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.

7 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.

  • 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.

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