The New Year had started with a bad decision.
Still relatively new to my diagnosis, only my mania was being treated, and I still struggled with the brief but severe episodes of depression I always had. Despite the occasional presence of thoughts of self-harm, they never held serious meaning. Having grown up with the condition, it was really more a matter of sometimes excruciating—but never fatal—pain. Like my asthma flare-ups. Manageable.
But with the New Year came a new idea: if mania meant temptation to engage in Funlust, then I could just use willpower. I decided to stop taking my Depakote cold turkey.
And with the sudden discontinuation of my meds that day, I would learn two valuable lessons. Tapering is important, and “mania” does not exclusively mean temptations to Funseek.
The withdrawal effects launched me into a bizarre mixed state. Same depressive thoughts, but with a new, unfamiliar feeling of impulsivity. So off I went to “get s*** done” and do something extreme. Hence, I decided to check into a hospital. While not yet the budding Disability Rights Advocate I am today, I figured that I had intelligence and competence enough to accomplish my goal: that 48-hour suicide hold I’d heard about. Couple days to cool off and then I’d be out.
Shortly thereafter, I was talking to the triage nurse of my local ER department. I told them about my “thoughts, plans, and intentions” to “overdose on medication” when I got home if “they did not admit me then.” I knew the trigger words, the concepts, and felt I grasped the general gist of it all—I was totally in control.
Having apparently said the right things, they gave me the paperwork to sign, lots of paperwork. While I wasn’t much in a reading mood, they made clear it was actually a 72-hour hold. Feeling now a little less in control, I signed the papers anyway—what was one more day?
I was then placed in a ER-esque room of several psychiatric patients medicated into a stupor. It looked to be a boring three days, so I thought I’d just join them. Sly as a fox, I told the doctor that I was on 50mg of Seroquel so that I could just nap straight through. After two and half days of napping, however, the doctor said that I was to be transferred to another hospital. I was puzzled: transferred for half a day?
But such curious musings were interrupted by the EMTs who then came in and asked me to get on the stretcher, which I did. Upon which I was strapped down, i.e. “restrained,” and carted off in an ambulance.
And that’s when it began to dawn on me that I had just signed myself into a situation in which I had no control.
If I had any legal rights, I knew nothing about them. And the hospital cared even less about them. As a law student who has now become intricately familiar with disability and mental health law, I would like to share the legal rights I did have in the state of California and how they were violated from the very start.
Right to Patients Rights Handbook
“Upon admission to a facility each patient, involuntarily detained . . . or as a voluntary patient . . . shall immediately be given a copy of the [DRC] Patient’s Rights Handbook.” (California Welfare and Institutions Code 5325)
I would not find out that such a handbook even existed until my stay two years later at a private hospital in Berkeley.
Right to be Free from Discrimination
“Patients have the right to receive mental health services free from discrimination” on the basis of race, religion, and [most pertinently in my case] gender. (WIC 5325.1)
I met my psychiatrist on the second day. In his 70’s and well established, he would waste no time making clear the balance of power during my stay. After discussing my symptoms, the conversation turned to my personal life and how I was planning on starting law school that year. He said that I should use this hospitalization as an opportunity to better myself both physically and mentally. “You have such a pretty face,” he said, “and would look great if you just lost 15-20 pounds.” Besides, he explained, studies showed that overweight women were discriminated against in hiring interviews. If I just “lost a little weight and looked cute in a skirt and some make-up,” I’d have an easier time getting legal jobs.
Shocked, indignant, and principled above all else, I looked him dead in the eye. “I plan on getting hired based on being the most qualified applicant for the job and not on the basis of having a body they’d like to [expletive deleted]. Because I’m not a prostitute.” Over the next few days, however, he would work on making it very clear that while that may be the case, I was a mental patient, and had no right to defiance.
Right to Refuse Anti-Psychotic Medication
“Any person subject to detention . . . shall have the right to refuse treatment with antipsychotic medication” absent a finding of incompetency or emergency. (WIC 5325.2)
It soon became clear that my “clever Seroquel trick” was actually pretty self-detrimental. While the sedative effect had worn off after a few days, the unpleasant side effects remained, so I told the nurse that I didn’t want to take Seroquel anymore. She said that when I saw the psychiatrist again in a couple of days I could discuss it with him. I made my request again that night. But like all nights and with all patients, she carefully watched to make sure I swallowed all my pills, even asking to see under the tongue.
Fourteen Day Certification
WIC 5250: A comprehensive array of requirements must be met for a 5150 [72-hour hold] to turn into a 5250 [14-day hold]. They can be summarized into four main categories: Probable Cause, Notice, Counsel, and Right to Appeal.
“If a patient has been held on a 72-hour detention, he or she may be additionally held for 14 days of intensive treatment only if all (emphasis added) of the following apply:
1) The professional staff has found that the patient meets the criteria of being dangerous to others, self, and/or gravely disabled due to a mental disorder.
3) The person has been advised of the need for, but has not been willing or able to accept, treatment on a voluntary basis.”
Lack of Notice
“Notice” of almost anything related to my 14-day hold began and ended with my being notified a couple days beforehand that I was scheduled to have a certification review hearing. This was the case even though the doctor was required to certify—in writing—that “I hereby state that I delivered a copy of this notice this day” to the person affected. As to notice of the hearing’s outcome, it seems that such a person is only entitled to oral notification of the decision at the hearing’s conclusion, which I did receive, although I don’t know if my advocate received the necessary written notification of the decision, which should have included a statement of the evidence. But this section’s second requirement that my advocate assist me in determining whether to appeal was not met. My advocate never even notified me of my right to file a request for release.
Lack of Counsel
Where Counsel is lacking, so usually is adequate notice.
WIC 5256.4 boasts of strong protections. I had the right to “assistance by an attorney or advocate, to present evidence on [my] own behalf, to question persons presenting evidence in support of the certification decision,” along with many others, none of which I was granted.
Bereft of any advocate or attorney assistance, little chance existed of mounting a successful defense against such—literally—expert opposition, even if I had been apprised of such rights. Consequently, my mother and I sat helpless and bewildered as my status was decided to be an “involuntary hold.”
Having no idea what the actual requirements for a 14-day hold were, I figured it had something to do with being crazy and hence felt I had cause for concern. It was already day 5 or 6 the day before my big “hearing with a judge” in the hospital. Having gotten over my depression back around day 2-3 (I’ve got rapid cycling to make Lance Armstrong jealous), back in the ER actually, I was now pretty happy hyper. In addition to my standard Depakote, the psychiatrist had added Zoloft. My symptoms: gregarious and ebullient, with a tendency to skip down the hallways of the mental institution on my way to line up for medications.
WIC 5252 requires that the provider certify the “specific facts which form[ed] the basis for [their] opinion that [I met] one or more of the classifications indicated above.” I would be interested to know what facts were fabricated from this behavior to suggest—and to the relatively high degree that the standard of “probable” requires—that I was a danger to myself or others.
As to (3), I doubt they would have felt the need to cover up all evidence of the record of heavy medication that I had voluntarily been taking all this time, which was, not to mention, the very cause of what they’d have to assert for (1). And it would have been least likely of all that I would have qualified under the “gravely disabled” category. My desperate and panicked mother, at the certification hearing, must have served as evidence beyond a reasonable doubt that I would meet the definition of a person who is not ‘gravely disabled’ by virtue of the fact that I could survive safely without involuntary detention with the help of responsible family.
Lack of Meaningful Opportunity to Appeal
Without Notice and Counsel, I had no way of knowing what facts had been asserted against me and if I was even allowed to address them, let alone how to counter them. Without this basic foundation on record, any meaningful opportunity to appeal could not exist even though 14-day hold decisions are especially in need of external review given the low qualifications of “hearing officers.” These individuals, entrusted to judge a person’s fitness for society based on their own perceptions, are rarely judges. Neither do hearing officers need to have any medical background. In fact, it appears that correctly determining when it is appropriate to circumscribe the freedom and liberty of individuals guilty of no crime is so easy that even a (certified) law student can do it.
Right to Make Physical Health Care Decisions
California Probate Code 4650 reflects the Legislature’s finding that, “in recognition of the dignity and privacy” expected by a person, even one who is considered mentally defective is nonetheless entitled to “the fundamental right to control the decisions relating to his or her own health care,” and is presumed to have this capacity unless found incompetent in a separate proceeding.
Perhaps brazenly emboldened by his recent victory in my Kangaroo court 14-day hold certification hearing, the doctor’s violation of my rights in this area seemed to reflect an attitude that taking the time to even fabricate grounds for a hearing on my ability to make health care decisions wasn’t even necessary. Furthermore, the healthcare “decisions” he illegally made on my behalf were so trivial as to be medically unwarranted given the serious grounds justifying my involuntary commitment.
My asthma—and resulting need for prednisone—had not yet become so severe. Hence, I weighed a little less and smoked a little more than I do now. Included in our activities was a daily “smoke break”—that’s actually what they called it—in which we all went outside (even if you didn’t smoke and didn’t want to) and were offered cigarettes by the nurses. Or, if you had a personal preference for a different brand, you could buy your own pack for the hospital to hold.
County hospitals are places of deprivation—deprivation of dignity, of security, of food, of social companionship, and so much more. Having a smoke together with—nearly—all the other residents provided a welcome distraction from our situation and a sort of bonded feeling of solidarity.
But a couple days after our “introduction” argument, the doctor and I had another tiff: he noted that my chart said I had asked to use my inhaler a couple times. He concluded his lengthy exposition about how smoking was bad by imploring me to accept his offer for smoking cessation assistance. “Defiant” as ever, I again stood my ground and respectfully, but firmly, declined.
During the next day’s smoke break, a confused nurse informed me that my pack of Camel Menthols had been disposed of. Annoyed at my having to smoke a hospital cigarette instead, I hadn’t imagined that it would actually be the last one for the remainder of my stay. Because the day after that, none of the nurses handing out cigarettes would give me one—“doctor’s orders on account of my asthma.”
Chivalrous as ever, the doctor entreated me to really try to lose weight as it would “really show off your figure as you’re already pretty,” and shared with me some horror story of how he had an aunt who started out “young and cute like me but really let herself go.” And, although hospital policy put no restrictions on allowing visitors to bring snacks to patients, he explained that my mother’s bringing me snacks like chips and candy bars was not a good idea. Ever the stubborn and intransigent mule, I told him that I was quite satisfied with my weight the way it was and enjoyed the snacks.
Again, the very next day my mother was told she could not bring in my usual snacks on account of “doctor’s orders.” As the meals now became relatively even more meager, I saw that patients could put in a request for larger portions. Having been put on a “dietary restriction,” my request was denied.
Growing ever more hungry and desperate, I asked my mom to bring apples and bananas, but to no avail, even then.
It was shocking to see how easily my fundamental right to make what few personal choices I had left about my health was simply swept aside, and on the basis of issues as petty as smoking and being overweight—not even BMI obese. But even more repugnant was that this last decision, as it appeared from the vast majority of our conversing on the subject, wasn’t even made out of concern for my physical health, but rather on the basis of sex discrimination.
“Rights” are meaningless unless they are enforced. The California Welfare and Regulations Code expounds at length on one’s right to access their medical records. Yet in my case it’s a right I may have permanently lost. A couple years ago it came to light that the hospital I was detained at was beset with problems of competence and corruption. It has since closed down.
My experience taught me the importance of having strong patients’ rights advocacy to enforce people’s rights. I plan to finish law school in the next few years and pursue a career as a patients’ rights advocate. Both “patient” and “advocate,” I eagerly await the chance to work with my fellow detained brethren so that they too can have the power and ability to be both.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.