AND miscarriage of justice bother me a great deal. I never suggested otherwise. The question is, why doesn't it bother you?

Maggie said...

"coming to the ER saying 'admit me!' but if they don't say they're dangerous, they can't get that true in the lobby of the prison, too, that people are there asking to come in???"

Actually, it seems the answer to that one is "yes." For some reason I thought you'd blogged about the guy who "robbed" a bank for $1 for the express purpose of going to jail, because he was having serious medical problems and couldn't afford healthcare.

But all that aside, aek does have a point. I'm sure it varies somewhat, but inpatient care can be really, really bad for a lot of people. I am wondering how many psychiatrists would ever know that, though. When it's nursing staff or technicians who are behaving abusively and falsifying and/or exaggerating on charts, how is the psychiatrist who spends 5 minutes with the patient going to figure that out?
Or when usually well-meaning parents exaggerate their kid's condition on the theory that the more treatment will make them better faster. Then the kid ends up in an inappropriate treatment setting, and the staff assumes that they're just a lying little twit when their story dosn't match up with their parents' description of the situation. (BTDT)

If inpatient treatment were more therapeutic, more individualized, and less degrading, you'd have a much better point. I've been under the impression that a large portion of people who are begging for admission are homeless. Homelessness is awfully degrading in and of itself.

(I got a 503 error when I went to submit this comment a second ago.. so I think I'm only submitting it once.)

jesse said...

Because I oft in dark abstracted guise
Seem most alone in greatest company...
Sir Philip Sidney, Astrophil and Stella, XXVII

Dinah's post is an attempt to understand some of the factors that might have gone into an involuntary hospitalization. It is therefore coming from a different direction from one which would explain all the considerations that need to be taken into account.

Decisions such as these are rarely made from only one factor. There are several, which taken together leads the doctor to decide as he does. So we might have a man who lost his job, is alcoholic, is thinking slowly, recently bought a gun, and whose father had committed suicide...but all of those factors are in the context of his wife and daughter having brought him into the ED because they are frightened that he will act on his dark thoughts. They know him well and "something is different" with him now.

We all know that suicide might be more likely when a depressed person is suddenly better - often because he had decided that suicide would be the way out and he is now calm - this is very hard to pick up and often is seen only in hindsight.

Another very important factor is what external events or thoughts mean to the patient. We pay attention not only to external factors but the internal ones. The loss of a job or of a girlfriend - what does that mean to him? An event which might be trivial to one person can be shattering to another.

Loneliness and alienation. Suicides may be precipitated by a small event, but one which leads a person to feel totally isolated. The very fact of a brief hospitalization, with the attention and care it entails (in a good hospital) may be what is needed to help a patient find hope.

Kelly Anne said...


Although there is a serious problem with the health care/mental health care system, I wanted to provide a ray of hope for those who are suffering and have no other place to go.

1) There are individuals who do find help in the hospital.

2) There are individuals who recover from a hospital crisis and return back to their life at an elevated level of functioning. The experience of being involuntarily committed is a process with many potential positives and negatives. As with any TOOL, how one utilizes the experience can make all the difference. (Although I recognize that not all the responsibility should be left to the patient)

3) There are many (but not all) psychiatrists who actually do want to help, yet are limited by many aspects of the health care system.
Making overarching generalizations about psychiatrists may strengthen the uncertainty suffering people have about asking for help.

4)If a system, process, and the people working in this framework are criticized (and on many occasions perhaps rightly so) without providing alternative care options...I'm not quite sure how this will help individuals who are suicidal.

The hospital experience can provide further networking options and resources which may come in many different forms.
Some people that may help include: social workers, doctors, nurses, family members, friends...etc.

Some activities that may help: feeling safe, getting a good sleep, communicating with family about your problems, communicating with other patients, communicating with other workers (social workers, occupational therapists), getting away from the daily stress of your own routine, engaging in new activities such as reading or drawing or doing art...etc...

rob lindeman said...

"The very fact of a brief hospitalization, with the attention and care it entails (in a good hospital) may be what is needed to help a patient find hope."

And there might be a long hospitalization in a bad hospital. Even a brief stay in a good hospital might not be needed for a person to find hope. In fact it's more likely than not to dehumanize him instead.

By all means, use all the compassion, love, and moral persuasion you have to try and convince an individual not to commit suicide. Just don't deprive him of his humanity by depriving him of his liberty. That's not love. It's coercion, force and fraud.

Sarebear said...

I enjoyed this post, and congrats on 1500!

I don't think this was intended to be a comprehensive, in-depth look at why involuntary commitments occur, just more a speculation from someone who sees things from a different perspective than we do (well, non-shrinks do) about some things that can affect the decision.

I smiled when you put in that thing about psychiatrists being evil. You must be a most understanding person to put that in, even if it was facetiously (which I'm not saying it was lol.)

Anonymous said...

I got the 503 error message, too. So, who knows if my previous comment will show up.

Anyway, congrats again on the 1500th post.

Aek mentioned "peers." When I read that it makes me laugh because it reminds me of reading my inpatient psych records that say I was "friendly toward peers and hostile toward staff." The only requirement to be "staff" in Texas psych hospitals is a high school diploma or GED. You want to be a psych tech in Texas? Better get your GED. They are not your peers, please remember that. They are the professionals.


Dinah said...

Blogger ate my comment.


I'm not outraged because I believe most people leave the hospital in a better state than they arrived in and the hospitals I've worked in are nothing like prisons. It just doesn't strike me as the end of the world-- basketweaving and stupid charting issues aside-- if someone ends up spending a few days in a hospital. If they kill themselves or someone else, it is the end of someone's world. The majority of people I've treated who've been hospitalized felt it was helpful, and those who didn't have been motivated to make changes so that it doesn't happen again. Mostly people just come out and move on with their lives, and that is good.
I do believe that people who feel they were mistreated should complain.
If you'd like me to lose sleep because someone is forcing Jared Loughner to take medications, it's probably not going to happen.

Okay, this horse is very dead. Time for a new topic. Unless of course I can inspired Clink to blog on the differences between hospitals and prisons, since she spends time in both.

The Alienist said...

O.K. Let's design a study to see if involuntary hospitalization works.

Hmmm. First we need to get ahold of a group of imminently suicidal patients. Since not all will be equally suicidal or have equally effective plans, we will have to measure the severity of their intents and the lethality an availability of their means. We will use these measures to pseudorandomly divide them into two subgroups. One group will be hospitalized and one group will not (but both will be equally sucidal). For simplicity's sake we will not use a healthy control group so that we won't have to involuntarily hospitalize non-suicidal patients. We will be careful to ensure that those randomized to the non-hospitalization group are not offered hospitalization if they again become suicidal (otherwise the amateur statisticians will inform use that if they die, then it was the hospitalization that made them do so).

The outcomes of this research will be very easy to measure. How many of each group died. Our null hypothesis will be that there will be no difference in death rates between the two groups. If, however, there are significantly fewer deaths among the hospitalized, then we will conclude that hospitalization was protective. If significantly more non-hospitalized patients die, then we can admit that hospitalization was harmful.

Anything less than the above type of research will not answer the question --it would have uncontrolled bias. The above study would not be very expensive. It would only cost a little for the psychiatric evaluations; it would lead to savings due to not having to hospitalize half of the suicidal patients; and it would only cost the deaths of a portion of the suicidal patients who are refused care.

See how little it takes to answer this very important question? I'm sure that those of you who cite a need for proof of the value of involuntary hospitalization would be happy to endorse this research project.

I'll just rely on the way our society normally solves all kinds of adversarial interactions. I'll do my best to make a fair and respectful decision, and the judge can ensure that my patient's rights are being upheld.

Dinah said...

Ah, the Shrink Rappers are growing tired of the whole debate on Involuntary Hospitalization (at least my co-bloggers seem less than enthralled).
I am going to refer interested parties over to the Alienist's blog-- he even has directions on how to get yourself involuntarily committed.

Looks like things are a bit heated over there:

Anonymous said...

Yeah, I read the suggestions over at the Alienist's blog. Sounds like those who got involuntarily admitted made the psychiatrist mad. E.g. two of the suggestions to get involuntarily committed included: pick a fight with the psychiatrist (threaten an attorney), refuse to do anything the psychiatrist says. That's a little scary.

The adversarial type approach never saved me from anything. It did, however, make me less likely to turn to those who would use that approach.

wv = sable. Sable island is known for its population of feral horses.


The Alienist said...


Yes, it is a little scary. It is scary for both the psychiatrist and the patient. I don't know of a psychiatrist who takes such an action lightly. Please remember that the psychiatrist is a person, too.

It's not necessarily that the behaviors mentioned on my blog make the psychiatrist mad (though it is certainly possible). It's that the behaviors listed show an inability to cooperate and find a better solution. To attack and threaten someone who is trying to help would make anyone wonder if the patient is able to voluntarily accept help.

I'm sorry for the extra post on this topic. I will let this one go, now.

Simple Citizen said...

1. We have a right to refuse treatment. If we're dying, we can order doctors not to intubate us, not to do CPR, etc...
2. The state has the right to prevent suicide. If you threaten or try to kill yourself - they can commit you against your will.
SO - What if a person makes a suicide attempt, is dying in the ER, but they have a Do-Not-Resuscitate order?

I recently researched this topic, wrote an essay - and I am seeking discussion.