Co-author of Committed: The Battle Over Involuntary Psychiatric Care
Co-author of Shrink Rap: Three Psychiatrists Explain Their Work
Columnist, Clinical Psychiatry News
Assistant Professor of Psychiatry, Johns Hopkins School of Medicine
Dr. Miller is an outpatient psychiatrist in Baltimore. She has an interest in psychiatry and social media.
In general, patients are involuntarily hospitalized when they are acutely psychotic, are suicidal, or both. Over the course of a hospitalization, people tend to experience a decrease in their symptom and usually leave the hospital feeling better than when they arrived. Given that patients obtain relief from tormenting psychosis and/or soul-crushing depressive episodes, we might expect that they would be grateful for the care they received when they were too ill to realize how desperately they needed help. Still, we often find that people are angry about the care they received against their will, and a portion of people feel traumatized by this treatment: they carry away distress and distrust that lingers with them for years after the event.
If you start off with the idea that forced care is a good thing, that it helps people get well at times when they may be too sick to recognize that they are ill and that treatment enables them to stay housed, working, connected to their loved ones, and out of jail and institutions, then you do it a lot. But if you start off with the idea that forced care is potentially traumatizing, in a way that leaves some patients with years of distress which may dissuade them from seeking care later–perhaps at times when they need care even more– then you alter your threshold for committing people to involuntary treatment.
The issues are complicated and there are many parties involved: the patient, the family, the doctors, society, the taxpayer, and the insurers, to name a few. But let’s make some assumptions. Let’s start with the assumption that psychiatric care may be traumatizing, and fears of involuntary or unkind treatment may discourage people from getting help. Let’s also agree that it is never in your patient’s best interest to seriously injure himself or anyone else and that there are circumstances where there may simply be no other option but to commit someone to the hospital for care, and to use physical force to keep everyone safe.
So what’s a psychiatrist to do?
– Carefully assess the patient, get input from family members and others who have treated the patient, and consider alternatives to involuntary treatment.
– Try to engage the patient in voluntary care. If that fails, try again. When it’s too easy to force care, we risk losing our motivation to expend the necessary energy to engage the patient.
– Explain the consequences of not agreeing to voluntary treatment. Coercion may be better than legal commitment.
– If there is no other option, treatment should be forced: a traumatized patient is better than a patient who died by suicide.
– Be nice to involuntary patients: they are our sickest and most dangerous patients and will likely benefit from remaining in our care. They may make us angry, they may be a lot of work, but an antagonistic treatment relationship is may be troubling to the patient and may make for very long work days
Once the patient is in the hospital
– Obviously, minimize the use of physical force
– Small acts of kindness are often greatly appreciated
– Ask people at the end of their stay for feedback; people often feel better if they feel their distress has been heard and perhaps there is something to be learned.
· Give the patient kudos for their hard work in getting better, even if it was rough journey for everyone. (Give kudos to the staff, too)
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