This discussion touches on issues that I care deeply about, have studied some, and have devoted a considerable amount of time to promoting in meetings and testimony at state legislative hearings in Texas. My comments:
“If you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully.” Yes. And if psychiatrists recognize that inpatient care can be traumatizing, why have inpatient settings not become more pleasant? Many maternity centers look nicer than my bedroom, pediatric hospitals have made their rooms more cheerful for children, and modern dentists have committed to pain-free dentistry.
“1. Increase utilization of psychiatric advance directives.” Okay, but where I live a patient can reject the psychiatric advance directive in a crisis and it becomes null and void. Include parents who devote years to caring for ill children in deliberations about involuntary hospitalization and listen without biased assumptions about their responsibility for the illnesses of their children.
“2. Enhance due process protections in civil commitment hearings, allow for vigorous patient representation and an opportunity for patients to tell their side of the story.” If psychiatry too readily chooses involuntary hospitalization, then civil rights attorneys from groups like Disability Rights Texas and judges who know too little about how profoundly the symptoms of psychotic disorders can affect a patient’s ability to make rational decisions too readily favor civil liberties over a need for treatment with consequences that too often lead to homelessness, imprisonment, or death.
“3. Eliminate hospital policies, such as strip searches, that can be distressing and humiliating for patients.” This will increase injuries to clinicians. In Texas, a state law doctors and nurses lobbied for made it a felony for a patient to assault a doctor or nurse while they are on duty. This has increased the number of patients going to jail. Why not, instead, lobby for a law that requires safety protocols in medical settings to prevent injuries? Such a law would be better for clinicians and patients.
“4. Ensure robust mechanisms for patients to report mistreatment at psychiatric facilities.” Yes and install cameras so accusations of mistreatment can be verified. Are reports of mistreatment often true or generally related to paranoia and delusions? Either way, what can be done to improve the patient experience? My adult daughter who once spoke glowingly about caregivers at a residential treatment center where she stayed for six weeks now talks of how traumatizing it was for her. When she began home visits later in her residential stay, she wanted to return in time for movie night with her friends. She wanted to give clinicians flowers and gifts. She hugged a clinician she saw at a grocery store. Now, as her delusions and paranoia have worsened, she has nothing good to say about her experiences in residential treatment.
“5-7” Related to crisis response and de-escalation training. Why has psychiatry not consistently taken a leading and outspoken role in advocating for a medical response rather than a criminal justice one? As pointed out earlier, doctors and nurses in Texas focused on punishment of those who assault them rather than prevention. Training in verbal de-escalation techniques is fine, but as Dinah Miller points out its effectiveness may depend on the personalities of those who are trained. Chuck Wexler, founder and director of the Police Executive Research Forum (PERF)* wrote that he does not think all police officers should be trained and deployed to psychiatric crisis situations for the same reason that not all officers should be trained in SWAT tactics—some just do not have the aptitude for such duties. He has also written that police can do a better job of using less force in situations where no gun is involved and it will be applicable to situations where mental illness is involved:
*From the PERF Guiding Principles on Use of Force: “Our work has centered on how the profession can improve in the key areas of use-of-force policies, training, tactics, and equipment. We have focused especially on two types of police encounters: 1. With subjects who have a mental illness, a developmental disability, a condition such as autism, a drug addiction, or another condition that can cause them to behave erratically or threateningly; and 2. With subjects who either are unarmed, or are armed with a knife, a baseball bat, rocks, or other weapons, but not a firearm. It is these situations—not incidents involving criminal offenders brandishing guns—where we see significant potential for reducing use of force, while also increasing officer safety.”
Early studies on the effectiveness of police de-escalation training often based their findings on the answers that participants gave to a questionnaire at the end of the training and not on actual results in the field. And one researcher found Crisis Intervention Training (CIT) to vary greatly in content from 40-80 hours of classroom training in some agencies to watching a short video in others. Gary Cordner and Harry Steadman have studied these issues and found the culture among city leaders, police chiefs, and police officers is more important than technical training. The US Department of Justice investigators of use-of-force incidents to wrote “culture eats policy for lunch,” paraphrasing the words of management consultant Peter Drucker who said “culture eats strategy for breakfast.” Recent studies of results of de-escalation training as applied by police in the field find that officers must react quickly when confronted with aggression in crisis situations and often resort to using force to resolve conflicts, which is unsurprising since they receive far more training in using force than in using de-escalation. Seth Stoughton, a former police officer and now a faculty member in criminology, says when police respond at least one gun is introduced to a situation where they may have previously been none. He believes police must be trained to be confident in their ability to use less deadly force. I think he is right, but I also think psychiatry has a role and responsibility to provide a medical response to medical emergencies like clinicians do for other types of medical emergencies. And, advocates cannot be allowed to parrot the anti-stigma line that persons with psychiatric illness are generally non-violent or more likely to be victims of violence while doing nothing to address the real over-representation of those with mental illnesses in jail and among those killed by the police due to symptoms that can include violence. Here are some ideas: (1) One African American activist told me that his people avoid calling the police and rely on one another for safety. NAMI should train family caregivers to avoid calling 9-1-1 and rely more on themselves and friends for de-escalation. (2) Pay peers to do wellness checks by phone and video chat. (3) Send unarmed responders and invite persons in crisis to come outside and talk rather than going into an unpredictable and potentially confining indoor situation much like the CAHOOTS teams do in Oregon. (4) Responders should bring along free snacks or pizza. (5) If there is no gun present, the response to aggression need not introduce a gun if clinicians and police are properly trained.
“8-9” Related to levels of care and new medications: These are laudable, but are longterm goals. In the short term, families of those with serious mental illnesses need to rely more on themselves and clinicians need to do more of the things noted above to immediately shift services away from legal perspectives and more toward good medical care. Attorneys and judges are already doing the work of protecting civil liberties and reducing overuse of psychiatric care. Psychiatrists do not need to do that work for them and should instead focus on improving psychiatric care.
“10-11” Related to data and research about outcomes: Yes. And it should include outcomes for persons treated in jails and prisons where I believe involuntary treatment is more commonly offered than in hospitals today.
“12-14” Related to availability of psychotherapy, government payment, and advocacy. Yes to all of these, though they may be unrealistic given a lack of money and political power among most persons with serious psychiatric illnesses. The time required for psychotherapy, government support, and political advocacy seem largely unavailable to the sickest patients judging by the numbers in jail and homeless--many of them are not even in the rooms where such issues are discussed because they are not invited, have no transportation if they were invited, cannot effectively communicate if they were present, and are unwelcome anyway since in their often dirty and disheveled state they would stigmatize those in the room who are functioning at a higher level.
“15-16” Related to snacks and internet time. Yes these seem easily achievable and things that psychiatry could do right now without passing new laws or expending large amounts of money. My main concern is that a lot of anti-psychiatry drivel is easily accessible on the internet and I think it has informed some of my daughter’s paranoid thinking. There are many other things psychiatry could do to improve services—again, just take a look at what other medical specialties have done to improve the patient experience.
“17-18” Related to voluntary treatment centers and allowed discharge of voluntary patients. Yes. To minimize the need for involuntary care, there should be walk-in and drop-off diversion centers where patients in need of care have pleasant experiences and choose to seek help. The discharge piece could be complicated in the case of patients who become violent or a danger to themselves. How does a voluntary treatment center maintain its reputation for being voluntary? If they call on armed police officers for help with behavioral symptoms, the word will get out that voluntary patients are being arrested and taken to jail. At the same time, should a person who psychiatrists believe is a danger to self or others be allowed to walk out? In Texas several years ago, psychiatrists lobbied for a law allowing them to involuntarily hold voluntary patients for up to four hours, just the amount of time they thought was needed to seek an involuntary hold from a judge. They talked of voluntary patients walking out with tragic consequences. I testified in favor of the legislation as a parent caregiver. The proposed law passed both houses of the state legislature with more than two-thirds of the votes in each, making it what should have been veto-proof. But after being pressured by Scientology, homeschoolers, anti-vaxxers, and civil rights advocates the governor vetoed the legislation on the last day of the legislative session when no time remained for a vote to override his veto. The legislation never became law in Texas.
So... maybe a traumatized patient is better than a dead patient. But what if the trauma of involuntary commitment makes some people kill themselves when they eventually get out? Maybe years later, so the clinicians who had them committed don't think of the two events as connected? Might even, mistakenly, think that the now-dead patient lived longer than they otherwise would have thanks to the coercive treatment, when it's actually the other way around? What if forced medication with horrible side effects makes some people kill themselves?
I'm not saying this because I think involuntary care shouldn't exist at all. I'm just saying these are also factors to be considered, if we're talking trauma vs suicide.
Btw, I've talked to madpeople who say one should never call a suicide hotline, because you never know what will happen if you do, you might end up in deep shit as a result. With some personal experiences to back that up ... This is in support of Awais' point, that transparency is important, because a lack of transparency can scare people off!
Final point: In Sweden, if you call the emergency number 112, they can connect you to institutions like the police, ambulance services, the mountain rescue, fire department, the normal stuff - or a priest. Since we're a secular society nowadays and the church isn't part of the state anymore, it happens from time to time that parliament looks at this list and goes hm, the priest is surely the odd one out here, maybe they should be removed? And then some researchers look into the matter, and every time this has happened, said researchers conclude that the priest should stay on.
Lots of suicidal people, lots of people in serious distress, opt to talk to a priest instead of suicide hotline/mental health services - and not necessarily because they're religious. Even atheists may prefer to talk to a priest because they're AFRAID of calling a suicide hotline/mental health services. Take the priest off the emergency number, and lots of people will just not call anyone at all.
This discussion touches on issues that I care deeply about, have studied some, and have devoted a considerable amount of time to promoting in meetings and testimony at state legislative hearings in Texas. My comments:
“If you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully.” Yes. And if psychiatrists recognize that inpatient care can be traumatizing, why have inpatient settings not become more pleasant? Many maternity centers look nicer than my bedroom, pediatric hospitals have made their rooms more cheerful for children, and modern dentists have committed to pain-free dentistry.
“1. Increase utilization of psychiatric advance directives.” Okay, but where I live a patient can reject the psychiatric advance directive in a crisis and it becomes null and void. Include parents who devote years to caring for ill children in deliberations about involuntary hospitalization and listen without biased assumptions about their responsibility for the illnesses of their children.
“2. Enhance due process protections in civil commitment hearings, allow for vigorous patient representation and an opportunity for patients to tell their side of the story.” If psychiatry too readily chooses involuntary hospitalization, then civil rights attorneys from groups like Disability Rights Texas and judges who know too little about how profoundly the symptoms of psychotic disorders can affect a patient’s ability to make rational decisions too readily favor civil liberties over a need for treatment with consequences that too often lead to homelessness, imprisonment, or death.
“3. Eliminate hospital policies, such as strip searches, that can be distressing and humiliating for patients.” This will increase injuries to clinicians. In Texas, a state law doctors and nurses lobbied for made it a felony for a patient to assault a doctor or nurse while they are on duty. This has increased the number of patients going to jail. Why not, instead, lobby for a law that requires safety protocols in medical settings to prevent injuries? Such a law would be better for clinicians and patients.
“4. Ensure robust mechanisms for patients to report mistreatment at psychiatric facilities.” Yes and install cameras so accusations of mistreatment can be verified. Are reports of mistreatment often true or generally related to paranoia and delusions? Either way, what can be done to improve the patient experience? My adult daughter who once spoke glowingly about caregivers at a residential treatment center where she stayed for six weeks now talks of how traumatizing it was for her. When she began home visits later in her residential stay, she wanted to return in time for movie night with her friends. She wanted to give clinicians flowers and gifts. She hugged a clinician she saw at a grocery store. Now, as her delusions and paranoia have worsened, she has nothing good to say about her experiences in residential treatment.
“5-7” Related to crisis response and de-escalation training. Why has psychiatry not consistently taken a leading and outspoken role in advocating for a medical response rather than a criminal justice one? As pointed out earlier, doctors and nurses in Texas focused on punishment of those who assault them rather than prevention. Training in verbal de-escalation techniques is fine, but as Dinah Miller points out its effectiveness may depend on the personalities of those who are trained. Chuck Wexler, founder and director of the Police Executive Research Forum (PERF)* wrote that he does not think all police officers should be trained and deployed to psychiatric crisis situations for the same reason that not all officers should be trained in SWAT tactics—some just do not have the aptitude for such duties. He has also written that police can do a better job of using less force in situations where no gun is involved and it will be applicable to situations where mental illness is involved:
*From the PERF Guiding Principles on Use of Force: “Our work has centered on how the profession can improve in the key areas of use-of-force policies, training, tactics, and equipment. We have focused especially on two types of police encounters: 1. With subjects who have a mental illness, a developmental disability, a condition such as autism, a drug addiction, or another condition that can cause them to behave erratically or threateningly; and 2. With subjects who either are unarmed, or are armed with a knife, a baseball bat, rocks, or other weapons, but not a firearm. It is these situations—not incidents involving criminal offenders brandishing guns—where we see significant potential for reducing use of force, while also increasing officer safety.”
Early studies on the effectiveness of police de-escalation training often based their findings on the answers that participants gave to a questionnaire at the end of the training and not on actual results in the field. And one researcher found Crisis Intervention Training (CIT) to vary greatly in content from 40-80 hours of classroom training in some agencies to watching a short video in others. Gary Cordner and Harry Steadman have studied these issues and found the culture among city leaders, police chiefs, and police officers is more important than technical training. The US Department of Justice investigators of use-of-force incidents to wrote “culture eats policy for lunch,” paraphrasing the words of management consultant Peter Drucker who said “culture eats strategy for breakfast.” Recent studies of results of de-escalation training as applied by police in the field find that officers must react quickly when confronted with aggression in crisis situations and often resort to using force to resolve conflicts, which is unsurprising since they receive far more training in using force than in using de-escalation. Seth Stoughton, a former police officer and now a faculty member in criminology, says when police respond at least one gun is introduced to a situation where they may have previously been none. He believes police must be trained to be confident in their ability to use less deadly force. I think he is right, but I also think psychiatry has a role and responsibility to provide a medical response to medical emergencies like clinicians do for other types of medical emergencies. And, advocates cannot be allowed to parrot the anti-stigma line that persons with psychiatric illness are generally non-violent or more likely to be victims of violence while doing nothing to address the real over-representation of those with mental illnesses in jail and among those killed by the police due to symptoms that can include violence. Here are some ideas: (1) One African American activist told me that his people avoid calling the police and rely on one another for safety. NAMI should train family caregivers to avoid calling 9-1-1 and rely more on themselves and friends for de-escalation. (2) Pay peers to do wellness checks by phone and video chat. (3) Send unarmed responders and invite persons in crisis to come outside and talk rather than going into an unpredictable and potentially confining indoor situation much like the CAHOOTS teams do in Oregon. (4) Responders should bring along free snacks or pizza. (5) If there is no gun present, the response to aggression need not introduce a gun if clinicians and police are properly trained.
(continued)
(Continued from previous comment)
“8-9” Related to levels of care and new medications: These are laudable, but are longterm goals. In the short term, families of those with serious mental illnesses need to rely more on themselves and clinicians need to do more of the things noted above to immediately shift services away from legal perspectives and more toward good medical care. Attorneys and judges are already doing the work of protecting civil liberties and reducing overuse of psychiatric care. Psychiatrists do not need to do that work for them and should instead focus on improving psychiatric care.
“10-11” Related to data and research about outcomes: Yes. And it should include outcomes for persons treated in jails and prisons where I believe involuntary treatment is more commonly offered than in hospitals today.
“12-14” Related to availability of psychotherapy, government payment, and advocacy. Yes to all of these, though they may be unrealistic given a lack of money and political power among most persons with serious psychiatric illnesses. The time required for psychotherapy, government support, and political advocacy seem largely unavailable to the sickest patients judging by the numbers in jail and homeless--many of them are not even in the rooms where such issues are discussed because they are not invited, have no transportation if they were invited, cannot effectively communicate if they were present, and are unwelcome anyway since in their often dirty and disheveled state they would stigmatize those in the room who are functioning at a higher level.
“15-16” Related to snacks and internet time. Yes these seem easily achievable and things that psychiatry could do right now without passing new laws or expending large amounts of money. My main concern is that a lot of anti-psychiatry drivel is easily accessible on the internet and I think it has informed some of my daughter’s paranoid thinking. There are many other things psychiatry could do to improve services—again, just take a look at what other medical specialties have done to improve the patient experience.
“17-18” Related to voluntary treatment centers and allowed discharge of voluntary patients. Yes. To minimize the need for involuntary care, there should be walk-in and drop-off diversion centers where patients in need of care have pleasant experiences and choose to seek help. The discharge piece could be complicated in the case of patients who become violent or a danger to themselves. How does a voluntary treatment center maintain its reputation for being voluntary? If they call on armed police officers for help with behavioral symptoms, the word will get out that voluntary patients are being arrested and taken to jail. At the same time, should a person who psychiatrists believe is a danger to self or others be allowed to walk out? In Texas several years ago, psychiatrists lobbied for a law allowing them to involuntarily hold voluntary patients for up to four hours, just the amount of time they thought was needed to seek an involuntary hold from a judge. They talked of voluntary patients walking out with tragic consequences. I testified in favor of the legislation as a parent caregiver. The proposed law passed both houses of the state legislature with more than two-thirds of the votes in each, making it what should have been veto-proof. But after being pressured by Scientology, homeschoolers, anti-vaxxers, and civil rights advocates the governor vetoed the legislation on the last day of the legislative session when no time remained for a vote to override his veto. The legislation never became law in Texas.
So... maybe a traumatized patient is better than a dead patient. But what if the trauma of involuntary commitment makes some people kill themselves when they eventually get out? Maybe years later, so the clinicians who had them committed don't think of the two events as connected? Might even, mistakenly, think that the now-dead patient lived longer than they otherwise would have thanks to the coercive treatment, when it's actually the other way around? What if forced medication with horrible side effects makes some people kill themselves?
I'm not saying this because I think involuntary care shouldn't exist at all. I'm just saying these are also factors to be considered, if we're talking trauma vs suicide.
Btw, I've talked to madpeople who say one should never call a suicide hotline, because you never know what will happen if you do, you might end up in deep shit as a result. With some personal experiences to back that up ... This is in support of Awais' point, that transparency is important, because a lack of transparency can scare people off!
Final point: In Sweden, if you call the emergency number 112, they can connect you to institutions like the police, ambulance services, the mountain rescue, fire department, the normal stuff - or a priest. Since we're a secular society nowadays and the church isn't part of the state anymore, it happens from time to time that parliament looks at this list and goes hm, the priest is surely the odd one out here, maybe they should be removed? And then some researchers look into the matter, and every time this has happened, said researchers conclude that the priest should stay on.
Lots of suicidal people, lots of people in serious distress, opt to talk to a priest instead of suicide hotline/mental health services - and not necessarily because they're religious. Even atheists may prefer to talk to a priest because they're AFRAID of calling a suicide hotline/mental health services. Take the priest off the emergency number, and lots of people will just not call anyone at all.
I think this is some serious food for thought.