Tuesday, February 14, 2012

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.

Clinical Scenario:

You are a forensic psychiatrist working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.


Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)


Liz said...

point taken-- clink. i have no idea which patients i would keep and which i would send for further treatment.

do i have a safe place to keep them at the jail where they can be monitored closely and carefully? could i keep them and have them be carefully monitored, and then, if their agitation continues to grow, have them evaluated at that point?

patients a and b:

i'd perform a physical and interview them to determine the reasons (in their understanding) they were brought to jail as well as preceding events. i'd also want to read the paperwork and speak with the arresting officer to enhance my understanding of the situation.

i'd re-evaluate my decision after i completed those tasks. i'm particularly wondering the age of patient b... if he's manic and whether he's been treated before.

patient c: de-escalation would be a nice first goal... is he aggressive when left alone in a room? does this agitate him or calm him down? i'd try letting him sit in a room, closely monitored. while he's calming, i'd try to do all possible information gathering... after he's calm and able to interact, i'd interview him and determine next steps.

you win, clink. i have no freaking idea, really, what i'd do beyond keep them safe and try to figure out what the heck is going on with them.

Dinah said...

Happy Valentine's Day, to you too! I woke up, saw this on my email, and it was like one of those dreams where you never get out of school. Especially with the "Please Discuss" requirement. Oh my.

Anonymous said...

Due to budget cuts, the only ones who get psychiatric care are the people who don't really need it., those who can see an outpatient shrink. Emergency psych treatment is an oxymoron where i am so it is not clear that someone charged with a crime would be any better in a hospital where everyone is ignored and drugged to the point that their angels and demons shut up, though they could still commit suicide on the ward and no one would know for hours. To be clear, this is not anti shrink, it is anti the system.

Rubin said...

Psych resident here. I agree with Liz. This is a very difficult situation. I would attempt the history (including collateral information) and physical with patients A and B. My gut reaction is to have both sent to the ER for basic labs due to the concern of intoxication but the risks of them falling through the cracks is another issue. Patient C would be monitored and assessment attempted once he has de-escalated.

jesse said...

OK, I'll take a shot at this. You know A and he trusts you. No medical history that would warrant an ER. No family so what he said he did to his mother, he did not. Keep him and check in every so often. B has a gash and perhaps an internal bleed, who knows. Send him to the ER. C, watch him, but not from too close or he'll bash your head.

Anonymous said...

A's mother showed up after a 30 year absence and he he shot her in the head. Or, A never talked about his mother so she was not known to anyone but he has had her tied up in the cellar for 15 years.

Anonymous said...

A's mother showed up after a 30 year absence and he he shot her in the head. Or, A never talked about his mother so she was not known to anyone but he has had her tied up in the cellar for 15 years.

Spritz said...

Easy. Patients A, B, and C are brothers. A was using what was in his begging cup to purchase a 40 oz at the local market. B works the register there. A call from B's controlling mother interrupts and derails their conversation. B says he was left at a mini mall by his mother when he was 8 years old. Strangely enough, B remembers having a brother who his mother lost at at that very same mini mall. B invites A over to meet his long lost mother and other brother. At the mother's home A and B are discussing angels and demons. Mommy Dearest butts in and claims that C is a demon. C gets enraged and goes after Mom with a knife. A(with no violent history) tries to save Mom by fighting C for the knife, accidently stabbing Mom in the throat. B gets in the way, causing his head to be gashed by the knife. B forces A to kiss the owie better because his Mom can no longer do it. C becomes violent because his mother was not killed by his own hand.
A gets a chic safety smock.
B gets an ER transport for that expensive new battle wound.
C gets a restraint chair and some quiet time with happy thought.

But on a more serious note, this is why all states should require CIT courses for their certification of peace officers. I am glad we do not operate that way here.

MM said...

I have trouble believing that mental illness alone can cause violence. I have been pretty seriously mentally ill and I have known others who have been pretty crazy, but although there has been a lot of violence in my life none has been committed by a mentally ill person. In fact a lot of the people I know became mentally ill from being raped, while their attackers would be considered sane.

Anon Anon said...

You know if you treat A he will come around to sanity and he trusts you so he's better off staying at the jail. B is more of an unknown and has a head gash that should be treated so he should go to the ER. C needs to calm down for awhile. You can't send someone that violent to the ER.

Anonymous said...

Patient B needs to go to the hospital. He is experiencing DT's from his abuse. He could go into seizures, and have high blood presure from such.
Patient A has a mental disorder possiabl from drug use, but is ok on meds. He needs a few more hours to come off any drugs, closly monitored in jail and recommened for on going counseling when appearing in court.
Patient C needs to be in jail for behavior disorders and neds to ahev some consequences for such.

ClinkShrink said...

Liz wants to know if there is a safe place in the jail to monitor people. The jail does have a psychiatric infirmary with an observation cell, but since these people haven't been booked yet you can't send them there. There is a cell in the booking area that is sometimes used to house people by themselves, until they can get booked and charged. These are not observation cells though, officially. That may influence your decision to keep all three patients.

Rubin would like to send out A and B, but would definitely keep C.

Jesse took an unexpected (to me) approach and suggested that Patient A is delusional about hurting his mother. (He's not, the police found her. Patient A's mother was just not known to the facility---with emphasis on the past tense.) He would send out B and keep C.

Spritz would keep A, send out B, and place C in a restraint chair. Ah, if only the jail had one of those! No, the booking area only has an unofficial isolation cell. And be sure to get some medicine into C before he goes into that cell because custody will not touch him again after that until he calms down. Unfortunately, C came in on the night shift and the duty lieutenant will refuse any request for show-of-force assistance when giving medication (even though the policy says they're supposed to help).

The two anonymi are falling in with the pack to keep A and C but send out B.

Great responses, everybody! I'm going to let this post ride for a bit to see if some of our more shy readers will come out and put up some thoughts. I've also got a Twitter buddy in the UK, @mentalhealthcop (good guy to follow!) I'm hoping will chime in with his experiences. Then I'll post the ending to all these stories. I'm glad people enjoyed my characters enough to fill in the back story!

MM: Most mentally ill people who become insanity acquittees are only violent as a last resort. It can happen, unfortunately, but it's not the norm.

ClinkShrink said...

Oh, I forgot to mention: the only phone in the booking area isn't working. And you have no fax machine.

rob lindeman said...

"People with mental illness require the right treatment, at the right time...." if they want it.

In MY opinion, you spend too much time complaining about stigmatization of the mentally ill, and not enough time considering what mentally ill people want.

wv = redisc. The CD the manufacturer mails you when you lose the original (that you were supposed to keep safe in a drawer somewhere)

Anonymous said...

So Patient C is agitated, covered in blood, but unlike patients A and B, it is not apparent that he was brought in on any charges so why did the cops bring him to a jail rather than a hospital? He may or may not have a record but did he commit a crime or offense? Take him to a hospital. Of course, people who are charged with something may still need treatment but this guy is in the wrong place.

ClinkShrink said...

Rob: It's a little hard to ask these three patients about their longterm aspirations. Maybe after they're done being tormented by demons or wrestling with police.

Anon: Patient C was under arrest, which meant police were planning to charge him once he quit fighting. We don't know the details of why he was brought in.

Anonymous said...

"Anon: Patient C was under arrest, which meant police were planning to charge him once he quit fighting. We don't know the details of why he was brought in."

I cannot understand how it is that the forensic psychiatrist would not be given the information about what led to the arrest. The police brought him in. He didn't appear by magic. I was brought to a hospital by police. They dumped me there but not before giving the staff a summary of why, in their opinion, they had been called to attend the scene. Hospital still had to figure out if I was psychotic or strung out on drugs. Hint: it wasn't drugs.

ClinkShrink said...

Anon: Yes, in most cases the jail psychiatrist doesn't know the details of what their patient has done (or accused of). They know the charge, but not specifics. In usual circumstances the police drop the defendant at the booking station, fill out the charging papers and leave. They are gone before the person is seen by a mental health professional. This is particularly true in large urban jails where literally hundreds of people may be brought in over a 24 hour period.

Anonymous said...

Keep A at least until you can see if he responds to same treatment. Send B to ED. C.....keep for a few hours, if no improvement, to ED for at least labs.

Anonymous said...

I almost agree to Liz and Jesse, for both sound perfectly fine. But I think that even as a clinical scenario it is best to pass a judgment when we have just one case in hand at a time, and things can always change with more information coming in. With three cases being considered together it can be just a guess, nothing more than that. And its always different in a real situation. However, it is best in each case to have more information before reaching at any conclusion.

Anonymous said...

I haven't read the vignettes yet, so I figured I'd play.

A - 72 hour hold, see if social worker can get him hooked up with community mental health.

B - If there's a hospital with a substance abuse ward, great. Should detox under medical supervision. If not, send to jail ("drunk tank") and evaluate in the morning.

C - Versed, send to jail, evaluate in the morning.