Over 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.