Shrink Rap: involuntary

Showing posts with label involuntary. Show all posts

Monday, March 26, 2012

Review of Crazy

No no, we're not reviewing what it means to be "crazy."

I recently finished reading Pete Earley's book, Crazy: A Father's Search Through America's Mental Health Madness. Fives stars, two thumbs up, all the way. It was a quick and engrossing read, I think I got through the whole book in three sittings.

Mr. Earley starts with the story of his son, a young man just finishing college, who becomes delusional and disorganized. Efforts to clarify a diagnosis and get him treatment are a bit difficult, in part because he doesn't really want help, and perhaps because these efforts span two states as the son is in school in New York but the father lives in Virginia. Earley goes to NY to fetch his son, and alarmed that he is so delusional, disorganized, and talking about death, he takes him to an Emergency Room in Fairfax, Virginia where he is told that the son can't be committed against his will unless he has already had a suicide attempt. The son goes home, does some strange things, then breaks into a random house where he shatters pictures, leaves water faucets running, and takes a bubble bath. He's no longer in the voluntary psychiatric system, per se, but is now charged with felonies that will prevent him from ever being licensed in his chosen profession. A plea bargain is reached-- for misdemeanors/probation/treatment-- but in court, the prosecutor can't cut the deal because the homeowner-victim won't allow the crime to be pled out without a felony charge. Does the victim really get to call the shots on what a criminal is charged with?

Earley is understandably frustrated with the system and all the roadblocks in everyone's way. He's worried about his son's future, and a bit terrified that his son will get sick again. Mike can't catch a break, and his diagnosis and criminal record seem to call his life to a halt for a while. The son does well on Abilify and Earley could be their spokesman.

The author decides to explore the system by spending a year following patients in the Dade County (Miami) jails and talks about a psychiatrist he shadows who sees his patients for an average of 12.7 seconds. Earley describes a whole jail unit full of really sick people who are combative, catatonic, and treatment-resistant, in a way I've never seen in nearly two decades of work in community mental health clinics. Never....well.... Clink says this is all in a day's work for her, but it's not routine stuff for outpatient psychiatry. The psychiatric unit he describes in the jail is disgraceful, with cold, naked prisoners lying on the floor next to the toilet, in need of blankets and kindness. It felt like a human zoo, only in animal zoos, the creatures are treated better, I hope. The tales Earley tells are sad ones, the people he follows end up still sick, imprisoned, or dead, and the system he describes simply doesn't work. And the patients, some of them are so sick that there is simply no place on earth for them, and Earley faults the state mental hospitals for releasing them. Even a well-monitored forensic patient ends up doing well, getting a job and living with his girlfriend, only to kill her.   It's all just horrible. Real life outpatient psychiatry isn't so bleak, and while there are some awful and sad stories, there are many people who do fine. I felt badly for Mr. Earley because he chose the most dismal of places to search for answers, and I think (or at least I hope) it's unlikely his son will end up in such devastation. Along the way, he talks with other parents and becomes involved with NAMI.

The author does a good job of getting inside the mental health system. I didn't agree with him on his easy separation of substance abuse and mental illness, and I don't think we know that drugs don't cause mental illness; they certainly exacerbate it, induce symptoms that mimic it, and make diagnosis and treatment nearly impossible in some settings.

Mr. Earley is a proponent of involuntary treatment. He talks to people while they are living on the street, eating from trash bins, victimized by rapists and robbers, and he doesn't buy that people should have the right to live this way. Earley twice quotes Wisconsin psychiatrist Darold Treffert as saying they get to "die with their rights on." He wants state hospitals back and he wants them to treat patients humanely.

If you oppose involuntary treatment under any circumstances, read this book: it will either change your mind or raise your blood pressure.

Oh, and if you'd like, try Mr. Earley's website and blog at http://www.peteearley.com/blog/

Saturday, January 14, 2012

Involuntary Commitment: Would you do it Again?

Ah, we're back to an old topic, involuntary hospitalization. Some people say they'd rather die than live through a week in a hospital again. I actually have not ever heard anyone say that about jail. I thought I'd ask if everyone feels that way. If you are very much against the idea, but have not been involuntarily hospitalized yourself, please-please-please, don't take my poll.

Thank you and Go Ravens!

Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

What We Need

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
     Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
     People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
     I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
     This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. Psychiatrists have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

Friday, January 13, 2012

I'm Sorry

Rob wanted to know if I was reading the comments on Dinah's post about involuntary treatment. He thinks that psychiatrists may read these comments, shrug and say, "Well, sometimes it's necessary."

I did read the post, and the comments. I can tell you that the decision to involuntarily admit or treat someone is never a "shrugging" issue. This is something psychiatrists hate to do. I mean, literally hate. We know it's something that can destroy a therapeutic relationship and undermine someone's willingness to seek care in the future. We know that psychiatric units can be horrible places to be and that admission is expensive, humiliating and sometimes traumatic. The decision to seek involuntary treatment is not done lightly or easily. You and some others may feel it should never be done, but I think that's an issue that may never get resolved between us. Maybe someday medicine may develop better ways to diagnose and treat mental illness, or society may evolve and decide that psychiatric patients are worthy of the time and money spent on other suffering people but we're not there yet. We deal with the present, as it stands, with what we've got.

Remember that there are comments that you don't read here. The missing comments. The comments that can't be posted because the suffering people are dead. On behalf of those folks, and the people who care about them, I'm sorry. I'm sorry that psychiatry as a profession and the mental health system failed you. I'm sorry that you had to hide your suffering from your friends and family, or maybe from your doctor, because you thought you had no choice. Clearly, something needs to change.

This is why Dinah posted about the issue and why I'm following up. As a group, we need to figure out better ways of doing things. The Shrink Rappers don't have the answer. We need to hear concrete ideas and suggests. General comments like, "Stop treating me like a child" or "Don't be a jerk" honestly aren't helpful. The commenter who suggested that patients should be allowed to have cell phones on the unit, to call friends or family when in crisis on the unit, now that's the kind of idea we psychiatrists need to hear. The discussion about post-discharge aftercare and the continuity gap is crucial. Please tell us more about that and about what kind of services or support would have been useful and what we need more of. I like the idea that this could also help catch people in early relapse. We need to answer the questions about these services: what, when, where, who and how.

Now let's get started.

Monday, January 09, 2012

Forced Treatment: Does it Help?

Go for it, I know we have many readers who oppose forced treatment.

In "Opposing View: Forced Care Doesn't Work" by Joseph A. Rogers in USA Today discusses the usefulness of forced treatment. While some would contend that people who are sick may become dangerous, lack insight, or be so sick they can't see themselves as ill, Rogers contends that by forcing people into treatment, they get turned off on the idea of getting care and that a better solution to the problem is to make psychiatric care something patients want to get. Rogers writes:

Studies have shown that what works is not force but access to effective services. We don't need to change the laws to make it easier to lock people up; existing laws provide for that when warranted. Instead, we need to create and fund effective community-based mental health services that would make it attractive for people to come in and receive care, and that would support them in their recovery.

I don't know if better access to good care is the whole answer, but it's not a bad place to start.

Tuesday, August 09, 2011

Cruelty and Context

I've always been struck by the similarity between solitary confinement inmates and monks. Historically, monks were kept under the vow of silence. They could only leave their cells to attend religious services. The only visitors they were allowed to have were their religious advisors. (If any of you have seen the movie Into Great Silence you'll know what I'm talking about.) The idea of the modern penitentiary came from this 'penitence' process: put someone in a room by himself, give him religious guidance while he's there and he'll reflect, repent and reform. This was how prisons were run in the Nineteenth Century too: prisoners were kept under the rule of silence and they could only come out of their cells for religious services or for work. No one ever alleged that monks became psychotic because of this though.

Then there's the psychiatric seclusion room. Again, a bare cell with a bed or a mattress, no visitors, no clothes except a hospital gown. There is no 'vow of silence' or 'rule of silence' though.

So what makes the difference between the prison segregation cell, the monk's cell and the psychiatric seclusion room?

Off the top of my head, the obvious one would be the 'voluntariness' (if that's the word) of the confinement. (Although some people became monks because it was either that or get thrown into the king's dungeon---crime did compel men into the priesthood!) Other would be the purpose of the confinement. Segregation is a disciplinary action for a misbehaving prisoner, although it could also be used to protect the safety of other inmates in the facility. The purpose of segregation is also, theoretically, reformation (and their is research to show that disciplinary infractions drop off after one or two episodes of segregation). Reformation and enlightenment would be the purpose of the monk's isolation as well. Psychiatric seclusion is used both for the protection of the patient and others.

As we've heard from some of our blog readers, involuntary segregation feels the same regardless of the purpose.

Saturday, May 28, 2011

Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
__________________________

In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

Friday, May 27, 2011

The Unwilling Patient: New Yorker Article

In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv

Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

Tuesday, October 06, 2009

Afraid of Commitment?

Posted for Roy (taken from his comments on the Demystify Me? post)

So is knowing your doc got a cute new puppy who likes cat toys TOO demystified?

And, to AA's point, civil commitment to prevent a suicide is indeed a proper concern, though I'd argue that ignoring a suicide risk is also of concern. Most states require us to hospitalize if there is a risk, but how that risk is defined varies from state to state.

The area of consternation is likely that different docs interpret "risk" in different ways, so one could go to an ER on 2 different occasions after overdoses taken while drunk, and end up committed one time and released another.

Commitment demystification: factors that increase the chance of hospitalization after a suicide attempt:
-lethality of the amount/drug type taken
-planning it out over several days
-a suicide note
-taking it in a manner that reduces the chance one is found in time
-buying the pills for that specific purpose (versus finding them in the medicine cabinet)
-living alone/limited social supports
-attempted hanging
-stabbing/shooting
-not having anyone to corroborate story with
-lying (thus how would one know you were being truthful about being safe)
-not having access to aftercare over the next several days to week

FYI: coming in to ER via police petition does not appear to increase risk of hospitalization.

Sunday, October 12, 2008

Washington State Task Force Recommends Changes to Laws

An article by Carol Smith in the Seattle Post-Intelligence discusses a task force's recommendation to the state's involuntary commitment laws after a man with a psychotic illness murdered Sierra Club worker Shannon Harps last year.

James Williams, a repeat violent offender with severe schizophrenia, has been charged with first-degree murder in Harps' death. Williams, who was under community supervision at the time of the murder, wasn't complying with court-ordered treatment and had been off the medications that helped control his violent hallucinations when he allegedly stabbed Harps to death.

Community corrections officers supervising Williams used every tool the system provided to try to keep Williams in treatment and out of trouble, said King County Prosecutor Dan Satterberg, who convened the task force to examine the case.

"The bottom line -- they ran out of tools, Mr. Williams was let out and 10 days later he was charged in Harps' death," Satterberg said.

Their recommendations noted in the story:

Change the state's involuntary commitment laws to mandate treatment for those with a significant history of violence.
Provide more tools for enforcing outpatient treatment in the community.
Reduce privacy barriers so police can know the mental health histories of people they deal with in "real time."
Allow those who make involuntary treatment decisions more leeway to consider past history of violence.

This issue of compulsory treatment is gaining more and more supporters, usually after this or a Virginia Tech-like story. It is something our society continues to struggle with -- the balance between civil liberties and the right to control one's own body on one side, and public safety and the responsibility that society has to "help" vulnerable people.

I see the pros and cons on either side. Personally, I think that when one's illness interferes with others, particularly other's safety (think epilepsy and driving, TB and isolation, STD and contact reporting), that is when society has a responsibility to intervene.

Resources:

1997 King County Mentally Ill Offender Task Force Recommendations

2008 King County Mental Illness and Drug Dependency (MIDD) Oversight, Implementation and Evaluation Plans

Details on the Implementation Plan (1.3MB Word doc)

PS: My apologies to the readers for my extended absence. If you knew what was going on in my life, you'd understand (all is well, though). A big Thank You to Dinah for keeping the flame alive!!

Tuesday, May 08, 2007

Tarasoff Overview & Inservice

Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.

First some background:

In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.

Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.

This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.

Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?

If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.

Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:

§ 5-609. Mental health care providers or administrators.

(a) Definitions.-

(1) In this section the following words have the meanings indicated.

(2) "Mental health care provider" means:

(i) A mental health care provider licensed under the Health Occupations Article; and

(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.

(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.

(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.

(c) Duties.-

(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.

(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:

(i) Seek civil commitment of the patient;

(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or

(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:

1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.

(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.

[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]

The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.

Tuesday, June 06, 2006

Side Effects: Possible Death

This recent post about involuntary medication & the potential to leave patients in limbo in the hospital reminded me of the recent dilemma involving Russell Weston, the Capital Hill shooter. Eight years ago this chronically mentally ill man walked into the Capitol and killed two people, wounding a third. Although suffering a chest wound, he received treatment at the scene and survived. He was hospitalized and taken to court for involuntary medication. The medication order was initially granted but the order was stayed to allow his public defenders time to appeal. The issue: if restored to competence, Weston could face the death penalty. Thus, he was kept untreated for years while the issue was litigated. Finally, in 2002, the Supreme Court turned down his final appeal and he was treated involuntarily. A four year hospitalization without treatment.

Dangerous on the Outside

[posted by dinah, not ClinkShrink]

The Maryland Psychiatric Society Council Chairman writes:

A case currently working its way through the Maryland legal system may jeopardize our ability to treat involuntary patients who are refusing medications.

To go before a Medication Review Panel, a patient must have already been deemed psychiatrically ill and dangerous outside the hospital by an Administrative Law Judge. A lower court decision in Kelly v. DHMH changes the interpretation of the Medication Review Panel law to require dangerousness inside the hospital in order to justify forced medication. This creates a situation where a patient, committed to the hospital by an Administrative Judge because they are dangerous if discharged, cannot be treated because they are not dangerous inside the hospital. The patient would therefore have to remain in the hospital indefinitely without proper treatment and with little chance of safe discharge.

--bolding mine, letter excerpted with permission.

I'm not an inpatient psychiatrist, and I'm sure ClinkShrink will have volumes to add-- ah, the case in point is one of an inpatient at Patuxent, a forensic facility-- but I'm wondering how this works.

Let me try for a scenario. Patient is delusional about a neighbor, thinks the neighbor is implanting electrodes in his body while he sleeps, might need to kill neighbor (remember, I'm inventing this, please feel free to add a better fictional case). He's hospitalized, where he's free from delusional intervention, says he still might need to kill the neighbor, but is not violent on the inpatient unit, refuses meds, can't be forced to take them-- he's not dangerous in the hospital-- and can't be discharged because he remains delusional about neighbor and potentially is homicidal. For the sake of completeness in my fictional scenario, the neighbor exists and is not implanting any electrodes in anyone.

I would contend that since the patient's premise is delusional, his reality testing impaired, there is no guarantee that he is not dangerous in the hospital (actually, there is no guarantee that anyone is safe anywhere, but....). What is to say he won't suddenly become delusional about a nurse, or believe that the neighbor has entered his hospital room (delusions do tend to follow people) and what is to say he won't elope from a locked unit? I have worked in three different psychiatric hospitals where inpatients have committed suicide on the units-- if people are hospitalized to prevent suicide, it's not totally fool-proof.

Somewhere in here there is the assumption that psychiatrists and/or judges can predict violence and be certain of who is safe and in what setting. If only that were true. The Last Psychiatrist contends, "We spend a lot, a lot, of money and time hospitalizing people who are not going to die."*

So, eventually our fictional patient gets tired of years on the inpatient unit (I could make jokes here about withholding cigarettes, but I'll resist the urge), takes his meds, is quickly cured, and goes home. A few weeks go by, during which time he and the neighbor share herbs and tomatoes from their respective gardens, and finally, our fictional patient decides he doesn't need treatment and stops his meds, only to become delusional all over again. My point being that while we may want to involuntarily medicate dangerous, mentally ill patients for the safety of society, once they are back in "free society" they are free to stop their meds. Treating mental illness in people with dangerous behaviors continues to represent a delicate balance between the rights of the individual and the safety of others. I've nothing brilliant to add.

Quick closer-to-real life scenario and a link to a forced-medication tale:

When I was a newbie resident on an inpatient unit, I briefly had a patient who was mentally retarded with a psychotic disorder. He would stop his medications, have a few beers, and the voices would order him to kill children. He had no history of violence, no one knew if he really would kill children, but the family repeatedly got a bit anxious when he sat on the front steps with a machete. This was his tenth hospitalization for the same chief complaint. He'd come in, restart meds (including a shot of prolixin decanoate), and be discharged within a couple of days, only to repeat the pattern. So, if I'm thinking about Kelly v. DHMH, then I'll wonder if the rest of our laws make sense.

And finally, Tuboglacier, the psychiatrist who blogs at May Shrink or Fade, writes a story on a similar theme in Substituted Decision Making, with Clam Juice.

*(-- I might suggest that perhaps hospitalizing them worked and that's why they don't die, but that's another post for another day)

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