As a critical psychiatrist, I am a daily witness to the civil rights abuses of people that struggle with mental health issues. The outrage I feel has compelled me into action to assist people caught in an unfair system. Last summer, I teamed up with attorney Elizabeth Rich to help a woman named Leslie.
I met Leslie last spring when I was covering for another psychiatrist at a rural hospital in Wisconsin. A single mother of three small children, Leslie had been admitted to an inpatient psychiatric unit two weeks prior, after she’d contacted a crisis line seeking help. At the time, she had suicidal ideation and a plan to harm herself, but no real intent to end her life.
Leslie had been placed on an emergency detention, which is the first step in the process for mental health commitment in Wisconsin. The process has two phases: After a 72-hour emergency detention at the time of admission, either the hospital takes no further action or the attending psychiatrist requests a probable-cause hearing (meaning he or she believes further hospitalization and/or mental health commitment may be required). The hearing must take place within three business days. A judge then determines whether or not to find probable cause based on testimony by the treating psychiatrist and any witnesses. The judge’s ruling will almost always concur with the psychiatrist’s recommendation, so it is usually a routine hearing. If probable cause is found, the patient must return to the hospital and two court-ordered examinations are to take place within a two-week period, after which a final hearing is held. The judge will rule at the final hearing for mental health commitment (or not); once again, judges generally follow the county psychiatrist’s recommendations.
The hospital’s attending physician did request a probable cause hearing for Leslie, and she therefore stayed in the hospital awaiting a final hearing that took place 10 days later. The judge placed her under a commitment to her county of residence.
Stuck in the Hospital
I was scheduled to work at the hospital for five days and after meeting Leslie, had intended to have her discharged at the end of the week. As I saw it, there was no further reason for inpatient care. She was no longer having suicidal thoughts, nor was she showing signs of depression or psychosis. She had had a medication adjustment, having been placed on an antidepressant, citalopram, upon admission and discontinued from her previous prescription for Depakote. (Depakote is an anticonvulsant or antiepileptic medication commonly used for mood stabilization. It has serious potential side effects and is contraindicated for women of childbearing age in most instances.)
However, the hospital’s social workers handling Leslie’s discharge indicated that the county planned to place her in a group home. They mentioned that the doctors who had seen Leslie previously were upset because they did not agree. One of the psychiatrists’ progress notes even said that there would be negative consequences for Leslie if she were to enter a group home. Because group home placements generally last 6 to 12 months, she was at risk of losing her full-time job or even custody of her children. One can only imagine how stressful it would be for a mom to have her kids placed in a foster home and her pets at the Humane Society while being forced to live in an institutional setting. It did not appear to any of us that a group home was indicated, so I told the social workers that I still intended to discharge Leslie on Friday.
The social workers reiterated that I could not discharge this patient. One told me, “She is court-ordered to be in the hospital.” That statement was false because in Wisconsin, the mental health commitment statute stipulates that patients stay in the hospital only “until stable as determined by the psychiatrist.” In spite of my efforts, I ended up having to keep Leslie there. I would soon be leaving, after which another psychiatrist would be working the weekend and yet another psychiatrist would be seeing her on Monday.
Bringing in a Lawyer
I could not stop thinking about the fact that Leslie had had three different psychiatrists recommend that she be discharged back home instead of to a group home. After several days of thinking about what I could do, I was able to locate the name and number of the public defender that had been representing Leslie for the court commitment process. I asked her whether Leslie could legally be discharged to a group home even without the recommendation or approval of her treating physicians, nurses, and social workers; she told me yes. I then asked her to call the county and request a hearing because, in my opinion, a group home was not the least restrictive setting. Mental health patients who are committed to a county in Wisconsin are supposed to be in the “least restrictive setting” possible. The public defender was able to schedule a hearing for the following Wednesday morning.
I changed my schedule so that I would be able to testify in person; my plan was to ask two of the other psychiatrists who had seen Leslie in the hospital to testify by phone that she did not need to live in a group home. I spent time gathering records and preparing for this hearing. The next day the public defender called me back and said the county was not even going to hold a hearing and that Leslie could return to her apartment, job, and caring for her children. We were ecstatic. We both believed that it would have been a violation of Leslie’s civil rights to prevent her from supporting herself and her family, and that she was a very good mother. I assumed that was the end of the story.
Picked Up in Handcuffs
Several months later, I was on call at the hospital where I work (not the hospital where I initially met Leslie in Eau Claire, Wisconsin) and was covering emergency room admissions to the inpatient behavioral health unit. That evening, I got a call from an emergency room physician at the other city hospital who told me he had a patient that had been detained on a “pick-up order” through the county. If someone is thought to be in violation of their mental health commitment order, their social worker can get an order from a judge to have the person brought to the hospital — usually in handcuffs, whether or not they are resistant. I asked the patient’s name. It was Leslie. The doctor said after observing normal mental status and behavior, “I don’t know why she is here, and she does not know why she is here.”
Leslie had not been experiencing any mental health symptoms, but suddenly the police came to her apartment, handcuffed her, and brought her to the hospital. It turned out that her social worker had filled out a form saying that Leslie had missed appointments and was not taking her medication. Leslie had, in fact, missed appointments, but it was because she was working double shifts one week and could not get a babysitter the next week. She said that she did stay in touch with the social worker regarding her whereabouts. Also, Leslie had been very sick with the flu and had missed some doses of her medications due to vomiting. She had also been placed back on Depakote prescribed by the county psychiatrist despite its risks to her reproductive health. Most importantly, according to the social worker, Leslie had had a “drastic change in her appearance.” She had dyed her hair red and gotten a facial piercing, which “raises questions about whether she was on the verge of hypomanic behavior.”
Leslie was not experiencing any depression, psychosis, or suicidal or homicidal ideation. She was not a danger to herself or others. Yet she had been picked up by police, placed in handcuffs, and brought to the hospital. All of the nurses were aghast that somebody could basically get arrested because they dyed their hair and got a facial piercing.
Leslie’s social worker intended to have her placed in a group home and came to the hospital to read her her rights, as is required by Wisconsin statute. However, the social worker did not meet the deadline; Leslie’s rights were to have been read to her at least 48 hours from the time of detention. These rights included receiving a hearing before a judge to determine whether or not group home placement was indicated. Yet Leslie’s social worker informed her that she was not entitled to a hearing because she was already “under a mental health commitment.” This was not true, and the staff at the hospital and I succeeded in obtaining a hearing for her.
Lining Up Witnesses
I was extremely upset by the way the county was treating Leslie and volunteered to help her prepare for the hearing so she would be allowed to return home. I took a chance by calling a wonderful attorney, Elizabeth Rich. Elizabeth had called me the previous winter to ask if I would help her get people off commitment in Wisconsin. I hoped she would return the favor. I called her on a Saturday afternoon and explained that we needed her to represent Leslie at the group home hearing. “I’ll do it,” she responded. “I’ll do it for free!” This meant registering as the public defender for the case.
As I explained earlier, Leslie had a legal right to a hearing before a judge within a 10-day period from the time of her original detention. The hearing was scheduled for the tenth day after; by that point, she had already been placed in a group home by her social worker after being incarcerated in the hospital for seven days. Generally quite compliant, Leslie went along with the whole process.
During the days leading up to the hearing, Elizabeth and I were working hard trying to line up people to testify on Leslie’s behalf. I asked Elizabeth to call the county attorney to beg him to drop the hearing since there were going to be at least two psychiatrists testifying that Leslie did not need to live in a group home. I then found a third doctor who had seen Leslie in the hospital and also agreed to testify. He believed that Leslie had bipolar disorder — a diagnosis with which I disagreed — and wanted to make sure that Leslie would be taking medication, but also thought a group home was unnecessary.
Then, Elizabeth asked me to have some of the nurses testify because they were so shocked that someone could be committed due to changing their appearance. The nursing staff had noted that Leslie was not experiencing any mental health symptoms that would require incarceration in a locked psychiatric unit. There was no dangerousness present, as is required by the Wisconsin mental health statute on involuntary commitment. In all, Elizabeth and I were able to round up seven witnesses — unheard of for a group home placement hearing.
On the day of the hearing, I was on my way to compete in a horse show several hours away. Suddenly, I got a text from Elizabeth Rich: “We won.” She explained that soon after she filed the case at the online court-system site indicating that we were going to have seven witnesses, the county dropped the hearing. I had the wonderful task of calling Leslie at the group home to tell her she could leave the next day and go back to her job and children.
Always the eager beaver, Elizabeth right away wanted to work on the next step for Leslie, which was to fight her upcoming recommitment hearing. Leslie’s original commitment order had been for six months, which would be up in September. Typically, counties will recommend an extension of the commitment, or recommitment. An individual under commitment in Wisconsin has the right to request a jury trial at this hearing. As part of this process, Elizabeth asked me to complete a mental health report for Leslie, which of course recommended no further commitment and no court-ordered medications. Elizabeth assured me that she had had good success requesting jury trials. Thus far, the county had dropped the entire recommitment process after receiving her requests because going through a jury trial is a tortuous process that takes a lot of the court’s time and the county’s money.
Soon after filing, Elizabeth learned that Leslie would not have a recommitment hearing. The county had indeed decided to drop the petition to extend her commitment. With a request for a jury trial and my emphatic report indicating that Leslie had been compliant and sought help when appropriate, the county had very little reason to hold her.
Leslie had one more month left on her commitment. For some reason, her social worker would not allow her to see me for outpatient medication management; she had to see the county-appointed psychiatrist. Leslie did not want to rock the boat and complied. However, the mental health statutes do not indicate that individuals under mental health commitment are required to see a specific psychiatrist. By not allowing Leslie to see the provider of her choice, the county once again violated her civil rights.
System: Out of Control
There is no end to the overreach of the mental health commitment process I have observed in Wisconsin. It is out of control. Elizabeth Rich and I have teamed up to continue our battle on behalf of Leslie and several other individuals with recommitment hearings coming up. We seek to reform the legal and medical practices in our state that do not help patients, often actively harm them, and deprive them of their rights.
According to Elizabeth, misinformation delivered by social workers during the involuntary commitment process is commonplace. Social workers confidently misstate the law regarding the rights of mental health patients. It may be that they are genuinely mistaken. More likely, they are pushing their own agenda on a person in a vulnerable state who is unrepresented by counsel. In Wisconsin, people subject to an involuntary commitment are entitled to representation by an attorney appointed by the public defender’s office, regardless of income.
Wisconsin also has very specific requirements regarding the principle that the “least restrictive alternative” must govern all aspects of the involuntary commitment process. Under the law, each patient shall “have the right to the least restrictive conditions necessary to achieve the purposes of admission, commitment or protective placement.” The Department of Human Services regulations also stipulate that “each patient shall be provided the least restrictive treatment and conditions which allow the maximum amount of personal and physical freedom…”
Once she was released from the inpatient facility after her initial detention and treatment, Leslie was subjected to what is euphemistically called “assisted outpatient treatment,” a failed paradigm of involuntary treatment and forced drugging. Leslie’s story highlights another glaring deficiency in the current system: the lack of freedom to choose one’s healthcare provider and to stop taking medication prescribed by the county doctor — even when the medication is contraindicated and harmful to the patient.
Medically speaking, one of the main problems I notice in my new role as a critical psychiatrist is that many of the same people who have repeated hospitalizations are also under commitment and must take court-ordered medications. These people tend to be admitted for obsessive suicidal thoughts and self-harming behavior, and the usual culprit is excessively high doses of medications. People with mental health issues who react negatively to antidepressants and other drugs are usually prescribed higher and higher doses, with correspondingly greater and greater agitation, akathisia, and obsessive suicidal thoughts. I see this especially in adolescents placed on high doses of antidepressants, which are not even FDA-approved for use in this age group.
Leslie’s heavy-handed treatment at the hands of the police is the norm in Wisconsin and elsewhere. It was completely unwarranted and unlawful. When someone on an involuntary commitment misses an appointment or engages in behavior that a county doctor or social worker deems “risky” or “noncompliant,” all it takes is a phone call to law enforcement to bring on the humiliating and frightening experience that was foisted upon Leslie. There is usually no attempt to use less restrictive means to gain compliance, such as a phone call to the individual, and no hearing before a squad arrives with flashing lights, attracting the neighbors’ attention. They look on as officers pound on the person’s door, then take them down like a criminal, handcuff them, toss them in the squad car, and haul them off to a lockdown inpatient facility.
This Wild West, “shoot first, ask questions later” approach has no place in a democratic society. Yet that is how alleged noncompliance issues are routinely handled. This is a clear violation of due process rights, as well as a violation of the least restrictive alternative requirements that every state has in place for involuntary commitments.
The Challenge Ahead
The lesson of Leslie’s case is that launching a successful attack on involuntary commitment and governmental excesses requires a strong attorney/doctor team. One is not likely to win without the other. However, it is not easy to find a doctor, like me, who is willing to depart from mainstream medical philosophy. Nor is it easy to find an attorney like Elizabeth, who is willing and able to buck the typical rubber-stamp judicial system, especially pro bono or at public defender rates. Also, we doctors need to be well-versed in the law, so we can spot legal issues such as those in Leslie’s case. Similarly, lawyers need to be well-versed in the science behind diagnosis and treatment of the “disorders” identified in the DSM. Otherwise, our ability to spot issues, cross-examine medical experts, and make effective arguments will be severely hampered. The Wisconsin-based nonprofit foundation Andrew’s V.O.I.C.E. — which stands for Victory Over Involuntary Commitment Excesses — intends to develop a webinar series to provide this type of education for attorneys and medical professionals.
In speaking out about and resisting these mental health system practices, I know I’m going against the grain. But it is very rewarding. I am helping people — but in a way I never anticipated when I decided to become a doctor.