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Sat Dec 15, 2012, 12:20 PM

Mental health commitment: A Retrospective Rant

Do you know how &^%$* hard it is to get someone committed? And, if you do, do you know how long it takes the hospital to turn them loose again?

I have been doing commitment and protective placement evaluations for more than 25 years, and have seen a dramatic change over time. It used to be that the courts were willing to commit people who were reasonably deemed to be mentally ill and dangerous, and, once they were committed, they were placed in hospitals where they received both pharmacological and "talk" therapy as appropriate.

In the old days, the process typically went something like this:

A person would be displaying signs of serious mental illness, and family would become concerned for that person's safety or the safety of others. They would try to bring the person in for examination and, if the person refused, they would ask the police to intervene.

The family or the cops would bring the person in to the psych hospital (or ER, if it was that type of hospital) for a 72-hour detention. Nursing staff would do an immediate assessment, and within 72 hours the person would be seen by at least 1 psychiatrist or psychologist.

If the shrink thought the person posed a danger to themself or others, a probable cause hearing would be held in front of a judge and, if probable cause was found, a 2-week observation period would be initiated during which time 2 doctoral-level shrinks would conduct examinations and give written opinions.

If they were in agreement that the person still seemed to pose a risk, a commitment trial would be held, at which the psychologists/psychiatrists would testify. The examinee would have access to a defense attorney (generally a public defender), and could get an independent examination if they wanted, paid for by the Public Defender's Office. They had a right to a jury trial, but usually didn't exercise that right because juries are usually easier to scare into a decision to commit than judges are.

The first commitment would run for 6 months, at the end of which time the examinee would either be released or the evaluation and commitment process would be repeated. Subsequent commitments were for 1 year.

Commitments are actually to the county of responsibility, not to a hospital. The county can, for example, decide that an outpatient commitment would be most appropriate.

These days, though, the whole process usually plays out somewhat differently.

Theoretically, the same process remains in place, but it usually works very differently in practice.

The person of concern will be brought in to the hospital. The county will not want to pay for care and treatment (mostly because they lack the funds to do so). A doc will examine the person within 72 hours, prescribe a medication, and declare that the person is no longer a danger to themselves or others, and will order them released. End of story.

On those rare occasions where the commitment process runs its full course, the person committed will likely spend about a week in the hospital. There will be no treatment other than medications. The county will decide that a nice, cheap outpatient commitment will do just fine. And the individual will be back out on the street with a prescription in their hand, which they will likely as not immediately discard because “They’re making me take these pills to mess with my mind.”

And of course, the mentally ill person will soon run afoul of the law, get arrested about a dozen times in the next 5 years, and begin a new career as a "habitual criminal," finally coming to rest in prison.

Now you know why we have about 10% as many psych hospital beds as we did 2 or 3 decades ago.

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Reply Mental health commitment: A Retrospective Rant (Original post)
Jackpine Radical Dec 2012 OP
leftstreet Dec 2012 #1
Jackpine Radical Dec 2012 #2
slackmaster Dec 2012 #3
Lisa0825 Dec 2012 #4
KT2000 Dec 2012 #5
Jackpine Radical Dec 2012 #6
XemaSab Dec 2012 #7
woo me with science Dec 2012 #8

Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 12:25 PM

1. No money for healthcare, but plenty for jails, prisons, courts

+1

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Response to leftstreet (Reply #1)

Sat Dec 15, 2012, 12:28 PM

2. Perzackly.

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Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 12:29 PM

3. Excellent post. K&R

 

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Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 01:01 PM

4. Yes, your second scenario is just about how it went with my ex-BIL

on at least 3 occasions. His family was so frustrated that there was nothing they could do to help him. And BTW, they had plenty of money. They could have provided the best help money could buy, but money couldn't keep him committed against his will. I've been out of that family for about 15 years, but I still occasionally wonder if he ever got better.

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Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 01:30 PM

5. Thanks for this -

Was watching coverage yesterday with a friend who had a child who had very serious mental issues. (He died in his 30's)
She started relating some of the traumatic details of his life that included his change from being a sweet boy who then started incorporating violence into his life. His beautiful, colorful and detailed drawings changed to stick figures killing each other, he was stabbing his mattress with a knife and more. She talked about the many schools she enrolled him into only to have him expelled because he had too many different problems. She talked about the psychiatrists, psychologists and tutors she hired to help. In his late teens he left home and insisted on living in the woods and caves. The people who would be his friends were into drugs who shared with him. She spent those years loooking for him on the streets and hills around LA.

As she watched the coverage, she zeroed in on the fact that mainstreaming him in public schools exposed him to ridicule from other students. She was feeling his pain all over again.

This woman did everything she could to try to save her son but nothing worked. She still thinks of ways she could have done better. She will likely do this for the rest of her life.

I am sure there were many people who have mentally ill children who watched the coverage with similar reactions. Knowing my friend has taught me that coping with serious mental illness is all consuming for the family - and they are pretty much alone.

We just have to do better. Hasn't there been research that shows better ways for supporting the ill person? Wouldn't it really be more humane to support them in group homes or in something more restricted for severely ill people so they can avoid the danger and exploitation of living on the streets and like you say - ending up in prison?



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Response to KT2000 (Reply #5)

Sat Dec 15, 2012, 01:43 PM

6. Yes, of course. The level of intervention & care

should be matched to the needs of the individual (rather than to the financial status of the county of responsibility).

But ya know what? Prison is cheaper.

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Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 01:44 PM

7. My mom worked in mental health in San Francisco in the 90s

It was a revolving door between the street, psych emergency, the hospital in Napa, halfway houses, cheap residential hotels, the street, psych emergency, the hospital in Napa, halfway houses, cheap residential hotels, the street, psych emergency, the hospital in Napa, halfway houses, cheap residential hotels, the street, psych emergency, the hospital in Napa, halfway houses, cheap residential hotels, the street, psych emergency, the hospital in Napa, halfway houses, cheap residential hotels... and the beat goes on.

Other stops on the tour might include living with family, jail, substance abuse programs, and group living situations.

Just being angry isn't enough to get someone even a 72-hour hold. Neither is being suicidal or just plain crazy.

Unless you've got money *and* you're fairly stable, psych services in this country are a joke.

And the thing of it is that it's probably cheaper to set a person up in a place like Napa, like "Here's your bed, here's your meds, lunch is at noon, you'll find the day room down the hall," than it is to pay for the cycle of non-treatment that my mom saw. Stable living situations produce stable patients. Crazy living situations produce crazy patients.

Almost all of these people were nonviolent, of course.

But right now we're putting out fires instead of addressing long-term solutions.

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Response to Jackpine Radical (Original post)

Sat Dec 15, 2012, 01:45 PM

8. Very interesting and informative post.

Thank you.

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