Do patients avoid psychiatrists for fear of legal holds?

mental-hospitalOver on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I’ve written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco’s transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably “bus-like,” and that there is a legitimate role for higher-cost “taxi-like” services for those willing and able to pay for them.

It’s important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even “bus-like” mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise “come to some agreement” with cash-strapped patients in ways taxi drivers don’t.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy “shallow at best.”

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the “5150” here in California), is uncommon in office psychiatry, and in any case didn’t bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who “truly need psychiatric intervention … from even attempting to access ‘help’.”

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it’s a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I’m sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I’ve reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there’s much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its “probable” likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won’t fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist’s power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don’t make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients’ fears of subjectivity and loose criteria are partly based in reality.  A casual “better safe than sorry” attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a “frame issue” as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn’t play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn’t truly interested in overcoming suicidal feelings, and I wouldn’t engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a “death by cop” scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one’s just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.

11 comments to Do patients avoid psychiatrists for fear of legal holds?

  • AA

    Too bad you weren’t this woman’s psychiatrist who fortunately just got released thanks to a judge in her state. She was hospitalized against her will a day after her husband had murdered her son and then committed suicide. She was held for 5 weeks and a 16 year old surviving daughter was without her mother.

    http://www.burlingtonfreepress.com/apps/pbcs.dll/article?AID=2014301240046&nclick_check=1

  • Nice. I certainly qualify for one of those T-shirts.
    Obviously, you did a good job with the guy who wanted to be convinced to live.
    And I’ve never had a patient tell me they were worried I’d commit them.

    Hey, I’m on your life traffic feed, the visitor from Baltimore.

  • Ann

    I have a question. Do you think people who can afford office visits to a psychiatrist may be more affluent or better educated? I have a graduate degree and have had a psychiatrist now for over 20 years. In fact, I make sure I find a good local psychiatrist whenever I move. I have never been fearful of “forced hospitalization” (though I have been hospitalized twice). I see my psychiatrist as a safety net so I won’t hurt myself. I don’t believe I am any smarter than others, but I haven’t ever experienced the “helplessness” one may feel if they have relied in government assistance for most of their life. If I had been raised in a family where members have been incarcerated, in foster care or on welfare, I may see treatment as just one more ‘institution’ that could take away my autonomy. What do you think? Ann

    • Hi Ann,

      We all react according to our own experience. Experiences of being mistreated by institutions, or by psychiatrists, naturally lead to wariness toward institutions or psychiatrists going forward. It only makes sense. Complicating this picture is how widely we generalize these lessons: Did our bad experience identify one “bad apple,” or did it show us the whole barrel is rotten? Also, some of us are less trusting to start with, whether from birth or early childhood, such that it takes less, or perhaps nothing at all, to “prove” that institutions or psychiatrists are untrustworthy. And if that weren’t enough, autonomy itself is a complex matter psychologically. If it feels shaky, then having to ask for help — from a psychiatrist, a teacher, or a car mechanic — can feel risky.

      Those who can afford office visits to a psychiatrist presumably have more money on average, and affluence is correlated with better education. Although I don’t know the data, it wouldn’t surprise me if the poor have comparatively greater lifetime experience with helplessness and institutional mistreatment, and as a result are more wary of psychiatrists on average. Thanks for writing.

  • That was a pretty gutsy thing you did with the guy who wanted you to convince him not to die. Totally the right move. But would most psychiatrists in your situation do that? I doubt it.

  • Stewart

    >> “A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.”
    You should at the very least admit that in holding this position, a psychiatrist is not doing anything therapeutic at all, but is actually filling the role of a policeman, albeit on a “pre-crime” basis. This action is done to prevent damage to others in society, not for the betterment of the individual. Psychiatrists should not claim otherwise.
    Of course, whether this psychiatric “pre-crime” detection is actually accurate or effective is another question entirely, but the first step comes in admitting what you are actually doing in this situation: you are not being therapists, you are being policemen.

    • Hi Stewart,

      I agree that any coercion is anti-therapeutic from the perspective of collaboration, which is the model I prefer, and which I believe is best in psychiatry and medical practice generally. Unfortunately, sometimes patients are temporarily incapable of collaboration. In addition to the less common “preventing damage to others,” legal holds, at least here in California, are more often placed to prevent damage to the patient himself through suicide or “grave disability” (inability to attend to one’s own basic needs). I agree it’s another question whether such holds are accurate or effective; I’ve expressed my concerns about that before and will continue to do so.

      Psychiatric holds are often compared to police detention. Certainly there are commonalities, particularly in how they are codified into law. But conceptually psychiatric holds are much closer to the practice of restraining delirious patients in hospital beds. In case anyone doesn’t know, it is routine in hospitals everywhere to physically prevent confused patients from falling out of bed, wandering away in a stupor, or pulling out their tubes and IV lines. Such patients are literally tied down so they don’t hurt themselves. Coercion isn’t the primary job of the internist or surgeon (or the nurses who actually do the restraining). Indeed, it is a distasteful part of the job that isn’t talked about very much, and it definitely isn’t medical “therapy”. Yet the intent is not to punish, but to prevent self-injurious behavior by a person who doesn’t know what he’s doing. Laws and hospital policies govern the practice, which obviously can be abused either through thoughtlessness or ill intent.

      Even though news stories occasionally report abuse of this practice, I have never heard a general call to end the restraint of delirious patients. We all agree that if our own confused grandmother were about to fall down the stairs or start a fire in her kitchen, we’d physically restrain her to prevent that. It’s a human reaction that I’m glad we share. Yet the same impulse to restrain a person whose voices tell him to “fly” down the stairs, or who momentarily feels like throwing himself down the stairs to end his psychic pain — suddenly that is “being a policeman”. In my view, it’s a healthy human impulse to want to intervene to prevent a confused or misguided person from harming himself. When codified into law such impulses demand strict regulation and oversight, of course. Just as medical restraints, and actual policemen for that matter, should be carefully regulated but not abolished. Thanks for writing.

  • Jer

    Hello and good day,

    Doing some research on involuntary commitment I found this entry on this blog and, although the entry is from 2014, I’d like to share my thoughts.

    I’m a man in my mid twenties. When I was 16, I attempted to commit suicide. Everyone knows what comes after a suicide attempt: a stay in a mental hospital, even against one’s will. And after almost 10 years of what I call my kidnapping with society’s consent, I still suffer from PTSD. I can’t get rid of my memories being locked up like an animal, in a room, “for my own sake”. Feeling helpless, unprotected, crying like a baby; being stripped of my most valuable thing: my freedom. I’m tired of feeling betrayed by the people I trusted most: my therapists.
    I can’t get help for my PTSD. How can you start a therapy with someone who would send you to hell again if you tell him you want to commit suicide? There’s no hope for me already.

    My point is, you advocate for involuntary hospitalization if everything else fails, let me explain how I feel about this:

    I am a free man since my first breath. It’s my intrinsic right as a human being. I know what you are thinking: “involuntary hospitalization saves many lives, besides, some people who attempted to commit suicide and survived are glad to be alive now!” This argument is potentially problematic. First of all, what would you tell me, a person who has been a victim of this way of thinking? A person who is not glad to be alive 10 year later, and not because he still has things to solve, because he is so traumatised, his self-esteem is so down for being treated worse like an animal (I would not even lock my dog in a room) that he cannot stand this sorrow anymore. My therapist is supposed to help me, but do not misunderstand this: my will is above all. And the argument: “you do not want to die, you just want this pain to end” is flawed. Of course I want this pain to end, that doesn’t mean I am willing to pay any price for it. And it is my decision how to do it: if following a therapy or killing myself.

    In a nutshell, I don’t think anyone has the right to lock anyone up and take his or her freedom. This world becomes a dictatorship if so. Not to mention cases like me, where we’d rather have died than going through that hell.

    Yours faithfully,

    Jer

    • Hi Jer,

      Thanks for writing and sharing your thoughts. I can’t fault your view that no one has the right to lock anyone up and take his or her freedom. I don’t happen to agree, but that’s ok. Reasonable people can disagree. If you haven’t already, you may be interested to read Thomas Szasz, a famous psychiatrist and author who shares your view.

      What I don’t understand is why you feel your freedom is lost. In the nearly ten years since you were temporarily prevented from killing yourself, you’ve had countless opportunities to die. Yet you chose to live. There’s nothing a psychiatrist or anyone else can do to prevent suicide in the long run. You have the freedom to live or die as you please. The only thing you don’t have is the ability to force a psychiatrist or therapist to stand idly by while you kill yourself. If you involve us, we have the legal duty to intervene (whatever you think of the ethics).

      So if you truly don’t trust mental health professionals to respect your freedom, avoid us. But as I wrote in my post above, that’s a pity from my perspective. Because we’re ok talking about suicide all day without forcing anyone into a hospital. I do it all the time. It’s only an actual plan you intend to carry out, and that you’ve shared with us, that we have to respond to. It’s safe to talk to a therapist about your PTSD, your past suicide attempt(s), even your current suicidal thoughts. Just as long as you don’t threaten suicide now, in essence daring the therapist not to respond when he or she must.

      • Jer

        Thanks for your reply Steven,

        I don’t know if you expected me to respond, but I think I’ll take a shot in the dark.

        You say reasonable people can disagree. Please understand that when I’m telling you that some people like me have been traumatised by a kidnapping and you tell me that you are okay with it, I get angry and misunderstood by your cavalier disregard for my feelings. I don’t pretend to be rude in the slightest, but this paternalism makes me… sick.

        I know about Thomas Szasz, thank you. Although I don’t fully agree with anti-psychiatry, it is true that it is the only movement that seems to understand us.

        I didn’t explain myself well, sorry. I feel I’m not free because someone has power over me. Someone has the power to lock me up, to treat me as he or she pleases. To pull down my underwear and give me a shot if a psychiatrist thinks I need so. To tie me up in a bed. And so on…That’s not being free. About what you said, you say I can kill myself, what I have to do is not say it. But that’s not being free either. Homosexuals can have sexual intercourse in Iran, yet if they say it, it will lead them to be hanged. I don’t think this qualifies as freedom. It’s not that simple as “avoiding mental health professionals”. Not to mention that people can be treated by force, at least in my country (Spain). It is mental health workers that keep on interfering in other people’s business (sometimes).

        Clearly avoiding you would be the most consistent thing. But that’s not fair for people like me Steven. We want help (you probably don’t know what it is to live with PTSD), and the price you force us to pay is: “remind you are talking to a possible kidnapper”. How am I supposed to talk about my problems for being kidnapped with someone who thinks this is okay? Your “policy” condemns people like me to a lifelong suffering.

        Thanks for reading.

        Jer

        • I’m sorry you feel angry and misunderstood, I don’t mean to be cavalier.

          There are many examples of protective detention besides psychiatric. Parents routinely detain their children, and some municipalities have curfews. Drunks are sometimes held overnight in jail to sleep it off. Delirious patients are tied to their hospital beds so they don’t wander away or hurt themselves. And contrary to your point above, nearly every dog-owner has locked it in a room at various times, either to protect the dog, or to protect others from the dog.

          Having your freedom curtailed at age 16 is the norm. There are numerous things we can’t do at 16 besides suicide. And while freedom expands with adulthood, it is never close to absolute. Protesting that “someone has power over me” is a distinctly adolescent complaint. Adults accept that living in society with others entails giving up some freedom. The alternative is to live by yourself on a deserted island. Psychiatrists and police are not the only ones who will intervene if you attempt suicide publicly or visibly. Your fellow citizens will at least attempt to dissuade you, and many will physically stop you if they can.

          So yes, you’re not entirely free. However, my earlier point stands: at least here in the U.S. — I don’t know about Spain — talking to a therapist about past suicide attempts (to treat PTSD), and even current suicidal thoughts, should not result in hospitalization. I talk to patients about suicide (and homicide) all the time in the office. It’s not my “policy” that condemns you to lifelong suffering, it’s that you’ve argued yourself into a tight little box. As a practical matter, you can get help for PTSD through peer support, online or printed self-help materials, general anxiety-reduction techniques, medications prescribed by non-psychiatric doctors — and with the help of counselors or therapists who aren’t nearly as autocratic and malevolent as you make us out to be. Best wishes for 2017.

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