Editor’s Note: This story contains an account of an involuntary psychiatric hold, which could potentially be triggering for readers. We recognize that this issue is contentious and likely to elicit strong feelings, but we believe it’s important to open up a space to talk about difficult issues.
“Life is not about wishing for better chapters to manifest in your life; it is about continuously writing them with your thoughts, beliefs, decisions and actions.”
The most difficult decision I have had to make as a clinician has been to place an individual on a 5150. This is the LPS (Lanterman-Petris-Short Act*) 72-hour hold that sends a person into a locked psychiatric unit for up to 72 hours. The emotional impact affects the individual who is going to be placed on the 72-hour hold, and their family. The emotions that are involved in the process of observing the person, collecting information, and finally making the life-altering decision are powerful and long-lasting for the person making the decision as well. That is, if they are compassionate and involved.
It is important that all who are involved in the field of psychology/psychiatry at any level be aware of the extensive ramifications of the formidable process of initiating the 72-hour hold, since it affects the course of many individuals’ lives, and profoundly and intimately affects – at the core – self-esteem, the ability to trust, and the sense of control over one’s own destiny.
Throughout this process the person most critically affected is the person in emotional distress, and this is because that vulnerable person will be stripped of their freedom, they will be pressured and possibly coerced into taking medication, they will be diagnosed and labeled, and they may be further traumatized and dehumanized. Their families will suffer similar fates.
As part of my job responsibilities when I worked in the ERs of community medical centers, in the psychiatric ER of a county hospital, in the LA Jail, and in a county-private outpatient clinic I had to take a course and a test in order to become designated to write LPS holds. I was aware from the beginning that having this “power” carried grave implications, and that I hoped I would not have to use it. But in several cases, as I will explain below, I could find no alternative.
I also and unfortunately found that several other clinicians used this powerful tool in ways that I would not have. The 72-hour hold, for example, can be used as a threat against someone who is perceived as noncompliant; a designated writer of holds can transition a person out of a crowded emergency room and into a “crisis evaluation center,” thereby quickly relieving the ER of a “non-medical” patient.
Although the 72-hour hold is for individuals who are at high risk for self-harm, harm to others, or “grave disability,” the majority of the cases that I found in the emergency rooms involved the third category; grave disability. With time and effort the immediate problem of the person not being able to provide food and shelter could be resolved by locating relatives, or programs for those who are alcoholic or drug-dependent.
My overarching goal was to protect every individual’s right to self-determination; to avoid labeling and the coercion to be treated medically, and to maintain some trust in people who are trying to help. All of this would disappear once the process of detaining the individual began.
The emotional impact of placing a person on a hold is rarely discussed perhaps because examining this aspect brings up issues of power and control, the reality of rights and freedoms (and their elimination), and the transitioning of an individual to a hospital where they may well be traumatized yet again. All of these issues unfold very rapidly, and as the 72-hour hold is written the feelings are often overwhelming for all involved.
The language of the 72-hour hold speaks volumes about the emotions and thoughts that it generates. The terms and phrases are negative and linked to the criminal domain; “detained,” “mental health disorder,” “court hearing,” “custody,” ” psychiatric evaluation,” and “you may make a phone call.” Often in these cases the person being placed on a hold is already in emotional distress, confused, and in the middle of a loud unfriendly emergency room environment.
They are also probably hungry, possibly in physical pain, and most probably alone. He or she has been brought in by police, and now another person is in an authoritative position telling them that they are going to be “detained” due to their “mental disorder” for a period of 72 hours, and sent to a “facility” for a psychiatric evaluation. They are told that their rights will be explained to them when they get to their destination. They are informed about why they are deemed likely to harm themselves or others, and/or are unable to provide for their own food and shelter. There are many and varied reactions to all of this information – most of them extremely negative – and Mary’s response was just one of them.
Mary G is a 32-year-old woman who lived in the bushes outside of the for-profit hospital where I worked. The hospital has no psychiatric unit, and there is no psychiatrist on staff. When there is a person in emotional distress the social worker is called in and, if needed, an outside consulting psychiatrist is called.
Mary had been brought in by the security guards several times when they found her wandering around the hospital or sleeping under a bush, and she refused to leave the premises. Nursing staff in the ER would give her something to eat after triage showed that she did not have a medical problem, and then they would show her the door.
Ultimately, her condition deteriorated. She had bruises on her face and body, and she was very thin, disoriented and agitated. She appeared to be hearing voices and she was responding verbally and behaviorally by picking up things from patient’s trays. At one point she picked up a plastic knife and made cutting motions against her neck.
When I met her I could find no record of her in the data base and from what she said my impression was that she was from out of state. She denied any mental health history. She said she had no family and that she was “fine.” When the subject of hospitalizations, medications or any related subjects were brought up she became fearful and paced the room. I noted the bruises on her body and several deep scars on her wrists but she denied ever trying to harm herself.
In her disorganized verbalization she did say that people “hit her” and that she thought she might be “dead already.” After a brief period of interacting with her and bringing her the only food (bread and water) that she believed was not “poisoned” she became more organized, and relaxed with me. She had no plan for herself but did not want to go to a shelter, as there people stole things and were rough with her. She just wanted “to go home” although she had no home to go to.
I could see that Mary was intelligent and had decompensated at least in part due to lack of food, support and abuses she had suffered. She elicited positive feelings in me and I began my search for a place or program that could take care of her. Mary had no ID, no paperwork at all, and this along with the fact that she had no disability income, no Medical insureance, and was seriously decompensated made for formidable barriers.
Programs and a few beds were available for those with chemical or alcohol addictions. Shelters were full, or in very dangerous areas downtown. There was the issue of self-harm and also of her being victimized if she were simply allowed to leave. I did not know her history and what any further decompensation would bring.
As with many other people in similar states Mary became more comfortable in the ER where she was warm and fed and listened to. I, on the other hand, was struggling with the choices, which were quickly narrowing down to the one that I did not wish to make.
Clinicians need to have strong emotional boundaries, but it is terribly difficult – if not impossible – to avoid feeling frustrated and concerned about the well-being of a person that may have to be sent to a locked in-patient ward in a psychiatric hospital.
The conversation with Mary came at a point where I had exhausted all alternative routes and was faced with the fact that Mary needed to be in a safe place where she had food, shelter, and hopefully time to recover enough to make a plan for her own care. I sat with her in a quiet place and shared with her my concerns about her being alone, being bruised and having no place to live. She repeated that she was “fine,” and appeared unconcerned.
When I said that I was going to put her on a 72-hour hold, and went through the facts of the hold – the detainment, the psychiatric evaluation and the criteria for the hold – she became upset and began to pace the room. She repeated the statement “No, you can’t do that. Not again” several times and I was aware that she had probably been through this before. She was angry and then broke down in tears. It was a very appropriate reaction to being detained and sent to a hospital. I felt terribly sad for her. I asked again if she could come up with a plan for herself and again she said that she was “fine.”
Although the decision had now been made I was not going to be free from the emotional burden of having made it. Mary was rambling incoherently now and I knew that she was in emotional pain and without much comfort that I could give to her.
Before the ambulance came to take Mary to the hospital I reviewed everything that I had done in an effort to come to terms with the situation. She became very quiet and withdrawn, retreating into some inner place that protected her from further assaults for the time being. I was unhappy about what she might face in the days ahead, and I was again terribly frustrated by the lack of resources that perpetuate the cycle of distress, and severely cripple any attempts to provide the kind of care that she needed.
I do not seek to compare my on-going discomfort with her terror and her trauma. I can move forward with proposing reforms, joining advocacy movements and thinking about a better future for vulnerable individuals. Mary, on the other hand, remains trapped in a system that resists changing its perceptions and its prescriptions for the well-being of people like Mary.
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*Editorial note: The Lanterman-Petris-Short Act, signed into law by Ronald Reagan in 1972, was intended to end “all hospital commitments by the judiciary system, except in the case of criminal sentencing, e.g., convicted sexual offenders, and those who were ‘gravely disabled,’ defined as unable to obtain food, clothing, or housing.” (Wikipedia)