Tuesday, June 18, 2013

What Would You Do? What Would You Want?

Courtesy of CNN, here are a couple real-life scenarios I thought I'd share with you. Both of these videos represent the kind of cases that a psychiatrist confronts in an emergency room. I'd like you to put yourself first in the position of the patient: suppose you've been sick before, but never this sick (let's take it for granted none of this is due to drugs for now). You have an advance directive in place that says you absolutely don't want treatment even if you're a danger to yourself (again, for the sake of the exercise it's an enforceable advance directive). You never addressed danger to others in your advance directive because you never anticipated it could get this bad.

What would you want done?

If you were the doctor, what would you do?

Now for the second scenario. Is there anything about this situation that might make your wishes or opinions different from the first one? What's the difference? And if none, why not?

Thank you in advance for thinking about these problems. All of you who commented on my Emancipated Patient post have taught me something and I'm grateful. I'm putting this up to learn more about your ideas, opinions and wishes. Please keep talking.


Dinah said...

Clink, where do you find this stuff? Great scenarios to think about.

Je suis said...

Having watched both videos, it appears that in both instances a crime was committed. this seems to me to be the crux of the matter; If a mental illness causes one to commit a crime, then that individual's options become limited. This is no different than someone without mental illness committing a crime, after all. In both cases I would venture to guess that these actors were arrested and charged with something. It is at this point that a psychiatrist should become involved, assessing the cause of these unusual actions, and if it is determined to be a mental illness, then involuntary hospitalization should be an alternate to imprisonment. This serves the intent of involuntary commitment, i.e. providing help for those whose actions are deemed to be out of their control, while also protecting the individual from the unnecessarily harsh legal entanglements that they might face for their activities while ill.
The advanced directive should be considered, but not binding, in cases like this, as the person's actions are clearly outside the norm of social acceptance, and a crime has been committed. Inmates lose certain rights, including, at least in some states, the right to refuse medications. Since involuntary commitment is so similar to imprisonment, this seems a fair trade-off - prison vs. hospitalization.

However, involuntary commitment should not be forced upon someone who has not committed a crime, even if presenting as mentally ill. For example, a depressed individual talking of suicide. While alarming, this is not a crime, and should not be treated as such. All possible avenues of treatment should be explored with such a person, including voluntary hospitalization, but they should not be forced into anything. Even if they then decide to forgo help,
and there is a high likelihood of suicide; it must be their choice. in this case, an advanced directive should be binding - the individual has not broken the law, and should have their wished respected.

Now, I recognize that there is the "dangerous to others" problem involved; but is it really that difficult? After all, what causes suspicion of dangerousness to others? Usually a comment about harming others, or a direct threat. Isn't this assault? Assault is the verbal component, battery is the physical component - so an assault is a crime, and we are back at the beginning, with a crime being committed.

Does this seem unnecessarily harsh, to tie mental illness to crime? Perhaps, but then, that's the system we've got already. Most of the severely, and quite a few of the moderately, mentally ill end up in encounters with the legal system as it stands, since the legal system is much less forgiving of mental illness. So really, nothing changes, except for the forced hospitalization of people dealing with mental health issues who have otherwise done nothing to warrant incarceration.

Anonymous said...

Je suis, what do you think of a person who gets hospitalized involuntarily for being "gravely disabled" -- too confused in his/her thought process to eat, find reasonable shelter, or protect his/herself from the elements? There's a lot of wiggle room here, but I'd want to see a person wandering in PJs in a midwest winter brought inside and kept there, even if no law has been broken.


Sunny CA said...

When I initially heard about these cases and when I review these videos, my major experience is feeling emotional pain at their situations. I ache for the nightmare they are trapped inside. I do feel that "it could have been I" when I watch the footage, and I fully understand their lack of comprehension of the situations they are creating, and the intense distress they likely are under.

There is no choice in either case but to take these people into some sort of custody, because they are "acting out" in a public way that impacts other people. Law enforcement officials who are summoned can arrest the psychotic & take him to jail or escort him into forced hospitalization with or without pressing charges, but they cannot do nothing at all because the situation can't be allowed to continue.

The airline passenger fared better than a similar man a few years ago who was shot and (I think) was killed by airport security on the spot, as he left the airplane.

My hat is off to the compassionate seatmates of the psychotic traveler who soothed and calmed the psychotic verbally for the rest of the flight, rather than show continued aggressive, coercive behavior towards him, once handcuffed.

In the end, the issue in my mind comes down to how humanely and kindly we treat psychotic patients once they are hospitalized or jailed. Those seeing the psychotic, except loved ones, frequently are not seeing the person, even staff on a mental ward. If you read the article above about the naked acrobat, his friends know him as a work-a-haulic leader of an acrobatic troupe, and a person who should be treated with kindness and compassion. From my experience he will not be treated in that way once detained.

Dinah, I think a topic for another blog post could be how forced hospitalization and forced medication could be redesigned to be kinder, gentler, and more humane for psychotic patients, and all mentally ill patients.

Do there have to be teams of men who tackle a patient and administer injections? Can't anyone think of a single way to camouflage oral medications in food? Is it realistic to expect a psychotic to sit, "behaving" in the day room listening to droning lectures about relaxation, planning leisure activities, reducing stress, when the psychotic is unable to follow the conversation? Is it realistic to expect a psychotic to "just behave" and not shout or do anything that his depressed, non-psychotic peers would do? It may be convenient to sedate the psychotic half out of his mind, but is this kind treatment? Is there any way to allow for patients to safely be allowed physical exercise within the ward? Many patients were not sedentary 24/7 before hospitalization, but are expected to be completely sedentary once inside. If a patient is pacing in the hallways, is a reasonable alternative activity from the patient perspective to be redirected to sit quietly in a chair? I would bet that naked acrobat will need to be heavily sedated to manage chair-sitting 24 hours a day.

I think it might take restructuring of facilities because a psychotic manic patient just does not fit into a ward of depressed or suicidal people, which make up the larger part of the hospital population. Currently the expectation for all hospitalized patients is a full day of quiet sitting, which may not be the best for any of the patients. The instruction and crafts offered are similar to low level, grammar-school type activities, which may not be appropriate for many adults.

Here is more about the naked man story, in the SF Chronicle, including a much longer video. He now faces deportation:


AN update is here:

Je suis said...

Your mention of a midwest winter reminds me of my turning point; that point where I started to view psychiatry in a more, shall we say, discriminatory fashion. I was not privy to the entire conversation of course, but essentially I overheard some of a conversation between a psychiatrist and a patient.
This patient was a homeless man, and on the day in question, the weather forecast was for a very much below freezing cold front to come in. I remember the psychiatrist telling the man to keep warm, even though the homeless guy had nowhere to go.
That's it. "Keep warm out there" - I still remember the exact parting words. So, why is it that psychiatry is so concerned on one hand, as long as you have a psychiatric disorder, yet so seemingly indifferent otherwise?
Why so much concern over gravely ill people, not so much over the homeless? Let me further explain:
I read an explanation of dangerousness, explained by a psychiatrist, as being more that
threatening or suicidal; it also includes such things as giving up a job - your source of income - without having another income source available. That's it, abruptly quit without another prospect and you are dangerous.
This was a criteria used in deciding whether to involuntarily commit. Yet the homeless do not have either a source of income to give up, or another in place, but we do not, as a rule, commit them. Why not?

So, as to the gravely disabled: who has made that determination? Perhaps they are just homeless, which means it's OK to leave them out in the cold to live or die on their own. I don't know. It's a grey area, definitely. I cannot answer for everyone on this point; just myself. And that is, if I should become so disabled, so unable to function or even process thoughts coherently, then do not save me. I am too far gone, and I do not want to live like that. Let it end. Perhaps it's similar to aging - the body reaches a point where it just cannot continue to function. We can keep people alive with machines long after that point, of course, but are we really doing them any favors? Maybe the mind reaches a similar point, and we are doing no favors by forcing existence at that point, either. I don't know, and neither does anyone else, despite their "expertise'. Here's a question to consider, however - can we continue to save everyone? every day, it seems, we have a new shortage of a drug that we all take for granted would always be available, the shortages are reaching critical proportions. What then, when resources run out?

Sunny CA said...

Je suis-
I was Involuntarily committed on a 5150 Gravely Disabled, and was nothing like you envision. Gravely Disabled admissions are not for people who up and quit thejr job or there would be no hospital space for anything but job-quitters.

I was still working and relatively OK the night before admission, then was a screaming, paranoid psychotic 24-hours later. I was not all that different from the men in the videos, except that I knew my brain was not functioning properly and asked my husband to take me to the emergency room where I finally "cracked" and became a shrieking, fearful, psychotic mess.

But, Je Suis, in-hospital, about 13 days later my brain started processing things reasonably properly again.

I am not a homeless bag lady. I have a paid-for house, savings enough to support me after a life of working behind me, and I forged a new career following discharge. Really, there can be life after being stark-raving mad. It helps greatly to not have committed any crimes while crazy, and I did not.

This is not to say that hospitalization was not traumatic. It was very traumatic, both from the perspective of how I was treated and the awful effects of the hospital sedation, plus the underlying, irrational, nightmareish terror of the psychosis, followed by the knowledge that there is risk of future psychosis.

jcat said...

As an onlooker, both of the videos made me really sad for the patient - that someone who is probably a nice-enough person generally is in a place where they are out-of-control, scared, disoriented.

As a patient, I've never imploded that spectacularly, and doubt that I ever would, because I'm an introvert, and my version of insanity involves turning my fears inward. But even so, with enough alcohol, I've done some wild and aggressive stuff that probably scared people around me. And I NEVER want to go there again. I'd like to know that if it does, that people would realise I need help that I can't ask for because - at the time - I don't believe I need any. I'd want someone to realise that I'm no longer the person who can make rational choices about taking certain meds or not, and to do whatever is going to get me away from the edge soonest. We can debate the niceties about which anti-psychotic (or even one at all) at a future date.

As the doctor, I'm afraid that my feelings about possibly being that patient would be really strong. My instinct would be to treat with anything and everything at my disposal, to try and get the generally nice person that the patient probably is back again, to get them to where the only choices they have aren't all bad ones.

I think what I've said applies to suicidal depression as much as it does to psychosis. Even if it doesn't look as scary for the bystander, from the inside it sometimes feels that way.

ClinkShrink said...

Je Suis: Just a question as a point of clarification--in my post I was asking readers what they would want if they were in the position of the person in the videos. Are you saying that you would prefer to be arrested, charged and taken to a jail rather than to a hospital emergency room?

Sunny: Thanks for the followup link. I thought these videos were a bit painful to watch too. I really wish the main stream media didn't seem to get such a kick out of publicly humiliating people with mental illnesses.

I liked the therapist quote in the article though: “Personally, I think he needs more of an organic doctor." 'Cuz we all know an organic doctor is so much healthier than those inorganic types :)

JCat: I think your description of what the doctor is thinking is pretty much spot-on. I think that's particularly true when the patient gets psychotic for the first time and you hear from the family what the patient used to be like. You want to make sure you do everything you can to try to bring that person back. Even for the chronically ill, you want to see them feeling and living the best they can.

It's interesting that nobody seems to be making the distinction I thought they'd make. In the first video, there was actual physical violence so the issue of risk assessment or prediction was moot. In the second video, there was never any actual violence. The patient made noise and scared people, but the only actual action he made was to reach into his pocket.

Maybe there's a sliding scale of behavior with a cutoff point beyond which any reasonable person would see a need to take a patient into custody?

Sunny CA said...

The reason the airplane incident is elevated in severity despite less extreme behavior is that on an airplane a psychotic person could potentially do something to jeopardize everyone, such as opening an exit door, to try to get out.

The sliding scale of behavior of a psychotic person is irrelevant except for law enforcement purposes.

Having experienced psychosis, it is my feeling that a person is not ever "a little bit psychotic". You either are psychotic or are not. Psychosis is very similar in experience and feel to a dream (nightmare) state. Though actual objects and people can be seen they are interpreted via this dream (nightmare) state.

Probably all psychotic people belong in some sort of restricted environment. After my hospitalization, my husband and I used to discuss what could the alternative restricted environment be, to avoid hospitalization, since I was so adamant that I never end up there again.

We do not have any escape-proof rooms in our house. I found several private psychiatric hospitals by searching online, which advertise their wonderful surroundings, and gentle therapeutic care, but doubt they are interested in treating psychosis, and they are all out of state. Imagine driving across several states with a psychotic spouse! It would not be safe for either the patient or driver, and treatment would be delayed.

I think the time for non-hospitalized treatment ends when psychosis begins, regardless of how well-behaved the patient is. It is possible that if there are enough kind family members, a person could be treated at home, and would cooperate with taking medication from trusted loved ones.

Depression and suicidal feelings are in a completely different category.

Anonymous said...

interesting questions. I agree that in both cases there are laws that have been broken so there's an expectation of arrest. If I had an enforceable psychiatric advance directive, while the psychiatrist would have to abide by it, a patient can always revoke it if she changes her mind. If it truly came down to go to jail or a hospital, I probably would choose the hospital as long as no medications were forced on me and as long as the time contained against my will was less than or equal to time I would be held in jail.

One concern I have with involuntary hospitalization is that determination of danger is so subjective. For example, while under an emergency detention for suicidal ideation, I learned immediately to say I'm not a danger to myself. Then, I asked to go home. The psychiatrist said you're not ready to go home because you haven't shown any emotion since you've been here. Apparently his own special mAde up criterion for determining danger is that I'm a girl, girls are supposed to cry, I didn't cry, so I was still a danger. he didn't have the slightest idea if I was still a danger or not. How will you know when these patients in the story are no longer a threat? When they agree with the opinions of the psychiatrist? How will you know?

I read an article today about two patients on depot injections of "zyprexa" who died with toxic levels of that drug in their bodies. I am going to hope the risk of death was not forced on these patients. I was reminded of how important it is to me to be the one who decides which medication risks I take. I don't want anyone else being able to decide I have to risk the side effects of a drug like that one whether I committed a crime or not.

Sorry had to put the drug name in quotes as it keeps being changed to the word cypress.

Pseudo kristen

Sunny CA said...

I was injected involuntarily with "Zyprexa" among other things. It was "Emergency medication".

I was horrified to discover, when I got out of the hospital(2005), that "Lilly" the maker of "Zyprexa" had just paid out $700 million in damages to people injured by "Zyprexa". In 2007, another $500 million was paid for injury to people taking the drug, but with $4.2 billion a year in sales, just for that drug alone, it is an acceptable cost of doing business.

Je suis said...

I am saying that it is a pointless distinction, the individuals in the videos most likely will be arrested and charged - or, apparently, deported - since the legal definitions that oversee mental illness are not the same standards used to define mental illness. Thus, one could be mentally ill and still be legally liable for their actions, which I suspect is the case here.

@Sunny CA
My point, and I do tend to use extreme situations in order to clarify it at times, was simply that there is a deep division in how "help" is made available. Does it matter that one is 'gravely disabled' vs. simply homeless in such a situation? The end result is still out in the cold, in that case literally. Yet "help" is withheld barring diagnosis; if diagnosed as 'gravely disabled', then by all means, get them out of the cold (in the example given), but if simply homeless, well, good luck and stay warm. Somehow.

I clearly don't grasp the 'gravely disabled' standard fully, as perhaps the term 'disabled' is complicating the issue. 'Disabled' is usually long-term, but in your case, it appears to be temporary?
How is the diagnosis made then? If it is one in which an individual cannot provide for their basic needs, how is that determined exactly? I ask because it seems that you went from functioning to disabled within 24 hours, and asked for help - how did the determination get made so quickly
while ruling out the myriad other
possibilities that could be causing your condition? That seems like a lot of testing in order to rule out a physical cause in a very short time. I am not doubting you, just curious, please don't take offense at my asking.

Also, while it's great that you had the resources to afford this, many do not. A psychiatric hospitalization, and subsequent care, is extremely expensive, prohibitively so for many, and therefore simply trades one untenable situation for another.
This is not helping anyone by running them into debt - many times it's debt that triggers an episode in the first place.

Ultimately, the issue presented here is one in which a psychiatric advanced directive was in place; and as such, I see no problem. In your case Sunny CA, you asked for help - therefore, you received it. You would, I assume, given the parameters, have also have it as wanted in a directive; one in which you filled out while your brain was processing things reasonably. So perhaps that's the answer: on a first time event, hospitalize until stable, then offer the directive: if it it refused, or filled out with requests for future interventions, then treat as if the individual wants intervention; if it is filled out with refused further interventions, or limited further interventions, then it is binding since the person knows what they can expect.

ClinkShrink said...

Je suis: "So perhaps that's the answer: on a first time event, hospitalize until stable, then offer the directive"

I think that's partly what I'm struggling to frame here. There are so many hypotheticals to address in a psychiatric advance directive and this makes a PAD more difficult to plan than a medical advance directive.

I'm thinking something on the order of this discussion:

Q. Under what conditions would you want involuntary treatment (to include admission and medication---specifics to be determined later in the document)?

1. Never
2. Only in case of actual danger to others
3. In case of actual danger to others and/or self
4. In case of risk of danger to others (no overt act, but risk apparent to reasonable person)
5. In case of risk of danger to others and/or self (no overt act, but risk apparent to reasonable
6. To prevent public embarrassment, job loss (miscellaneous customized circumstance specific to person--eg. "don't let me end up on a CNN YouTube video")

I'm thinking about this because even some of the "no treatment under any circumstances" readers here seem to hesitate when presented with the actual risk of danger to others arise.

Steven Reidbord MD said...

Great discussion. I wanted to add a perspective as a psychiatrist practicing in San Francisco, where the naked-acrobat incident occurred. As in most cases of psychotic violence or even milder misbehavior, public reaction about this event was harsh, and largely disregarded its unwilled nature. Many online commenters declared with bravado that they would've beaten the man into submission, and that those who were there and didn't were wimps. They lament that he wasn't shot dead.

Of course, this is easy to say online; everyone's a hero behind his keyboard. But my point is that mentally ill people have gained substantially by this admittedly ill-defined and at times abused special status. A bizarre naked man assaulting strangers in a subway would himself be the victim of vigilante justice, and likely a violent police response, were it not for some recognition that he is ill and not merely evil. Much of the public would be more than happy to ignore the niceties and just beat the guy senseless.

The points raised here about the vagueness of "grave disability" or why compassion is doled out unequally are good ones. But please don't lose sight of the other side of the coin. For hundreds of years the mentally ill have been absolved of crimes — big ones anyway — because they didn't know right from wrong at the time. It would not be progress to revert to the bad old days before this was taken into account.

The airplane incident sounds like it was handled about as well as possible under the circumstances. Maybe there's hope for humanity after all.

Sunny CA said...

je suis
From my perspective the "Gravely Disabled" term is a legally created term, to be used for mental patients who obviously need hospitalization, but who are not a threat to others and who are not a threat to themselves which are the other two ways a person can be involuntarily hospitalized. I much prefer that I was admitted as Gravely Disabled even though the result was the same. I had not shown myself to be a danger to others or myself and would have felt wronged to be labeled in that way, though it is a technicality because the result was the same.

Oddly I asked my husband to take me to the emergency room, but was involuntarily hospitalized.

The determination was made to hospitalize because I came into the emergency room grabbing onto my husband's arm, shrieking at the top of my lungs in a primeval way, unnaturally terrified of everything. I imagine I looked totally bonkers. I doubt it took an MD to figure out there was a problem at that point, and there was zero wait in the lobby. I was into the ER instantly. I know they did a brain scan so a physical basis was considered. I do not know if they tested for anything else, but I do not now nor then do drugs, and I mostly am a non-drinker, and my husband knew this was a radical change. Also, it was clear, even if there was a physical basis that I could not be sent to a medical ward. When I went to the emergency room, I had never had any sort of similar episode, was not on psych meds, and did not know what lay ahead on the mental ward.

Regarding homeless: The involuntary committment laws were written with a particular purpose in mind, getting psychotic and dangerous mentally ill into the hospital, and were not created to be a social safety net for society.

Regarding my being lucky: Well, yes, I am lucky that when my brain derailed I had good medical insurance and I had been saving money for 30 years. We paid our portion of the bill by cashing in investments. Still it was a financial hit.

Those questions are really tough because I know that if I had a problem in the future that perhaps required hospitalization, if I were at all non-rational I would be very unwilling to go to the emergency room or volunteer to be hospitalized again under any circumstances. I would be willing to seek help from a trusted psychiatrist, assuming I had one (my trusted psychiatrist is past retirement age). While rational, numbers 2-6 all seem pretty compelling to me. I would not want to ever hurt anyone. I would not want to be running naked in BART shoving people (and I am really bad at handstands and the splits..joke). I would not want to be on CNN. I would not want to scare an entire airplane of people.

When it gets to 4 and 5 above, I am not so sure. If I were screaming and yelling and acting crazy, but would be willing to hang out at home and take medications that would bring me out of a psychosis, it would be a whole lot better than being in a hospital. I would worry, though, that perhaps loved ones around me would not actually be safe, and I have pets that I would want to be safe.

When I was psychotic in the hospital, I felt calm and safe when my husband was visiting. He would sit on my bed with his back against the headboard, and I would wrap myself around him, and lay my head on his chest. I do not think I ever would have hurt him while psychotic, so it may have been possible to have me stay in the home, but he has said he would not have been able to manage the situation.

Je suis said...

Sunny CA
"Gravely Disabled" is indeed a created legal term, and as such, carries with it a certain elasticity as to the boundaries of its definition. For example: it's to be used for patients who obviously need hospitalization - obvious to who, exactly? This is why lawyers exist, ultimately; to argue over the minutiae of legal definitions, because there is always some vagueness inherent in the wording. You say you prefer that you were admitted as gravely disabled because you had not shown yourself to be a danger to others or yourself; but technically, you had. Gravely disabled is a condition wherein a person is unable to take care of his or her basic needs for food, clothing, or shelter. As I posted earlier, if giving up a job without the prospect of another can be considered a danger to self, then being gravely disabled is, by definition, being dangerous to oneself.

I asked about testing because it seemed to me that the diagnosis occurred rather quickly; almost too quickly to rule out all the possible causes of your behavior at the time. Remember; you know that you do not do drugs, but the physicians do not. And that's just one possibility. That's why I was interested in just how quickly the diagnosis was made.

Regarding homeless: the involuntary commitment laws were not written just for the psychotic and dangerous, and they are certainly not used as such. They were conceived altruistically enough: to get help for the people that need it. But, as always, the best of intentions often go awry.
The definitions of dangerousness keeps expanding, the criteria for mental illness keeps widening - look at the new DSM-V - and more and more behaviors that once were normal or quirky are now illnesses. As far as a social safety net: that is exactly what involuntary commitment is. A net to catch those individual deemed in need of help, whether they want it or not.

Yes, you were lucky that you had good insurance and savings; in this day and age, that's a commodity that's fast disappearing for the average folk. I will say it again: psychiatric help often comes at too exorbitant a cost. If the price I have to pay for being saved is the loss of a lifetimes savings, or crushing debt, then for God's sake, don't save me. Trading one inescapably negative situation for another is not my idea of being saved. In fact, it's rather sadistic; holding out hope while at the same time creating another situation that's cause for despair. No thanks, just leave me be; at least I've come to terms with the first problem, and I just don't have the strength left to fight another losing battle.

Sarebear said...

I've read only a couple responses to this, but just watched and have to say I'd want the docs and other people to do whatever was necessary for everyones' safety first off, and then what was necessary to get me the care needed, even if it is what I'd not want in situations less severe. I haven't figured out yet what I'd want in what situations, but I'd default to keeping everyone safe, first, and then the help necessary to help me not be however I was acting that was what required the interventions in the first place. I know I'd not want ECT however under any circumstances. There's a variety of meds I'd not want (such as Lamictal, I'm never taking that again) ever, but even if they gave them to me once out of the hospital I could stop (and it's not like Lamictal is a fast acting agent, either, and my doc has written down I believe a variety of reasons it shouldn't be given to me but I guess I oughtta check on that).

I'd always default to the safety of people first even if when back to myself I'd judge some measureas as too harsh or unwanted. Maybe I'm naive, I probably am since I've never been admitted for psych reasons, involuntarily or otherwise.

Sarebear said...

If this is too much of a side trip, ignore it.

What Sunny was saying about there is no a little bit psychotic, and if you are psychotic, you need to be in the hospital . . .

I think I needed more supervision than I had, but I had as much as I could get, although no one but my psychologist knew (and he didn't know for most of the week) that I was believing that things were real that weren't real, ie, that Spock was coming over for lunch, that I'd be soon meeting with a Cornelius and Zira (Planet of the Apes) and other things.

This was in the week after my second knee replacement surgery. Oh, my mental processing/cognition was oh so very molasses slow, I meticulously spent hours and hours working out when I needed to take which medications, hours and hours working out this schedule for even just half a day's worth of meds (a variety of psych meds plus a variety of post-surgical pain meds, including oxycontin and percocet). In retrospect, figuring this stuff out shouldn't have been in my hands in that mental state but I wasn't even capable enough of making sure that was safely handled, either.

My parents would drive up 75 mins every day and home 75 mins every day to take care of me most days in the first couple weeks I was home; the first four days they got there before my husband went to work at noon; after that they'd get there an hour or two later. They'd leave in the evening an hour or two or three before he got home, starting at an hour early on and leaving sooner the more recovered I was.

However that first week . . . I wasn't doing so well at keeping up with my exercises, or the leg machine (although still better than I did the machine first surgery, because the first oen was of a diff design that kept messing up in scary a nd painful ways); eventually after a week of everything I kind of shook myself and told myself I didn't have time for all this, that I needed to get about doing my exercises and getting better and that whatever th is wierd mental stuff was, it was bad for my recovery and I needed to move forward. When I woke up the next morning, my mind was clear and I was able to proceed with everything.

Sarebear said...

I've not ever been officially told I was psychotic, so I don't know whether believing things are real that aren't real qualifies, along with the mental molasses and not being capable of making sure I was safe, especially medically and medicinally speaking. I'd sometimes realize after half an hour or an hour that the things I thought were real that weren't, weren't actually real. But then more would happen. Some things seem wierdly happening at normal speed, like the home physical therapy, while so many other things, esp. complicated medication schedules and stuff, seemed to cram what would normally take me five minutes to figure out, into 5 hours . . . that five hours seemed to pass both more slowly and more quickly than normal.

So, part of me shudders to think at the times that week I was left alone, with all the damage that could have been done in my weird mental state, however, nothing bad did happen other than my MIL saying traveling up 20 mins was too far to come (when my aged, 75 yo parents were traveling 75 mins (or more, depending on traffic) each way). I don't do things for others quid pro quo, but it still hurt a bit since I've stayed with her for most of a week post back surgery, to help her, and stuff.

So, I was recovering from two knee replacement surgeries and not mentally all there, and I survived, at home. Probably not the ideal thing but it worked out. Maybe I was just "a little bit" psychotic? Maybe I wasn't.

Oh, and Spock and Cornelius and Zira never showed up. That would have been a nice distraction from everything else, if a bit freaky. (I only told my psychologist partway through that week during a moment when I realized stuff wasn't real that I thought had been, there's so much other stuff but those three characters are all I can remember clearly enough).

Some people have a pathetic support system (my parents weren't pathetic!). If I ever went weird again, I'd probably have to weather it myself.

Anonymous said...


Yeah, I do get uneasy when it comes to danger to others. I wouldn't want to be harmed by someone else, and I would not be able to handle it if I ever hurt another person. My thoughts when I saw those videos is that I hope they are taken to a hospital and not punished for being ill.

It seems very clear to me when it comes to suicidal ideation (at least in terms of what I would and would not want), things becomes a little more gray to me when it's about danger to others.

If my medical records are accurate, I was apparently psychotic once upon a time. I admit I did do some pretty crazy things which I suppose is why I kept being referred to a psychiatrist - who I refused to see for quite a long time. Even though I am stable now on medication, I am glad that I wasn't forced back then to see a psychiatrist (with the exception of the one emergency detention) or to take medications. It would have been a disaster, and I would have fought it tooth and nail. I'm quite stubborn. I'm sure no one has noticed this.

I just got my hemoglobin a1c back and it's elevated for the first time ever. Diabetes was one of my biggest fears about antipsychotics, and in fact I refused Zyprexa for that very reason. Unfortunately, the others are not without risk and my fears may be coming true. The choices sure suck, but I want to always be the one who decides which decision sucks less. Risk of psychosis versus diabetes. What a choice. Yuck.

Pseudo Kristen

Anonymous said...

One of the true gifts of my numerous hospitalizations is getting the chance to see how people who initially present as very very sick can, in short time, return to the very very sympathetic, caring, thoughtful, complete human beings that they really are.

We all joke about "going crazy" as if that's a place you don't come back from, but being psychotic really isn't the end of the world.

So, in keeping with that, I do want the psychosis to be seen as an illness
-- something covering up the real person inside -- no matter how much I protest. Especially if I'm acting "strange" in public, because the strangeness will frighten people, who will call the police, who are quite likely to shoot me (even more so if I were male and brown).

But that takes a willingness to accept that my thoughts and actions may not always be under the control of the person-I-am-now: a very humbling thought.
A tough one. I have acted in ways that now make me cringe, and see that as illness at work -- so I guess that's another gift .

(My theory is that physicians commit suicide so often because they're so accustomed/acculturated to trust their own judgment, to a fault.)

Because suicide is considered a "rational choice" by many people in this country -- in some circumstances -- it's easy for the suicidal mind to think that, yes, my circumstances qualify. But pry my head open before my various attempts and you'd find some very confused thinking.

NotARobot, still.

ClinkShrink said...

SareBear: I'm glad you're doing better and I'm not surprised you'd put the safety of others first. A visit from Spock might have been entertaining but I think I'd draw the line at talking monkeys. If I wanted to hear that, I'd listen to our podcasts ;)

PseudoKristin: I think it was a good sign that in the news report it mentioned the DA was at the scene at the time of arrest. To me that indicates heightened awareness that there may not be charges. As far as "being stubborn" goes, I always say that the other word for that is "persistent", and that's an excellent quality to have when you're struggling your way back from psychosis. I say that as one who is somewhat...um..."persistent" myself.

NotARobot: I totally agree about the gift of being able to see the "real" person return with treatment. That's what the general public often doesn't understand about my insanity acquittees---that's it's possible for a normally kind, caring and responsible human being to do something awful and grotesque under the coercion of psychotic thinking.

Sunny CA said...

Sorry for your difficult times, Sarebear.

Je suis said...


"I'm thinking about this because even some of the "no treatment under any circumstances" readers here seem to hesitate when presented with the actual risk of danger to others arise."

I'm thinking that the danger to others isn't as big an issue as it appears, because in order to be a danger, one must either threaten or act in a way that is harmful. Both of these activities are illegal, being either assault or battery; and both would lead to the scenario I outlined in my first response to this post. The only problem here is the determination of dangerousness, which is why I refer back to the APA testimony that a psychiatrist cannot determine dangerousness with a degree of accuracy any greater than the layman can. If a person has not threatened (assault) or attacked (battery) another, then there is no solid basis for the commitment on the dangerousness grounds. Remember, I do advocate for psychiatric interventions once this has happened, but not before. The more difficult issue is the gravely disabled one, but I think that with a directive in place, that problem resolves itself, and without a directive, then the individual is treated as if they accept treatment until rationally able to state otherwise.

Sunny CA said...

je suis-

Your last sentence disagrees with my experience. Once committed the patient is kept as long as the doctor wants, not until the patient becomes rational. I was rational for 9 days before being released, then was required to do a month of post-hospitalization. The way this happens is that initial involuntary admission is for 72 hours and during that time the patient is committed for a lenthy time; release to be determined by the doctor.

Jwe suis said...

Sunny CA
I should have been more clear; that statement was how I feel the situation should be resolved, not how it actually works. Your experience validates many of my points, however; there is far too much imbalance in favor of the psychiatric professional over the patient, which leads to a lot of the distrust and avoidance of psychiatric care.

Sunny CA said...

I agree with you, Je Suis.

Anonymous said...

Let's say immediately after admission both patients in the videos say they realize they should not have done/said what they did, the guy who pushed the woman demonstrates no further acts of violence and puts on pants, the guy who talked about the CIA and people poisoning him no longer speaks of these things. How long do we keep them?

The length of stay is what concerns me because not all of the commitment criteria are based on objective facts. For example, in my state a patient can be court ordered for 90 days of inpatient treatment if a judge agrees with the psychiatrist's opinion that the patient:
(A)is mentally ill; and
(B)as a result of that illness the examined person is likely to cause serious harm to himself or to others or is:
(i)suffering severe and abnormal mental, emotional, or physical distress;
(ii)experiencing substantial mental or physical deterioration of his ability to function independently,
which is exhibited by the proposed patient’s inability, except for
reasons of indigence, to provide for the proposed patient’s basic
needs, including food, clothing, health, or safety; and
(iii)not able to make a rational and
informed decision as to whether to submit to treatment.

The examining psychiatrist can say "that the examined person's condition is expected to continue for longer than 90 days." How do they come up with 90 days as the magic number? Why not 89 days? Why not 6 and 1/2 days and 25 minutes? 90 days is just so random. If the patient is better after 11 days, the patient can still be kept for the entire 90 days?

Under the criteria above, in my state any patient with a diagnosed mental illness could be screwed in the future if a psychiatrist ever decides to try and have them committed. All they would have to do is say:
A. the patient has a mental illness (which is based on their opinion or that of another mental health professional);
B. they are under severe emotional distress (which would be kind of expected and natural for folks being held against their will);
C. the psychiatrist opines the patient can't take care of her health because of her mental illness (they could come up with pretty much anything as an example, i.e. the patient has diabetes and does not have tight control of her glucose - which is also true of some diabetics without mental illness, she had an infection and didn't finish the entire bottle of antibiotics - which is also true of a lot of patients without mental illness, etc);
D. and the patient refuses the examining psychiatrist's order for treatment - let's say for the example the patient refuses Zyprea and the psychiatrist attributes the refusal to mental illness.

Even though my baseline would be to refuse Zyprexa under any circumstances (as I am disgusted with the pharma company regarding their handling of reports of hyperglycemia, and I do not want to develop diabetes), and even though medication non-compliance cannot be attributed to mental illness considering how many Americans without mental illness are noncompliant with medications, an examining psychiatrist could attribute it all to mental illness even if it's not. I would be screwed as I would never recognize a need for Zyprexa. The problem with basing commitment on a psychiatrist's opinion is that assumptions can easily be wrong. Where is the patient's protection, during a commitment hearing, against an incorrect opinion? (I fear a patient's baseline stubbornness, I mean persistence, to treatment could too easily be attributed to mental illness when it's not).

Pseudo Kristen