Monday, October 28, 2013

Whose Rights Trump?


For as long as there's been Shrink Rap, there have been people writing in to tell us their awful stories about how they've been mistreated on inpatient psychiatry units.  Strip searches, restraints, seclusion rooms, lousy food, boring activities,  disrespectful care, feelings of helplessness, and a general sense that inpatient treatment is not always about fostering a healing process.  With the pressures that insurance companies exert to get patients out of the hospital as soon as possible, it's not about healing, it's about keeping people safe until the moment they can be booted out to heal elsewhere.  Still, the stories get to me, and my heart goes out to people who've experienced care that leaves them feeling so vulnerable, physically & mentally uncomfortable, and generally yucky (for lack of the proper scientific term).  Our readers have made me sensitive to the issue of patient rights and they have inspired ClinkShrink and I to want to write a book about forced psychiatric treatments.

This is the thing, as much as I feel for people with these awful stories, I feel pulled.  Physical restraints sound horrible; I personally would be terrified and furious.  But since the use of restraints has been curtailed by patient rights' advocates and laws, the rates of hospital assaults and murders have risen.  Don't the nurses have the right to be safe?  Don't the other patients on the unit have the right to be free from the fear of being raped, assaulted, or killed in the hospital?  I'm not suggesting that we restrain everyone ---not by any means -- I'm just asking the question. Obviously, if an out-of-control, violent, and disruptive patient can be managed with the judicious use of medications, more staffing, calming interventions with talk-downs, or seclusion without restraints, then those methods should be used.  But some patients are terribly sick and terribly dangerous.  Whose rights come first? 

Let me tell you about Mr. Kelly.  Mr. Kelly raped two women he didn't know and he broke into a house and killed a child and her father (strangers to him).  At his hearing, the judge questioned whether he was competent to stand trial.  He went to a forensic hospital where he could be evaluated and he was found to be delusional and incompetent to aid in his defense.  He'd remain in the hospital until he was competent to stand trial.  Mr. Kelly was a perfect occupant of the hospital, a model patient. He wasn't violent or difficult.  And he didn't want to take medications because he did not agree with the doctors that he was delusional.  A clinical review panel said he was sick and needed medications, and he fought the decision, taking the case to the state and it eventually made it's way to the state's court of appeals.  The court of appeals decided that a patient who is committed to a hospital for being dangerous to himself or others can not be medicated against his/her will if he is not dangerous inside the hospital.  

This ruling applies to all committed patients, even those who haven't raped, murdered, or jaywalked.  If you're committed to a hospital because you're dangerous (say you are delusional about your neighbors and you're going to kill them in self defense, but they aren't in the hospital), well now you can't be forced to take medications and you can't be released because you're dangerous outside the hospital.  Wait, really?  Yup.  Funny catch-22 isn't it? Or apparently some hospitals may be warning the victims then releasing the dangerous patient.  If you're the patient who doesn't want to take the medications, this is good, you've got rights and you've been released.  What if you're the person waiting for the subway who that released patient pushes onto the tracks?  Whose rights were more important?

Okay, so back to Mr. Kelly.  He couldn't be medicated.  He sat in the hospital for 8 years at a cost to the taxpayer of $208,000/year before he was declared competent to stand trial and was found guilty for his crimes to go off to prison.  If you were the mother of the child he killed or one of the women he raped, how would you feel?  Would you want the closure a trial might yield a bit sooner?   Is Mr. Kelly's right to refuse medications more important than the victims' rights?  What about the taxpayer's rights to have their tax dollars used more efficiently (I'm sorry to add a money issue here, but our state furloughs workers, and Mr. Kelly got over $1 million worth of hospital care when many go untreated).  

Our readers might say "but I wasn't going to kill anyone, I wasn't going to bite the nurse, or assault another patient."  Assaults in hospitals are common, and the staff does not necessarily have any special abilities to know which agitated patients will escalate to violence and which will not.  These are all tough situations and obviously there is no good or precise answer here.  It would be so nice if there were.

I did have the thought that seclusion rooms should have plexiglass screened iPads built into the walls so that patients could watch movies, read, listen to music, or play games and not be bored.  The activity might be distracting and help them de-escalate sooner. 

25 comments:

Anonymous said...

Whose rights trump? I think my rights end where yours begin or however that saying goes. But it has to be an actual danger to others, not some hypothetical what-if scenario. There needs to be a direct threat or violent act. If a patient says, "I'm going to kill or harm so and so," then yes intervention of some sort should be expected. But, if someone is delusional and paranoid and has voiced no threat, then no I don't think forced treatment should be given. There are lots of delusional, paranoid people floating around who may fear their neighbors but won't harm them. We cannot treat all delusional people like they're potential killers, just as we cannot target all young men of a particular age group, just because some men in a particular age group are violent.

Kendra's Law was created because the guy who ended up pushing the woman into the subway was turned away from voluntary treatment, treatment he was actually seeking. Looks like they would have instead increased funding for voluntary treatment since that's where the breakdown was, rather than putting the funding toward more forced treatment.

Pseudo-Kristen

Anonymous said...

I would have no problem with Mr. Kelly being forcibly medicated if mental illness caused him to do it. He killed and raped people. He was violent toward others.

Pseudo-Kristen

Dinah said...

Inside hospitals, people are not generally restrained for verbal statements (a calm, I'm thinking of killing people doesn't do it) but rather for agitation, getting in someone's face with a threatening tone, being physically disruptive (so maybe frantic pacing might inspire seclusion) or actual violence (spitting, hitting, punching, or throwing objects, even if not at someone).

Kelly was hospitalized to evaluate his competence to stand trial-- to understand the charges against him and to assist with his defense-- a "pre-trial" issue. I saw no mention (it may have been there) of the idea that an insanity defense would be used to explain his crimes. Once competent, he pled "not guilty" and was found to be guilty. It's a high standard to be not guilty because of mental illness, you need to both be mentally ill and not understand that your actions are wrong. This is why our jails are filled with mentally ill trespassers, and people who commit minor crimes, but it's rare (?--1% or less)for someone to be found not criminally responsible for serious violent crimes.

It is an interesting, and totally different question, as to whether doctors should be medicating people to make them competent to stand trial so they can be tried and then killed in death penalty cases.

So, Pseudo-Kristin, do you have a problem with Mr. Kelly being forcibly medicated to stand be able to stand trial if mental illness was not cause of his criminal behavior? He'd had many felony convictions and many burglery charges/convictions before the murders/rapes.

Anonymous said...

...If Mr. Kelly did not commit crimes because of mental illness then that is not a medical issue. I think if he is delusional and not fit to stand trial then we can assume he committed his crimes because of mental illness. That or some kind of organic brain disease. If a brain tumor, seizure disorder that causes violent outbursts, mental illness, etc is present I think we need to assume that it, at least, may have been the cause and should treat accordingly (with or without consent).

I think this is also best for the patient. It would probably be a relief for a patient suffering from violent outbursts as the result of alzheimers, or some other brain disease, to get treatment and no longer feel violent.

Dinah said...

Anon: ClinkShrink is the expert here and perhaps she could do a post for us on the difference between pretrial and trial issues.

You can't stand trial in our country if you're not competent, and this is not necessarily connected to anything to do with the commission of the crime.

PsychPractice said...

This reminds me so much of a patient who was admitted when I was a unit attending. He was behaving erratically and scarily at home, and his family was frightened of and for him. He wanted to be discharged, and we went to court to retain him and won. He then refused meds. We went to court for medication over objection and lost. I had no idea what to do with him. I ultimately got pressured into discharging him by the administration. I think this patient was very high up in my thinking when I decided to leave the hospital and go into full time private practice.

Anonymous said...

I spent the better part of last evening trying to find any study that backs up your assertion that as use of physical restrains has gone down, the numeber of assaults has gone up. Couldn't find one.

Anonymous said...

I don't like the idea of medicating someone for the sole purpose of making them fit to stand trial. Medicating someone to make them less violent and for the sake of crime prevention isn't something I would have a problem with. That sounds like two separate issues to me. If the mental illness was totally unconnected to the crime then it's purely a medical thing and the patients should choose how they wish to proceed.

Would this even be an issue if a patient signed a DNR and had a heart attack before standing trial for a violent crime? Or would the physicians at the hospital all be saying, "We have to save him so he can stand trial!" What if the patient had terminal cancer? Would a judge order he not have the right to die until the trial was over? Would they just have to keep on with aggressive treatments in order for him to be well enough to stand trial rather than allow him to die peacefully with minimal intervention (which would also cost less). Then they can let him die once the judge rules.

If I were a doctor I don't know that I would want to work in a system like that. I think there has to be a separation between medication for health and safety and medication to fulfill the needs of the justice system.

Anonymous said...

Basically, I'm saying I don't think people should be medicated just so they can stand trial.

Dinah said...

Anon on Social Justice of medicating for trial: I agree, this is a weird issue. But given that the law is that one must be competent to stand trial, what does one do with someone like Kelly? Would you like to take him home with you? At the moment, the answer seems to be that we hold people in a secure hospital indefinitely if they are not able to stand trial. Sometimes that's the case even with medication. And sometimes that's the case when they've been charged with minor, non-violent crimes -- they can't be tried, so they can't be released. See Pete Earley's book Crazy for the vicious cycle this can become.

If you have a heart attack while awaiting trial, you get treated. I imagine you can refuse treatment for a terminal condition while awaiting trial. It's all sticky.

Dinah said...

Anon with restraints.Interesting, Clink was at AAPL last week and told me of two separate psychiatrists talking about how in-hospital violence has gone up since the use of restraints has gone down. I emailed one of the people she mentioned, who said that his state hospital has preliminary data that suggest that pt-on-pt and pt-on-staff violence have gone up with the reduction of restraint and seclusion. So hearsay, not peer-reviewed studies. Thanks for catching that.

Anonymous said...

Wow, so much to think about.

"So, Pseudo-Kristin, do you have a problem with Mr. Kelly being forcibly medicated to stand be able to stand trial if mental illness was not cause of his criminal behavior?"

Yes, if mental illness did not cause him to be violent then I would have a problem with medicating him to make him fit to stand trial. They should medicate him if he was violent due to mental illness, but not to convenience the court (or society). Otherwise, then we should just medicate all violent prisoners simply because they're violent. That's a bad idea. Medicating a mental illness that has caused violence against others, is okay with me.

P-K

Anonymous said...

Dinah wrote, "Interesting, Clink was at AAPL last week and told me of two separate psychiatrists talking about how in-hospital violence has gone up since the use of restraints has gone down."

Has violence gone up because restraint use has gone down, or is it because the quality of care in psych hospitals has gone done (i.e. reduced staffing, less therapeutic activities, more of a punitive rather than therapeutic atmosphere, etc). It would be important to know. I'm reminded of the saying, correlation does not equal causation.

P-K

Dinah said...

P-K: Agreed. There may be many factors here, and there likely are.

So what do you do with the likes of Kelly?

Anonymous said...

I think I'm getting in over my head here. I guess if mental illness did not make Mr. Kelly violent and he's not competent to stand trial, then we hold him until he becomes competent (which may or may not ever happen). But, if we hold him for years without a trial, then haven't we violated his right to a speedy trial guaranteed by the 6th amendment? Yuck. This is complicated.

P-K

Joel Hassman, MD said...

Hmm, so I guess this thread is leading towards a claim that antisocial and sociopathic behaviors and outcomes are psychiatric issues alone, and thus psychiatry, again, alone, should be reponsible for this population.

I don't do this "lol" thing, I like to type out HA HA HA! And it is a loud, long, sarcastic sounding laugh.

This agenda basically only serves three groups, in order of who perversely benefits the most to least: obviously the criminals who want to avoid incarceration; the forensic subspecialty who will maximize income stream for the increasing and burdensome population that will just crush the usual psychiatric inpatient system that in fact these forensic psychiatrists will miminize their contact role with these patients; and finally the antipsychiatry group who sees this just decimating psychiatry, be it in a prolonged fashion.

But, no one is really paying attention to the impact on the true, pure psychiatric patients who have to share their inpatient space with these wolves, and also no one wants to listen to the general psychiatrists who are not forensic trained and have to do what, 80% of the care interventions for these criminals who have NO interest in care interventions. Oh, and be at the same level of risk as their colleagues on the units, the nurses, aides, dietary, occupational and therapy staff just to name a few.

Yeah, I know this because I have done it. It is obscene, it is insensitive, and it is intra professional abuse.

I truly look forward to the dissent of this comment. I write about antisocial issues ongoing at my blog because it is becoming pervasive, and I honestly think if not outright accepted, at least tolerated to a pathetic level.

Just remember this one little post I wrote about 1 month or so ago: 40% of our voting population alone tolerates torture or taxation without restraint. Two overt behaviors I feel are antisocial.

Hey, as I always note, just my opinion. Dinah's post is very thought provoking, but, the outcome is just frustration provoking as well.

Anonymous said...

Dr. Hassman, for what it's worth I do not believe someone with mental illness who commits a crime should be in the same facility with someone with mental illness who has not committed a crime. I think when criminal activity is involved, mental health treatment that is provided should occur in a forensic hospital.

P-K

Anonymous said...

I have no problems with warehousing the criminally insane in some separate limbo facility specifically designed for holding people too ill to stand trial but who have been violent in some way.

Psychiatrists who want to work with that population are free to do so.

Anonymous said...

Anon comment pt1: I heavily disagree on this. I still tend to believe that most of the patients who do get physically violent are going to remain that way for the rest of there life.
Are you telling me that prison folks folks should be restraining him?
Well, lets say that that is yes. Guess what, it has already been tried, the results are kinda mediocre -- compared to providing rewards.
Prison folks already know that they better keep the prison food at the right temperature, otherwise riots will begin.
They also know to provide time out of the cell if they inmate behaves properly. If they don't, those privileges are out.
Well, the next issue is what about co-morbid psychosis? Well, and to that I say the exgragated inheritablity of it: bigthink.com/devil-in-the-data/mental-illness-its-not-in-your-genes

Anonymous said...

Anon comment pt2: Turns out, the largets cohort twin studies (non-adopted) finds that at the most, its inheritibality is below 20% at max.

Then what are the hidden variable? Environment!

Check out the efficacy of Collaborative Problem Solving. Essentially, when the people behind the program implemented there wares in a psychiatric hospital, the rates of restraints and seclusion went down by over 50%.

Also, the 5th-axis rating also went up.

Next, ever heard of Delancy Street? If you haven't, Google it.

Next, the case that you provided it an extreme one. Lets face it, there are opportunity costs in the world. Money spent on treatment and keeping a rapist in prison for the rest of his life is would be better spent on preventing rape in the first place.

Anonymous said...

Anon comment pt3: Well, so whats the solution? Legalize prostitution! There are many studies by the Independent Institute, if you check it out.

Bam! Rapes go down.

Next, what is the unintended consequences of such poor treatment to their patients? [1]

Well...first go back a few steps.

Whats the purpose of prisons?

Answer: Two. Keep dangerous people inside for the rest of there lives and also use it as a deterrence. (People engaged in white collar crime are usually placed exclusively for deterrence).

It turns out most of the prisoners don't have life sentences. Thus, deterrence returns back to take precedence here as well, even for some violent crimes. [2]

How do we prevent violent crimes? Check out Delancy Street. And... read a harvard psychology professor's take in his book The Blank Slate which features twin adoption studies which have been conducted for the last 4 decades:
[...]Even growing up without a father in the house, which does correlate with troubles such as dropping out of school, remaining idle, and having babies while a teenager, may not 'cause' the troubles directly. Children with experiences that should make up for the missing father, such as having a stepfather, a live-in grandmother, or frequent contact with the birth father, are no better off. The number of years that the father was in the house before leaving makes no difference. And children whose fathers died do not have the poor outcomes of children whose fathers walked out or were never there. The absence of a father may not be a cause of adolescent problems, but a correlate of the true causes,which may include poverty, neighborhoods with lots of unattached men [...] , frequent moves (which force children to start from the bottom of the pecking order in new peer groups), and genes that make both fathers and children more impulsive and quarrelsome.[...]
____

Anonymous said...

Anon comment pt4: In light of the above excerpt, please tell me if how a 1 month or 2 month or even 6 month psychiatric admission will 'cure' the person?

Couple with with [2], and the work of Carl Hart on drug addiction, and you come to the conclusion that if are to carry out any meaning activity to reduce crime, you need to lock people up for the rest of their lives or alter the civilian environment.

Guess what? We don't even need to that hard.

We already know how to reduce crime committed by extremely violent people. Check out scandinavian 'prisons' and their re offending rate.

Tell me the difference between those 'prisons' and the psych wards here.

Again, in light of all of this, shouldn't it be at least acknowledged that patients accused of violent crimes should be segregated from the rest of the involuntarily committed population?

If the people who really are negatively affected by psych admissions, is there a co-variate? Apply common sense, and come to the conclusion that a large majority were never brought into by the criminal justice system.

_____
>Don't nurses have the right to be safe?
I say: don't skydivers have the right to be safe?
I also say: those nurses should quit if they don't like their jobs.
_____

Anonymous said...

Anon comment pt5: Ultimately, lets discuss [1]. The simple fact is, a good chunk of people trying to seek care will self-censor any talks of suicide (fearing they may be taken to psych ward, during therapy), thus hindering treatment. Now, when the person does get agitated and talks about suicide and has all the plans ready, about (lets guesstimate) 30% successfully end their lives and the rest are take to psych hospital.

Bam! With those hospital treatment charges and higher insurance rates. Patient, yet again enters into depression. There yet again is the loss of therapeutic alliance, due to those self-censoring patients continuing to behave that way (remember the dubious efficacy of CTOs that was recently published?).

Then eventually recovery is impaired and there is a second, more lethal, suicide attempt, thus, raising the total suicide rate (under the guesstimate) to 40% ( which includes the initial 30%).

From the 60% still alive (remember, most of them are more strongly inclined to self-censor after they exit psych ward), recovery is yet again inhibited.
____

Anonymous said...

Anon comment pt5: Ultimately, lets discuss [1]. The simple fact is, a good chunk of people trying to seek care will self-censor any talks of suicide (fearing they may be taken to psych ward, during therapy), thus hindering treatment. Now, when the person does get agitated and talks about suicide and has all the plans ready, about (lets guesstimate) 30% successfully end their lives and the rest are take to psych hospital.

Bam! With those hospital treatment charges and higher insurance rates. Patient, yet again enters into depression. There yet again is the loss of therapeutic alliance, due to those self-censoring patients continuing to behave that way (remember the dubious efficacy of CTOs that was recently published?).

Then eventually recovery is impaired and there is a second, more lethal, suicide attempt, thus, raising the total suicide rate (under the guesstimate) to 40% ( which includes the initial 30%).

From the 60% still alive (remember, most of them are more strongly inclined to self-censor after they exit psych ward), recovery is yet again inhibited.
____

Anonymous said...

Anon comment pt6: Why is the above scenario more desirable in the zeitgeist, compared to, those people who express suicidal thoughts, actions, plans, continue to function that way and not greet them with a psych admission?

Surely, perhaps the total suicide rate from both the scenario will result in equal suicide rates, but in the latter case, the people who don't commit suicide, have far higher 5th axis rating.

Live free or die -- and lock those persistent offenders for life.