Eleanor (not her real name) talked to me at length about her experience as a patient who had been committed to a psychiatric unit. Eleanor came to the emergency department in distress. In fact, she was screaming inconsolably when a physician gave her an injection of a sedating medication and filled out a “5150,” the California jargon for an involuntary hold. Eleanor’s stay on the unit lasted three weeks. During that time, she was repeatedly held down by security guards and injected with medications, and she spent a good deal of time in a seclusion room where she felt she was running out of oxygen. She crouched by the bottom of the door, trying to suck in air, all the while convinced that the staff were trying to kill her. It was a traumatic experience for Eleanor; to this day, she finds it difficult to ride in a car with the windows up, and years after her hospitalization, she continued to visit my psychiatry blog as part of an effort to process an experience she wanted never to repeat, one she readily called traumatizing.
Doorway to Psychiatric Care
The emergency department is the doorway to involuntary psychiatric care, and most emergency departments don’t have psychiatrists on-site. The most crucial and controversial decision in psychiatry often falls on the shoulders of an emergency physician, with or without the help of a mental health professional. Patients are involuntarily committed because they are acutely suicidal, acutely psychotic, or both. Someone is worried they might be dangerous.
The forces in play here are considerable. We have patients, who may be too impaired to make decisions or even see that they are ill and who should ideally have the right to autonomy over their medical decisions. We have society, which may worry that people with mental illness pose a danger to others. We have the families, who watch a loved one suffer and miss the wonderful opportunities that life has to offer but who may have their own agendas for wanting a family member to be in the hospital. We have the doctor, who wants to do right by patients while simultaneously serving as the gatekeeper for resources (that rare psychiatric bed) and worrying about the malpractice implications of a bad outcome. We have the taxpayer, who pays for lost productivity, disability benefits, and institutionalization of these patients. Finally, we have the insurer, who wants to pay for as little as possible. All of these agencies are quietly in the background whenever a decision is made to involuntarily hospitalize a patient (or not).
The most crucial and controversial decision in psychiatry often falls on the shoulders of an emergency physician, with or without the help of a mental health professional.
If doctors in the emergency department begin with the idea that forced care is a good thing—that it helps people get well at times when they may be too sick to recognize that they are ill, and that treatment enables patients to stay housed, working, connected to their loved ones, and out of jail and institutions—then they do it a lot, sometimes with a “better safe than sorry” approach. However, if doctors start off with the assumption that forced care is potentially traumatizing in a way that leaves some patients with years of distress, then the threshold for committing patients to involuntary treatment is significantly altered, and involuntary hospitalization gets viewed as a last resort.
Sometimes, there is simply no choice but to hospitalize people against their will and to use physical force to keep everyone safe, especially when patients are delusional, disorganized, and agitated. This is not something that should be done lightly. Involuntary treatment initiates a process whereby the treatment team becomes the adversary to the patients they are trying to serve. It makes for long and difficult days for everyone. Furthermore, when it comes to suicidal patients, we don’t know if involuntary care prevents suicide. Still, it can be very difficult to let a suicidal patient leave an emergency department if the doctor believes the patient is at risk of dying.
We know very little about involuntary psychiatric treatment. There are no national statistics on how many people are involuntarily hospitalized each year, and there are no statistics on how common it is for people to be traumatized. What we do know is that in the battle over involuntary psychiatric care, there are no organized patient groups lobbying for legislation to make forced care easier. There are, however, organized groups of people who call themselves “psychiatric survivors,” who feel they have been injured by what psychiatrists have to offer. There is no doubt that our treatment of those with psychiatric disorders needs to be more thoughtful and respectful. Ultimately, forced care puts us in the very awkward position of being the adversaries to the people we are trying to serve.
Smoothing the Way for Psychiatric Treatment
So what’s a doctor in the emergency department to do? I would contend that if, after careful assessment and consideration of less restrictive alternatives, there is no choice but to involuntarily hospitalize a patient, the first action should be to try to convince the patient to sign in voluntarily. This seems obvious, but it doesn’t always work out that way. Why would busy doctors expend the effort to convince patients to sign in if they could more easily force care?
Remember that Eleanor came to the emergency department seeking help; she would have signed in to the hospital, but that option was never offered.
Obviously, the use of physical force should be avoided unless absolutely necessary to maintain a safe environment. While restraints, seclusion, and the forcible injection of medication may be necessary to keep everyone safe, the ED setting is one where patients easily escalate. They may have been brought from their homes by the police in handcuffs, and they may be required to wait hours or even days for evaluation and admission. From the point of view of anguished patients, this is embarrassing and difficult. Force should not be used for strict adherence to policy—for example, to force a person in no obvious physical distress to have admission lab work. It didn’t serve United Airlines well, and it doesn’t serve psychiatry well!
Finally, I would say be nice to involuntary patients. They are some of our sickest and most dangerous patients and will likely benefit from remaining in our care. They may make us angry, and they may be a lot of work, but these patients need us. Like all human beings, those in need of emergency care may well appreciate small acts of kindness.
As difficult as involuntary care may be, the truth is that it’s better to have a traumatized patient than a dead patient. Still, there are times when involuntary treatment could be avoided or when the trauma could be mitigated. It’s effort worth making.
Dr. Miller is an instructor of psychiatry at Johns Hopkins School of Medicine and has a private psychiatry practice in Baltimore. She is coauthor of Committed: The Battle Over Involuntary Psychiatric Care and Shrink Rap: Three Psychiatrists Explain Their Work.