Somebody called me from a psychiatric instutition saying she's held against her will.

In My Humble Opinion
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Sure. I also recommend reading the linked thread regarding Annie’s experience as there as much procedural information there, as well.

People are referred to a crisis clinician for an assessment. Referral sources can include: self, family, friends, school systems, therapists, prescribers, social services, medical or mental health providers, or police. Crisis assessments/evaluations are conducted in homes, schools, hospitals, service agencies, and other outpatient settings. When an assessment is done, it is always triaged–if there is immediate risk or concern, that is always addressed first. This can include anything from possible intoxication, to safety, to a medical concern.

Once the individual is deemed appropriate for an assessment, the clinician begins the interview. The context of the referral is the starting point. The individual is also interviewed. Case conceptualization and treatment planning are never made in a vacuum. Multiple sources of history and information are not only encouraged–they are desired. It’s just good practice. Collaborating happens on both ends: history, records, providers, motivation for admission is all explored. And each case is reviewed in depth.

Most of the work I did was in the ER, third shift. It made it difficult to collaborate for care, but we did it. And I presented each and every case to a supervisor for consultation. Assuming that someone met one of the criteria for admission: harm to self, others, or severely impaired judgement, the process continued. The case was typed up into a 26 page report (even if they were not admitted, the assessment was 26 pages typed) and then presented. This was the beginning of a long and tedious process. And of course, this is assuming the person is medically cleared for an admission. That in itself can take days. And of course, services to meet special medical needs are not available in all hospitals. I once re-evaluated someone who returned from a 4.5 hour trip each way to a hospital because when she arrived, she learned they were not equipped for her oxygen tank.

Insurance companies (save Medicare) have to approve admissions. This involves calling an insurance company and requesting a call back from the case reviewer. That can take minutes, hours, or even over a day or so. That person is trained in mental health–and have often worked in the field at some point. They then listen to the case presentation, and often re-present/consult with others on their end. Assuming they say yes, it is only after they have grilled the clinician for “what other levels of care have been considered?” They are paying–they would rather have someone follow up with their outpatient provider or go to respite or something cheaper. Inpatient psych admissions where I worked averaged $3,500/day. As the highest level of care, it’s rarely appropriate to pull out the big guns first. For anyone.

Assuming someone meets criteria and has been approved for admission, then it’s on to the bed search. I have admitted people who deny suicidal or homicidal thoughts, plans, intent, or means. But they also said that Jesus told them to set small fires in their apartment complex to activate the second coming of Christ. The fire department confirmed this, upon inspecting the surroundings when a small fire had started in a corner of the building. Are people allowed to be crazy? Sure. Would you want that guy as your neighbor because of his “civil liberties”? What about your grandmother’s neighbor? He was living in a low-cost setting with many elderly folks. But I digress.

So I call the hospitals. I talk to someone who agrees to relay the request to present the case to the intake person. That can be a nurse or doc, and again, is always done with more consultation. If they are busy, or it is shift change, or admitting someone else at that moment? Again, you can wait hours. This is just to present the case. And many times you can present to one shift and the next shift will deny. And there are many factors to consider: the makeup of the milieu at that time. Whether the person has been there before. Conflict of interest on the unit (a nurse’s son can’t be admitted to her unit). And of course, that there may not be beds. Or low staff. Or they want further medical clearance first. Or to speak with that person’s other providers directly. Or they are uninsured or wrong insurance. And I have had hospitals reject admissions–to where someone waits in the ER for up to 8 days. Eight.

And whenever I admit someone, I remind them that self-admission is always preferred. I explain that it is about having more voice in your treatment–like quit versus fired. Obviously, the 72 hour minimum is never guaranteed (as in, that is the minimum), but I am honest and open with people about that. Once the receiving hospital says yes, the transportation needs to be set up. That means coordinating with an ambulance company that is both covered by the insurance, and willing to make the transport. Weather, distance, crossing state lines…those are some of the common barriers. And then once people arrive? Well some hospitals want to then do their own medical clearance yet again.

Shall I go on? This isn’t some glamorous process designed to make people unnecessarily miserable. ERs tend to get annoyed with psych patients. Inpatient staff are underpaid. Finding beds can be a nightmare. Insurance companies are protective of their funds.

I’m not biased. This is all true. Ask any crisis clinician anywhere. Placing people inpatient is not easy. I’ve been spit on, sworn at, kicked, had furniture thrown at me, and had a knife pulled on me. I’ve fought for someone to be admitted who was denied admission by my supervisor, went home, and then took his life. I’ve had a mother cry and beg me for an admission because her daughter was found wandering the streets naked, on another continent. I’ve also had a mother drop off her 10 year old saying she wanted me to send him to “one of those Maury style bootcamps.” I’ve challenged insurance companies, doctors, and admissions people. It’s hard work, but once someone is referred, to admitted, to when they are discharged, there have probably been at least 50 people involved. And that is low balling it.

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Re my prior question does anyone know what it typically costs an insurance company or the state or county for processing and implementing a “72 hour hold” of a person.

Any hard numbers?

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$3,500/day in a public hospital–that’s the stay itself. Doesn’t include ambulance, eval, etc.

That’s assuming that the person isn’t staying in the ER for more than a couple hours. In addition to accumulating ER services, they have to be re-evaluated each day. Crisis evaluations cost $ too.

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I do know here in Colorado Springs the VA contracts out with a private, for-profit corporation-owned hospital, and someone at the VA told me they’re really pushing PTSD diagnoses and sending lots of vets off for 72-hour holds. Anecdotal, but there ya go.

I imagine for the VA it’s a political thing, and for the private hospital it’s big bucks.

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I also forgot to add that an insurance company can say yes, but that yes has a time limit. If the placement can’t get made in a certain time, the authorization expires and the process starts over.

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Thank you, living_in_hell, that was really very helpful. If I may, I’d like to ask one professional question. I’m a home health nurse. How can I connect with your position at the the hospital to let you know what information I have that might be useful when my patient shows up in your ER? I’ve found hospital personnel really loathe to talk to me. (And given what I’ve seen of some home health nurses, I can’t really blame them. Home health nurses aren’t always that great.) I’ve spent literally hours on hold, and been hung up on or lost in transfer land more times than I can count. Is there anything I can do when I have important information to get it to you? And, perhaps even more important, what can I do to get information from you when you send them back home to me? Official channels often take 2 to 3 weeks post-discharge to get me records, and that only after approximately 412 faxes of the Release of Information forms. Any tips?

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The VA is under a lot of pressure to address the PTSD issue…which frankly is a whole other problem…there are many comp and pen claims that are bogus attempts at folks squeezing money out wherever possible. Don’t get me started on this.

Most hospitals get money for any admission. Sure. But ever seen an inpatient unit at a typical public hospital? It’s not exactly the Plaza Hotel…and most employees work many jobs. Including psychiatrists. You make more in private practice than working on a unit.

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You’re welcome. Absolutely–a crisis clinician always wants information. As much as possible, from as many sources as possible. Know your local crisis teams–I worked through a community mental health clinic that subcontracted with the hospital. They have 24 hour staffing and team communication is vital. So get to the crisis team, and the info will get relayed and considered. As for the discharge, whenever you can find out (providing you have releases and such) where someone is admitted, find the unit social worker/discharge planner. Again, this person WANTS collaboration–sometimes continuity of care is what stalls a discharge! Get to know who does discharge planning, and work directly with them. Even more ideal is when you can be part of the discharge planning in person–true wrap-around, patient centered care.crucial to access and flow is continuity and collaboration of care.

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One more thing…in my experience, crisis clinicians (the “shrink” who assesses the person after the initial referral is made) don’t work for hospitals. So considering we are salaried, what’s the incentive for us to admit someone or not? We are objective third parties with no investment other than being clinically sound, in where someone ends up. The report has to be written either way. All this conspiracy and money making stuff makes sense as a sleazy tactic if you are furnishing your own house. The hospital didn’t pay me and frankly, the unit at my hospital was often my last choice. They did give me a nice closet to work in though. My desk touched three walls and I had to pull the chair out of the room (and sit on the desk to make calls) if I wanted to close my door.

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Thank you. Unfortunately, we have over 200 hospitals in Chicago, so getting to know the teams at all of them is impossible. But that doesn’t mean I can’t start with the ones my patient population uses the most! Time to get some more business cards printed and just start bugging people in person. :slight_smile:

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Many teams cover numerous hospitals…the one that eventually took over our team was responsible for 8 hospitals.

You can also network through one hospital–I had an intake person at one hospital who was very familiar with the point people at the other hospitals. She’d worked at those facilities or with them for years.

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living_in_hell, thank you for your thoughtful posts; I find that sort of post to be much more constructive as compared to the first one I responded to.

You clearly have a difficult job, and I can understand you responding emotionally to someone who argues against the system you work in. Clearly, you are not the monster that some (not anyone I know on the boards) anti-psychiatry types might like to paint you out to be. Neither, however, are you unbiased, despite your claim otherwise. We are all biased by our own beliefs and experiences, and it is in recognizing our biases that we can account for them and present a more truthful account.

Your explanation is very detailed - at first blush it comes across as rather more complex than I have previously encountered. Perhaps I am misreading, but many of the cases that I’ve read do not require quite so many people to initiate a psych hold. I am not in a position to know where the discrepancy comes from.

AHunter3 and I share many (but not all) of the same beliefs when it comes to protecting the rights of those who have been labelled “crazy” (a pretty insulting term for a seasoned professional like yourself to throw around so casually, don’t you think?). I cannot speak for him, but I think it’s safe to say that you’ve mischaracterized his position rather severely. For myself, I can say that, even taking your account as truthful, I am still very concerned that our system is lacking in the most basic protections when it comes to involuntary commitment.

On the other side, it’s also very clear that it is all too often difficult or impossible to provide the kind of care a person may need, and there are certainly many instances where someone who needs help will (successfully) refuse the help that is provided, sometimes with disastrous consequences.

Caring for people with severe mental health issues is a difficult and messy task - I believe it is the case that many people who need to receive care against their will wind up without it, and also that many people who would fare better without such a strong intervention as an involuntary hold will find themselves without the resources and protections needed to refuse inappropriate treatment. My own biases cause me to be more concerned about the latter situation, but I recognize that any improvements to our current system would require paying attention to both areas in which our system fails.

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I thought it was inherent in my post–it’s not the preferred route of treatment. Inpatient is the exception, not the rule. Any healthcare provider (ideally) practices by this…if someone has a headache you don’t perform brain surgery. It’s a thought out, tedious, collaborative process.

I don’t use the term “crazy” in a serious way. Ever. I was using it here, in a certain context. I dont approve of “shrink” but you dont hear me whining about it here, do you? If the MH crusaders want respect, they may want to think about their role in using “jail” “looney bin” “shrink” “imprisoned” as well. Don’t you think?

And please don’t patronize me. I already have a pretty clear idea where you stand. I love what I do and am damn good at it. I also think I have a much more informed basis to form my opinion. If you think that one or two people decide someone’s course of treatment, you are really under- informed. What IS your experience anyway? You say “read” cases, but if we are all so biased, what’s yours based on? What you read here?

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If even part of that intake laundry list of requirements and evaluations is true how can you rationally hold that position? Is it more likely against all financial and business logic that there is some real world crisis of sane people getting arbitrarily, unnecessarily and very expensively locked up, or is more likely that people who were mentally disturbed when they were institutionalized have a huge bone to pick with mental health professionals after they got better, and dislike the stigma of having been considered mentally unstable.

I can especially see people who were on drugs having this attitude re being “better” now they are no longer using.

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With all due respect, Orr, you are responsible for posts such as this:

It baffles and outrages me that anyone could be subjected to an involuntary committment on such grounds, but I have no illusions that it doesn’t happen, and probably more often than most people are willing to accept.

So if being “biased” means telling you the complexities of a process that you clearly know little about, then biased I am. I shared with you a process. Sure my tone is in there, but how is sharing details of a process biased? Why would I make it up? What do I have to gain? I worked 3rd shift. I also worked a full time day job. You think I had something to gain at 0300, waiting for return calls, while getting screamed at by ER docs and crisis patients and insurance companies for minimum wage? Sure. I really had no desire to be home, sleeping. Ever.

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While I’m at it, I’ll share another thing that I’ve been thinking about that I feel is related.

I used to work direct care for individuals with DD/MR, and did so for a number of years and in a variety of settings. It was very difficult, under-appreciated work, likely in ways very similar to some of the professionals who’ve posted in this thread. It took a particular temperament, and, even with that temperament, a lot of work and introspection, to maintain a caring and thoughtful mindset when dealing with people who sometimes cause damage to property, harm themselves or others, or sometimes just refuse to put their damn shoes on. Many people in that field do not have that temperament.

Some of the places I worked did pretty well. Management was involved and attentive to clients’ needs, there was extensive communication between all levels of staff, from the lowly DC to the psychiatrists and psychologists who developed the medication and treatment plans. Even at the best places, however, there were instances of abuse, neglect, and mismanagement. At the best places, these problems were discovered quickly and corrected. At the worst places, these problems were the norm, and speaking out against them got me fired. In all of these places, the paperwork was “up to snuff”, even if the actual situation was not.

I considered myself to be pretty good at my job, and where my skill was imperfect, my intentions were unassailable. If someone were to come in and complain that the system for caring for the DD population was deeply flawed, I might take it somewhat personally. But never would I dismiss their concerns out of hand - I’ve seen it myself. Never would I conflate the fact that there are inadequate resources to provide for this population with the idea that it cannot be the case that perhaps many people are placed in situations that are more restrictive or intrusive than their actual need warrants.

So, in addition to the occasions in which I’ve encountered crappy doctors doing crappy things, it is this background that informs my perspective, in which my concerns remain even despite statements such as those by living_in_hell. I simply cannot believe that never is there a Beta Error, only Alpha Errors, and I simply know better than to think that the careful, professional, and high-integrity behavior of 'Dopers in the field is absolutely universally the case throughout the field.

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You need to learn how to read. I did not say the system was perfect. In fact I said otherwise.

I can’t debate with you because you are living in some la-la land and have clearly been away from the field for so long you don’t even know that DD/MR aren’t even preferred terminology.

I also get this vibe that you think I am callous and heartless and burned out. While I may be projecting, I don’t like it. Because it isn’t true. I fight hard for my patients–whether getting them more help or believing they are more capable than they may think they are.

I read this thread and the Annie thread, and you continue to present as someone who really doesn’t want to consider facts, even when those facts are presented to you by people who know more than you do. I also think it’s hilarious that you are quicker to dismiss me, and other professionals describing PROCEDURES AND LAWS than you are to dismiss someone who has been seen by hundreds of eyes and now inpatient…we are all wrong, right? It couldn’t be that this woman who is inpatient may have had a psychotic break and part of her delusions are that she’s there against her will? If you are so compassionate, why don’t you consider that maybe she IS safer there, and we aren’t all heartless beasts?

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Only Alpha Errors, and never Beta Errors? That would be unreasonable to believe.

Involuntary commitment is a pretty invasive approach, and most professionals will choose less intrusive interventions, as even living_in_hell acknowledges (if I may characterize it such). My position is that there is a lack when it comes to protections against when the system fails due to incompetence or malice. Those accused of crimes receive a trial, have legal representation, and are presumed innocent by law - and even that system is flawed. Those accused of being dangerously mentally ill do not receive all of those protections (although there is sometimes a hearing, but the individual may sometimes be given psychotropic drugs prior to such a hearing). It’s certainly not a simple analogy, and the solution is beyond my ability to envision, but that should clear up for you what I mean.

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I read very well, thank you. Didn’t you ask me not to patronize you? And yet here we are…

I believe you fail to realize why you cannot debate with me. The other posters in this thread are doing just fine in this conversation.

BTW, yes it has been a couple of decades since I worked in Direct Care.

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This deserves a better response. I think you may be right, you may be projecting. My opinion of you is that you seem upset (although I could be wrong), and are argumentative towards me. I don’t know enough to label you as callous, and my guess is that you are above average, at least, when it comes to the care at which you attend to your professional responsibilities. But I think you have been careless in some of your posts.

If you think I am someone who doesn’t want to consider facts, you are mistaken. I remember that other thread, and I remember that I thanked Shodan and changed my opinion about a statement I made (how many people on this board can make THAT claim?). I also recall thinking at some point that I may have jumped in too strongly on Annie’s side, and should have maintained a more neutral stance on the particulars of her case, but I don’t believe I made that statement explicitly.

I beseech you to take a step back and reevaluate your opinions.