Thursday, November 22, 2018


Whenever a tragedy with a mental health angle occurs, there are predictable responses. These vary in awareness of the realities. As I have made my living working with psychiatric emergencies for forty years, I know enough to be at least moderately helpful, and from time to time I reiterate some points that get consistently missed.

After the fact, and working from scraps of information, many people conclude that it was patently obvious that the bomber or shooter or pact suicide was dangerous and ill.  Therefore, they believe that the emergency room, or clinic, or hospital messed up by not picking up on the obvious and moving to treat that person. Well, we could always do better, as in everything else, and sometimes it’s true, but that conclusion is often spectacularly wrong.  No, that’s just making excuses. The guy told them he was thinking about killing people and was also suicidal. We admit over 2,000 people a year to our 150-bed involuntary facility, and every single one of them reaches some threshold of dangerousness, enough that it has to hold up at minimum, at a probable cause hearing.  The suicide and homicide rates of our discharges is not that much higher than the general population. (The self-harming rate is much higher.)

Yet they have said and done dangerous things, which is how they got to our hospital. When I read the news stories of what the killer said when he was brought in for evaluation two months or two years before, I am seldom impressed with how alarmingly dangerous the statements are. I have known thousands of people who have said or done similar things. Sometimes the quotes or actions do sound more alarming to me, but not reliably. Most usually, the person is acting more rationally after a little treatment and is no longer actively suicidal or homicidal.  We have to decide what is the safe amount of time after to hold them to reduce the risk.

There will also be accusations that “they said he wasn’t dangerous.” Read more closely.  No one says that. What happens is that people need to do or say things that we can bring before a judge and make a case that they are dangerous enough to lock up and/or force into treatment. Because this is America, and you can’t just think someone’s dangerous, lock the door for as long as you like, and not have to answer to anyone.  You can have that world if you want it, I suppose, but you are going to need to raise the number of expensive hospitals about tenfold, filled with people who could be working and caring for families.

Outpatient treatment has variations on this. The ER and clinic people can say “You need treatment” all they want, but it’s usually entirely voluntary. Even if there is court-ordered treatment, it’s usually limited and rounding up people who don’t show for appointments can be tricky. 

You learn early in this business that if the mental health system has ever touched someone, there is lots of the general public which believes we are still responsible for making sure they don’t do anything bad ever again.  I’ve had many family members complain to me in anger over an admission “You let him out too soon three years ago, and I told you he would be back.”  To us, three years is a long time of a person somehow surviving in the community.  That’s a successful discharge.  Hell, sometimes we will call a week a successful discharge, of a person having a volatile six months.  They might be in six times.  We used to keep them for those six months instead.  They got worse. Being out and dealing with everyday problems is good for you.

Xavier Amador is particularly good at explaining mental illness. Longer talks specifically for affected families and treating professionals will show up in your sidebar if you switch over to Youtube, and are also good.

1 comment:

Texan99 said...

My father, who died in 1995, was a very heavy drinker. Towards the end of his life he was hospitalized and developed DTs--not too physically unpleasant or dangerous, but he had significant delusions, mostly benign, thank goodness. He figured the reason so many people kept coming into his hospital room was that he was hosting a party. If a doctor spent too much time with him, he'd apologize and explain that he was neglecting his other guests. I assumed that my job was to try to talk him back to reality and was surprised when his neurologist suggested it would be best to go along with him.

That's the approach I've always followed since then. If someone's doing something unsafe you may have to get creative, but if the delusion is benign it seems best not to argue. Some years ago my mother-in-law developed delusions after brain surgery, believing, for instance, that she was in jail. She kept asking us what she was in for. She didn't seem awfully unhappy about it, so we just joshed her a bit and assured her that her lawyers were hard at work springing her. A few days later, when she was well enough to go home, the delusions had dissipated. As long as we seemed cheerful, concerned, and confident, she picked up on those feelings even though she wasn't up to following any technical or reality-based arguments. She got the message we really needed her to get, which was that she couldn't get up and leave just yet, but everything was going to be fine.

There was a great "House" episode where a guy talks down a doctor who has accidentally ingested hallucinogens. She's terrified by some obscure process she believes has been done to her--something removed, I think--so he plays along and tells her warmly and confidently that he's going to reverse the procedure and restore whatever it was. It was like adding a chapter to a fairy tale, logically nuts but possessing a kind of intuitive or narrative appeal. The point was that it was a good story, satisfying to hear and experience, and considerably more helpful than hearing "you're just hallucinating, calm down."

Another think I know to be helpful, if the hallucination is not too overwhelming, is to have a friend calmly reassure you that, while you're certainly seeing whatever you report seeing, it's more like a picture, and nothing you really have to worry about. Enjoy the ride.