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.