Psychology, the law, and being committed

Great Debates
1

An exgirlfriend of mine found herself in an odd situation a while before I new her. She had recently started a graduate psychology program and knew few people in the area. She purchased a mini-barbecue unit in order to grill some fish.

She was never one of those people who are terribly aware of their surroundings and didn’t know that grilling indoors was a bad idea. She grills up the filets and blows out the flames, failing to realize that the coals were still hot (or that that is how you are supposed to cook things on a grill anyway).

In a half hour or so she starts to feel very sick. Huge headache, vomiting, what have you. She begins to realize it is something in her apartment, so staggers outside in the freezing cold in just a robe with her cell phone. The fire company comes and vents out her place and takes her to the hospital where they find she came pretty close to dying.

All better you think? Lesson learned? Not quite. She has to appear before a judge because they think she was trying to kill herself and they don’t want to let her go. She says she did not know enough about carbon monoxide or how it is produced to have known that that would even be a method of suicide. She explained that she had not severed ties with anyone, tidied up her business, or done any of the things one normally does before suicide.

Apparently this was not enough, though, as they committed her anyway. When you are committed by a judge they can pretty much keep you as long as they want until they determine it is safe for you to leave. You have no control. Oddly the only way she was able to get out (after about a week) was by telling them what they wanted to hear, that she must have “subconsciously” wanted to kill herself and that she would try to work on things. This is similar to very famous psychological experiment (I don’t have the site but I am sure anyone in psychology her could provided it) wherein perrfectly sane people were committed to see how the system handled them. Though they acted perfectly sane, their sane behavior was construed as indicators that reinforced the idea they were insane. No one believes a sane person in a nut house.

So, this leaves me with the point. Our government (laws may vary by state) has the right to imprison us without a jury trial for an indefinite period of time when we have done no wrong. I understand in some cased this may be necessary, but for those who are abused by it there is no recourse. Telling everyone you are sane just reinforces their belief that you are not. Is this right? Do we even have the right to protect people from themselves? Isn’t his opening the door to the ideal way to remove political dissidents (though I do not believe that has yet been done)?

2

Could it be that your friend told you this version of the story to save some face?

I’ve been working in mental health for 15 years now. If it’s one thing I’ve learned, it’s that nobody wants to pay for an inpatient stay if it isn’t absolutely necessary. We’re talking about at least $600 a day.
This has become more the case over the last 7-8 years too. When did this happen?

But let’s assume that your version of the story is acurate and there was a miscarriage of our laws.
I find it really hard to believe that she was hospitalized without giving the evaluator some indication that she was a danger to herself, or a danger to others.
I gotta say, I’m not real big on the existence of “common sense” but sheesh! I think she might have been an acute danger to the community if she didn’t have the sense not to have an open fire in her house.
A grad student not understanding why fireplaces have chimneys? Come on!

And she didn’t have to lie. All she had to do was make it clear to the staff at the hospital (treatment center, whatever) that she wasn’t suicidal, had no ideation, intent or plan.

Are you sure this story wasn’t made up?
Did it happen like in the 70’s or earlier?

Laws to protect people from making the permanent decision to kill themselves when in the throes of mental illness are sound, they have checks, and are a good idea.

At absolute worst, there was a mistake made, but I doubt it.

3

I agree with greck. It sounds pretty far fetched. Generally, mental health professionals have no desire to hospitalize people any longer than necessary (necessary meaning provide treatment and avoid being sued). I have never, ever heard of people being hospitalized for a speculated subconscious desire to hurt themselves. I suppose it varies by state, but it is also not true that you may be involuntarily committed for an indefinite stay, at least not without re-review. In my state, initial involuntary treatment is 48 hours, I believe. I think after that it is 30 days. I would have to double check on that first though.

4

Medical professionals in “college areas” often have to deal with lots of drug/alcohol problems, hidden or disguised eating disorders, and suicide attempts.

Since they so often are required to apply hammers, everything begins looking like a nail.

In college, I once went several days straight without sleep and became delirious. The doctors at the emergency room where I was taken wouldn’t believe that I wasn’t on drugs. They actually drew blood four times to repeat the tests that kept coming back negative; when they couldn’t find anything, they decided that I had meningitis and gave me a spinal tap to check.

When I finally came to (the combination of sedatives they administered to “relax” me and exhaustion took nearly two days to wear off), they questioned me dilligently about what drugs I had supposedly taken and insisted that they would soon find out anyway when the toxicity screens came back, so I might as well tell them. (I’m fairly certain the more sophisticated tests had already come back and been negative.)

After I said that I thought the combination of sleeplessness (I normally need quite a lot) and dehydration would more than account for my condition, they said “All right, if that’s the story you’re happy with.” Then they wanted to keep me for several more days for observation and an MRI – and when I asked why they thought these things would be necessary, they replied that they thought they would be a good idea (well, duh).

As I insisted on leaving, they insisted on giving me a prescription of antipsychotics “to help me sleep”. As far as I was aware (and I’ve never found any evidence to indicate I’m correct) even the atypical antipsychotics aren’t prescribed as sleep aids. What was even more amusing was that, as soon as any nurse entered the room and glanced at the informational sheets left by the doctors, they exclaimed “they’re just to help you sleep”. Riiight.

In summation: don’t assume that doctors are competent, and don’t assume that there must have been clear evidence that this student was trying to harm herself. There are enough overzealous and well-intentioned doctors that the OP’s story could well have happened.

5

Ok, they commit her because they say she was suicidal. What is their incentive to release her if she doesn’t back them up? If the says the right thing they look good. If she refuses, everyday you stay in one of those places you credibility goes down. People assume you would not be in there unless you have a real problem. Denying the problem is evidence of its severity. If they release her and she was never suicidal, it looks bad for them.

The problem is worse in college towns. Some colleges are so paranoid about suicide they get fellow students to spy on others for the signs. The shrinks in these towns need to be quick to see that those the college questions are suicidal if they want to do a good business. Also, once you admit you are suicidal, the college is happy because they can use that to throw you out if they feel like it. They probably won’t unless you rock the boat, but they like having the option and shrinks seem happy to give it to them.

6

It’s perfectly credible that someone might unwittingly be grilling indoors without having “suicidal tendencies”. There are lots of stories of people who grill indoors floating around (here’s a “police beat” report from Kalamazoo, Michigan of such an incident involving college students) and most of them amount to “wow, I did not know that”.

Did anyone check to see if the doctor involved had an ownership interest in the property? Back when I lived in a college town, most doctors had shares in the REITs that owned most of the student apartments. I’ve known doctors scummy enough to commit someone in order to protect their own investments or to punish someone who hurt them.

7

This was Rosenhan’s 1973 study on labelling and mental illness.
Here is a link.

8

  1. Their primary goal is evaluation. If that evaluation comes up negative, the patient leaves.

  2. Credibility in “those places” is based on the same things upon which we base credibility anywhere else. The longer you stay the more or less credibility you will develop depending on how credible you are.

  3. With suicidality it MOST CERTAINLY IS NOT! Denial is big for people with addictions, trauma, anyone who’s goal is to maintain some facade while not changing the dysfunction (and actually, it’s not really evidence of severity in these cases either).
    This is not the case with people who are suicidal. People who are suicidal do not want to maintain suicidality. They kill themselves in order to quit feeling that way in fact. People who are suicidal are usually quite honest about it when asked directly (assuming it is safe to do so). The most important thing a person can do to stop someone from completing suicide is to ask them if they are considering it.

  4. again, the goal of a psychiatric hold is evaluation, assessment

9

It’s also possibly that this was a backlash. Mental Health professionals are always accused of doing too much (in this case) or not enough (recent immolation suicide by MIT student). Often, lawyers make rules based on the last big stink, and the staff has to try and follow those rules. Allowing someone who could easily be accused of being a danger to others to walk on out could be a serious legal issue. That said, your friend’s story sounds hinky. For one thing, your average fireman and EMT has seen the absolute worst of human stupidity and have a pretty good opinion (if asked, and they probably were) about stupid versus dangerous/suicidal.

Additionally – if she did indeed tell the docs “that she had not severed ties with anyone, tidied up her business, or done any of the things one normally does before suicide,” well, that’s kind of odd. (Not to mention inaccurate.) You get enough kind of odd things in a row and they add up.

10

greck, the point is that because of the bias on the part of the evaluators, it’s very rare for an evaluation to come up negative. Just the fact that an individual has been ordered to a psych eval by a physician is enough bias to lead many MHPs to assume that the individual is, in fact, deranged, and thus prejudices the evaluation. Some of the more egregious examples are documented in legal and psychological literature.

Once a physician makes the decision to suspect that an individual is mentally ill, the mental health system will bend over backwards to support that physician’s conclusion, even if it is incorrect. This is, in my opinion, the operation of the “thin green line” and reflects the fact that a doctor who inappropriately orders a patient confined can be subject to substantial legal liability. The MHS protects the doctor and the hospital by always finding cause for the confinement and then extorting the admission and waiver from the patient during the forced confinement (by making release conditional on signing the admission and waiver).

As to funding: since the state pays for people who don’t otherwise have insurance, you can always get at least a few weeks of funding for just about anyone. And most college students have at least some form of insurance that’ll pay at least for sixty days or so, and generally you can extort the admission that protects everyone from a lawsuit by then. The cost of sixty days of mental health confinement is nothing compared to that of a multimillion dollar libel or malpractice judgment.

11

greck, I am absolutely sure it happened. She wasn’t happy about talking about it and was very embarassed and I had confirmation elsewhere. As to how accurate her story is, well who knows. I can very easily see this person making the honest BBQ mistake. Though smart she is not very aware.

Though she was not suicidal, she was mildly depressed, so my guess is that they took this as evidence that it must have been a suicide attempt and refused to believe otherwise. As she is in this field herself, she has since discovered that this sort of thing is not too uncommon.

Also, it is entirely possible that much of this was CYA on the part of the doctors. There is currently a law suit pending in my town against a psychiatrist who’s patient went nuts and shot a couple people on campus. Maybe they were extra paranoid because of this.

12

One of the biggest problems with some psychological diagnoses are that the criteria for them are so broad or undefined.

Do you sleep too much, or not enough?
Do you eat too much, or not enough?
Do you feel tired and anxious most of the time?

If so you are depressed!!! (Never mind that this could refer to 90% of all adults in America.)

ADHD is a similiar diagnosis.
Do you have trouble concentrating in school while the teacher reads War & Peace in a monotone voice?
Does your mind wander when you are supposed to be doing 500 long division problems?
You got ADHD!!! Give that boy some Ritalin.

The suicide prevention is important. I would prefer to err on the side of caution. I feel for your friend. I think I would freak out like her and start spewing DSM-IVR stuff. Then, of course, they would commit me for being in psych… I mean only nutsoids go into psychology.

13

It doesn’t strike me as being anything out of the ordinary. Anyone can be committed involuntarily.

At least she caught on pretty quickly how to push their buttons and obtain release.

14

Here in Illinios, the emergency involuntary commitment of an adult person without a guardian is controlled by statute. Before an emergency involuntary commitment, there are many checks to assure that it is done fairly. The petitioner (the person asking somebody be involuntarily committed) must show:

  1. “Immediate hospitalization is necessary for the protection of such person or others from physical harm.”

  2. “A detailed statement of the reason for the assertion that the respondent is subject to involuntary admission, including the signs and symptoms of a mental illness and a description of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the time and place of their occurrence.”

  3. Any interest the petitioner has (financial, legal, etc.) that may make it a conflict with the rights of the person.

  4. A list of witnesses to these facts.

  5. Lying in the petition is a crime.

Then, once the petition is completed, it must be accompanied by a certification.

If it is not possible to get a certfication, the petition must include the additional information:

Once that is done, a person can be involuntarily held for only 24 hours maximum to obtain a mental health evaluation.

This outlines the law surrounding an emergency involuntary commitment. Once a mental health evaluation is done, then there are a whole other group of checks on holding the person more than the original 24 hours. A copy of the petition has to be provided to the subject, an attorney can be appointed to the subject, and a hearing must be held. I’ve personally done plenty of these hearings, and if there is truly a question whether somebody should be held, then the hearing officer will generally release the person.

I highly doubt the facts contained in the OP are complete and true. There are some important facts missing, such as the paperwork and evaluations that had to have been done to hold the woman, etc. There are many checks to make sure this law is only used in those rare cases where it is necessary to protect a person’s life, and it is a rare case indeed where it is abused. Speculating that the doctor had an interest in the apartment, or some other underhanded motive involved is just plain silly.

15

Here in Illinios, the emergency involuntary commitment of an adult person without a guardian is controlled by statute. Before an emergency involuntary commitment, there are many checks to assure that it is done fairly. The petitioner (the person asking somebody be involuntarily committed) must show:

  1. “Immediate hospitalization is necessary for the protection of such person or others from physical harm.”

  2. “A detailed statement of the reason for the assertion that the respondent is subject to involuntary admission, including the signs and symptoms of a mental illness and a description of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the time and place of their occurrence.”

  3. Any interest the petitioner has (financial, legal, etc.) that may make it a conflict with the rights of the person.

  4. A list of witnesses to these facts.

  5. Lying in the petition is a crime.

Then, once the petition is completed, it must be accompanied by a certification.

If it is not possible to get a certfication, the petition must include the additional information:

Once that is done, a person can be involuntarily held for only 24 hours maximum to obtain a mental health evaluation.

This outlines the law surrounding an emergency involuntary commitment. Once a mental health evaluation is done, then there are a whole other group of checks on holding the person more than the original 24 hours. A copy of the petition has to be provided to the subject, an attorney can be appointed to the subject, and a hearing must be held. I’ve personally done plenty of these hearings, and if there is truly a question whether somebody should be held, then the hearing officer will generally release the person.

I highly doubt the facts contained in the OP are complete and true. There are some important facts missing, such as the paperwork and evaluations that had to have been done to hold the woman, etc. There are many checks to make sure this law is only used in those rare cases where it is necessary to protect a person’s life, and it is a rare case indeed where it is abused. Speculating that the doctor had an interest in the apartment, or some other underhanded motive involved is just plain silly. Almost as silly as it not being out of the ordinary and that “Anyone can be committed involuntarily.”

16

But all of those steps require relying on the opinions of individuals.

Tobacco executives testifying before Congress all swore that they didn’t believe that cigarettes caused cancer. Oh, sure – they’d seen countless studies showing a link, but they didn’t believe it.

How is it possible to prove that a physician didn’t honestly believe something? If the physicians claims that the OP-girl’s actions and speech gave him an intuitive sense that she was trying to kill herself, how can we determine if he’s not telling the truth?

17

This is why the psychiatric inmates’ liberation movement wants “mental health” commitment to refer back to the more general laws for declaring someone incompetent.

There are decent safeguards built in to prevent Creepazoid Pennybags from having Rich Uncle Pennybags declared incompetent just because he wants control of his uncle’s estate.

There is no reason and no excuse for a shadow process to exist for treating someone as incapable of making their own treatment decisions solely because they are alleged to suffer from a “mental illness”. If I am schizophrenic (and the doctors did say that I am, which is pretty much the functional definition of it if you see what I mean), but cannot be shown to be incompetent through the workings of a regular competency hearing, then my schizophrenia, and my decisions about treatment or lack thereof, are my business and no one else’s. (Similarly, if I enjoy the mental condition I’m in and turn down offers of psychiatric treatment and then go on to commit crimes, I should be subject to the same laws and punishments that would be applicable to a non-schizophrenic committing the same crimes).

Commitment hearings in NY basically work like this: a special mental hygiene court that only hears cases of this nature is convened, often right on the grounds of the psychiatric hospital; the psychiatrist’s testimony carries the weight of expert opinion, and, since the hearing is occurring at all, that means the psychiatrist is going to say that the subject of the hearing is mentally ill and lacks insight into his or her condition (and is therefore/and/or) is a danger to him/herself and/or others. The subject of the hearing gets to explain, as a nonexpert whose testimony is not impartial and is already impugned as psychotic babbling, why he or she does too have insight into his/her condition and does not need or want psychiatric treatment (a difficult maneuver when “lack of insight” is defined as “doesn’t understand the need for treatment”).

Volunteers from Mental Hygiene Legal Services are appointed to represent the subject but many are undertrained and often do not take an adversarial role (i.e., do not argue and present evidence supporting the subject’s right to refuse forced treatment). A strategically savvy subject with the wherewithal to pull it off will have obtained an independent psychiatrist’s opinion (therefore coming in with a dissenting expert opinion) or, lacking the connections/money to do that, will request independent evaluation in a separate psychiatric setting rather than using the observations of the doctor or other doctors at the same facility to support the doctor’s position.

Some judges are good and fair, many are rubber-stamp weilders, and more than a few are dedicated to the principle that it is the court’s responsibility to keep all lunatics locked up for the protection of the community.

In NY, if anyone other than a police officer draws the attention of a psychiatrist to your questionable behavior and the psychiatrist decides that you may be in need of treatment whether you agree or not, the psychiatrist can have you taken by the police to a psychiatric facility where an admitting psychiatrist will supply the second concurring psychiatric opinion (usually automatically, though it isn’t supposed to be), and then they can hold you for 72 hours’ observation before designating you as “involuntary”. Only after you have been deemed “involuntary” is a commitment hearing scheduled, so it doesn’t occur immediately.

If, on the other hand, a police officer observes your behavior and decides that you are nutty and dangerous (to self or others), you can be taken and held in a psychiatric facility for 30 days before they are obliged to convene a hearing.

The psychiatric facility is not obliged to present you in the courtroom in an undrugged state or in street clothes, so at your commitment hearing you may be in hospital robes and slippers or even in a straitjacket, and if, in the hours prior to your hearing, a psychiatrist or staff nurse thought medication was called for, your brain may be full of Prolixin or Haldol.

The judge is not obligated to speak to you or allow you to speak in your own hearing, and some do not.

18

Hamlet, it is attitudes like yours that make abuse of these laws so easy and ubiquitous. You are so ready to doubt this person and believe her accusers simply because they are mental health professionals and she is accused of being mentally ill.

Really, one can’t expect much from a profession that gave us the Minnesota Multiphasic Personality Inventory (MMPI). This test was designed by finding out how mental patients with known diagnoses answered a set of questions. If you answer like a schizo, voila you are a schizo. The problem with the design is that they did not even bother to get a wide sample of people who do not have a diagnoses to correlate against, so it would be possible to test sane. For all the test designers knew from their studies, it is entirely possible that many perfectly sane people could test as schizo. One excuse for this is that not having a diagnosis does not mean you are sane, just you have not yet been diagnosed. Mind you, it is supposed to be a tool used in conjuntion with others including patient interviews, but often it is interpreted by itself.

There are plenty of mental health professionals who are competant and ethical. All it takes is 2 that aren’t to get a sane person committed.

19

Of course it does. It is nigh but impossible to have completely objective test for “Mentally Ill” or “danger to himself or others”. That doesn’t mean we don’t do it at all.

People lie. And that helps exactly how? They’ve made it a crime to lie on the petition and the certification and in testimony.

Why would you. Pointing out that these kinds of determinations are subject to opinion and speculation does not mean that we should not be doing it.

20

Those protections are not just for those occasions, but also for all cases.

I agree. That is why there is no “shadow process” but a process that has numerous checks on potential abuse and which require hearings to be conducted.

I don’t understand the difference between incompetence and emergency involuntary commitment. In Illinois, the finding of involuntary commitment necessitates a finding of incompetence, albeit temporarily.

Your description of commitment hearings in NY sounds much like that here in Illinois. However, I was taken aback by your statement:

I cannot believe that in N.Y. you can be committed for 30 days based on nothing other than a police officers word. I know of no State that allows that.