S2 Episode 5: 988

Jesse: Previously on Committable.

Hannah Zeavin: Is a hotline going to, no matter what, intervene? Or is the hotline seated at a place where it waits for the caller to come to them and then sticks with the caller no matter the outcome? 

Tim Wand: That's the thing. There is no evidence whatsoever to support the idea that risk assessments reduce acts of harm. This preventative detention component of mental health laws means that we can take away someone's civil liberties in advance of them harming themselves, when there's no empirical evidence to support our ability to predict acts of harm, such as suicide. 

Nev Jones: What does it even mean for your whole outlook, much more broadly, like on society, when ostensibly helping institutions end up being experienced as a source of harm?

Jesse: This is Committable, a podcast about involuntary commitments. I'm Jesse Mangan. While producing season two of this podcast we were focused on one person's experience with involuntary psychiatric detentions. And during that time one of the most widely discussed changes to mental health interventions in the US has been the rollout of 988. Proposed as an alternative to 911 that could decrease the amount of police-led interventions for people experiencing distress.

But what is 988? How does it work? Does it really reduce the risk of police involvement in these types of calls? To learn more about the rollout of 988, what it is and how it works, I spoke with an Aneri Pattani.

Aneri Pattani: Hi, my name is Aneri Pattani. I'm a reporter with Kaiser Health News, where I write about mostly mental health and substance use.

I'm also a part-time Masters of Public Health student where I'm focused on learning and working on suicide prevention. 

Jesse: And what is 988? 

Aneri Pattani: 988 is the new number for the National Suicide Prevention Lifeline, which for years used to have a longer 1-800 number. And so the shorter three digit number premiered in July of this year with the idea that it's easier to remember and that more people could use it, especially in emergency scenarios where we know sort of by default we call 911.

But for mental health emergencies, hopefully 988 could become that easily remembered go-to. And 988 also comes with sort of an influx of federal funding to help call centers answer those calls and to bring on more staff to get them trained. And I think the long term goal from some mental health advocates is that, you know, maybe this funding and this number can start transforming the mental healthcare system more broadly.

Jesse: And so, there's federal funding coming in and they're changing the number. Where is the federal funding coming from, and then where is it going to become 988? 

Aneri Pattani: A lot of the federal funding is coming from the Biden administration, from, you know, the Health and Human Services department. It's a little over 400 million that was sort of pushed with 988. And the idea was that if we're gonna have the shorter number that people can remember and more people are gonna use it, then you have to have the capacity to answer those calls. And so a lot of it has gone to the local call centers that answer these calls, and there are about 200 of them across the country.

And the idea is to give them the money to hire more staff who can be answering the calls and to train those staff. And to give them infrastructure to do things like respond to texts or web chats as well. But this is not a long term funding goal for these places. This is a one time infusion to kind of get it up and running.

When 988 premiered the idea for long term is that, when Congress passed the laws that created 988, they allowed every state the option to add a charge to people's cell phone bills that would fund 988 long term. A similar mechanism is used to fund 911. The thing is, they kind of left it up to the states to pass legislation that would actually add that bill on, and so the vast majority of states right now haven't done that.

So there's no long term funding plan in a lot of states for this system. 

Jesse: One of the things that's gonna be really regional, local, is what type of response there is if there is an emergency. So, is it a crisis response team? Is it the police? Is it peer support? Whatever it is. Is there clear guidelines or criteria about what situation is going to result in whatever local emergency response there is?

Aneri Pattani: 988 has a policy that they call the imminent risk policy. To step back, 988 was created to be an alternative to 911, so the idea is that it's supposed to avoid involving police. It's supposed to be this separate system where counselors are trained to talk to people about, you know, what are their reasons for dying? What are their reasons for living? Can they connect you to social services, food, housing, resources, or therapy? But they do have this policy where if the counselor feels a caller is at, Imminent risk is the term they use. Which essentially means if the counselor on the other end of the phone says, I think this person is going to hurt themselves or someone else immediately if nothing is done, then the counselor can initiate what's called active rescue or emergency rescue, where essentially they call emergency services.

And depending on where you are, that might be a mobile crisis response team, or in a lot of the country  it's going to be police. Those emergency services would respond to the person's home. That can happen if the caller says they're in need of emergency services, but it can also happen even if the caller doesn't want that, if the counselor who's on the other end of the line thinks this person is in immediate danger.

Jesse: I want to take a moment to try and map out how this system works. 988 is a rebranding and simplification of the number for The National Suicide Hotline. The National Suicide Hotline is run by SAMHSA, the Substance Abuse and Mental Health Services Administration. The agency within the US government tasked with making behavioral health resources more accessible. SAMHSA contracts with a non-profit to manage 988, that non-profit is called Vibrant Emotional Health. Vibrant partners with the approximately 200 different local hotlines that make up the 988 network. 

Each one of those local hotlines is required to sign a contract with Vibrant that guarantees that the local hotline will have some form of imminent risk policy that allows for the possibility of forced interventions.

The federal government is investing about $400 million to establish this 988 network, and a hotline does not get access to that federal funding unless they sign the contract with Vibrant. But what does that look like in practice? How does a hotline operator determine who qualifies as an imminent risk? What sort of screening test is being used to determine that a forced intervention is appropriate for this collar?

Rob Wipond: These tests are not very reliable, they've been shown to be unreliable again and again and again. Even the National Suicide Prevention Lifeline's own researchers admit that this is so unreliable it really shouldn't be used, but they use it anyway. 

Jesse: This is Rob Wand. 

Rob Wipond: So my name's Rob Wand, one of the things I do is freelance journalism. It's been my main source of income for the past 20 some years, and I've always been interested in civil rights and the psychiatric system since it happened to my father many years ago. And that's how I got involved in it. And I started kind of researching and writing about it off and on over a long period of time.

And then in the last couple years, I've written a book called Your Consent is Not Required: The rise in psychiatric detentions, forced treatment and abuse of guardianships, where I really provide what, as far as I know, is the most comprehensive sort of look at the phenomenon of psychiatric detentions and forced treatment across North American culture today.

As far as I know, a book like this hasn't really been done since the era of asylums where people have really looked at what are all the ways in which this is occurring in our culture? Who is it happening to? Where is it happening? What are the reasons behind it? So that'll be coming out in January of 2023.

And one of the things I looked at in this is the use of hotlines as a mechanism for bringing people into psychiatric incarceration. 

Jesse: If we take sort of a broader perspective and try to look at how this system is structured, we have a non-profit, Vibrant, they're getting a contract from the federal government.

What does that mean? What are the requirements here? What is Vibrant doing? 

Rob Wipond: So Vibrant Emotional Health, they've changed their names a couple times over the years, but that's its current name. Have long had a contract with SAMSA to administer the National Suicide Prevention Lifeline. That's been an 800 number, well, it's been a number of 800 numbers because they also run an NFL helpline for the National Football League. They run a veteran's hotline, so they run a number of hotlines and some of them in some ways also flow through this National Suicide Prevention Lifeline. So that contract has been around for a while, I posted it on my website if anyone wants to see that particular contract. And it specifies in it that they need to have a policy and practice of tracing some calls that come in for anyone that they believe might be, you know, falling into a certain category of person, shall we say, for the moment. 

But in this category of person, yes, they're supposed to call 911. That's the current methodology they contact 911, or a public safety answering point it's called. And the public safety answering point has the capacity to trace virtually anybody's device that they might be contacting 988, or 911, or any of these numbers. Basically they have call tracing capacity. 

Jesse: And what is this screening test? How does it work?

Rob Wipond: It's a very simple screening test, kinda like a little decision tree. They try to, if they're skilled at all, sort of flow it into the conversation, so you don't really know that you're being put through a test. 

But they're required to do it if they're at all concerned, and you'll notice once you're aware of what the questions are. There's simple things like, you know, are you feeling suicidal? Do you have a plan? How might you do it if you were going to do it? You know, are you feeling different than abstractly thinking about the idea versus kind of really feeling like you might actually do it? They try to distinguish between those kinds of things, and that's essentially it. It's a volunteer often that's staffing this line, sometimes it's a professional, it doesn't really make a difference because even for highly trained professionals these tests are not very reliable. They’ve been shown to be unreliable again and again and again. Even the National Suicide Prevention Lifeline's own researchers admit that, yeah, this is so unreliable it really shouldn't be used, but they use it anyway. And that's basically how it's done.

So somebody just kind of makes a judgment call. 

Jesse: It is important to note in these conversations that there are a lot of people who rely on these hotlines, who have used them and had positive experiences, life-affirming experiences. These hotlines are an important resource for people to have access to.

Which is why it is also really important for people to know how they work, what the potential risks are.

What triggers police involvement? Is it only 911 that can trace calls or can 988 do that by itself? 

Rob Wipond: What I will highlight is that Vibrant Emotional Health and other mental health organizations have been lobbying the government to give the administrators of 988, i.e. these people we're talking about that run the centers, that run the helpline centers. To give them higher level powers, direct powers to do that call tracing themselves. To not have to go through 911 or the police.

And they've been using the argument, Oh, it'll just make everything so much faster. So there are enormous privacy implications, confidentiality implications, to that potentiality. And it has not yet been implemented at that level. There are some technical hurdles and because some people have spoken out with concerns about it, the government is going a little bit more slowly than they might otherwise have done. 

In looking into the question of can this be done and should it be done, i e, should the administrators of the 988 number have the same kind of high level cutting edge call tracing surveillance powers that 911 has, and will continue to have? You know, there's a new next generation of technology coming out soon for 911, to do that even better.

Jesse: My recollection of some of the press talks that people involved in SAMHSA did for9 88, and some of the ads I saw for 988, I recall them saying that they don't trace calls. And so to clarify, what you're saying is while that's happening, Vibrant is going to the government to get the authority to start tracing calls without 911?

Rob Wipond: Yeah, this is one of the terrible things, you know, I call it a lie. You know, I will explain what I mean by that. That unfortunately the mental health system, and mental health organizations, and psychiatrists, and other kinds of practitioners engage in a lot. They really mislead the public. So yeah, even now, even after I've written a whole series of articles for Mad in America website about this, you know, revealing all the facts about this in great detail. And even now, when other journalists from other major mainstream outlets have twigged to this as people are talking about it on social media and said, Well, do you trace calls? They're still denying that they trace calls and technically it's correct because they do not themselves have the power, the technology to do the call tracing. 

And then the other thing they're doing, even as they've been telling the public this and reassuring the public. They have been very busily, and this is all in the public record, lobbying the government very heavily to get those call tracing powers themselves. So they aren't amending their own comments to these journalists by saying, Well, we don't currently have the power to do the call tracing, but gosh darn it, we really want it and we're lobbying for it, cuz I think the public should know that.

Jesse: All hotlines accessed through 988 are contractually obligated to employ some type of risk assessment that has the potential to result in a forced intervention. Quite possibly one that involves police. 

There is no reliable data that these sorts of assessments are accurate, or that these sorts of forced interventions are helpful to the people who experience them. But there is a significant amount of data indicating that forced interventions, and the forced hospitalizations that can result from them, can cause serious harm. 

So if the federal government is contracting with Vibrant, and Vibrant is contracting with local hotlines, and all of these contracts require some sort of imminent danger or risk assessment policy, then is anyone in this chain tracking the outcomes? Is anyone tracking what happens to the people who do experience a forced intervention?

Rob Wipond: No, they're not tracking it. They themselves did a study of that issue, which is available on my website as well. Where that was the conclusion of the study was, Gee, we should be tracking these outcomes and finding out, is this a good thing? What we're doing, is it helping anyone? And of course, one of the reasons that that is such a big concern, and I would say I've never heard anyone in that situation not get detained, at least for some time in the hospital. You know, when you're brought in as a result of a hotline reporting you, and the police bringing you in, in every case that I've ever heard of or seen, people were detained. At least for some amount of time. 

Being incarcerated in a psychiatric hospital is an enormous, traumatizing experience for most people. Suicide rates actually skyrocket after hospitalization, even among people who are not suicidal to begin with, numbers of studies have shown this. So it's enormously concerning and the hotline staff, or administrators, are well aware of this. One of them even did explicitly say to me, you know, like, “Yeah, it is a concern that we do this. That we're locking people up, we're getting them locked up. Even though we don't know that it in any way, shape, or form helps them.”

It's just kind of become policy and practice within our society. Like, well, what else are we gonna do? That kind of question follows quickly cuz they're not thinking. Cuz I think there are a lot of things we could be doing differently. 

But anyway, that's the logic, what else can we do? It's an emergency, let's just get this person detained and brought up and no, there are no real outcome studies of, was the person in the end grateful? Was the person traumatized? Were they locked up for days, weeks, months? What happened? Did they die shortly thereafter Anyway?

You know, what was the outcome? And we really need that. But that's true across the board I would say too. In my book I explore this, there's really no body of evidence to support forced psychiatric hospitalization as in any way producing positive outcomes.

Jesse: One thing that sort of strikes me about this concept, or this setup, is if there are people within the call centers, presumably there are people probably within Vibrant, maybe within SAMHSA as well, who would acknowledge that forced hospitalization or even just police showing up at your home, is not inconsequential. It is not necessarily a guarantee of any positive outcome. 

So, we're acknowledging that there's a consequence here, but it seems like it's not a consequence anyone wants to deal with and they're just shifting the blame. Cuz you're calling the call center, the call center operator can acknowledge, I don't like doing this but sometimes I have to, I don't know what else to do. So they shift the blame to the police. The police come and pick you up. Police say, I'm not qualified to do this, I'm gonna bring them to the ER. They bring 'em to the ER, they shift the blame, and the ER is not qualified to handle someone in emotional distress. They shift them to a psych facility. 

I don't know how to view it other than people just passing the blame from one group to the other and not even tracking what the outcome is. 

Rob Wipond: Yeah, that's a disturbing way of describing it, but I think unfortunately probably pretty accurate, that it is that. The first person in the line just kind of goes, Well, I'm worried this might happen, I don't want to be responsible for it if it happens, and I know for a fact I can stop it now. Right? If I send the police around, no matter what, that person's not gonna be able to do whatever I think they might or might not do. So that's what I'm gonna do. I'm gonna act on that basis.

And that kind of makes sense if that's all you're thinking about, is that immediate intervention. But if you think a little bit further and you start out asking the what ifs, and then if you look at the little bit of research we do have on what does in fact happen once that person ends up at the end of that line you described. Which is pretty much how, I interviewed everybody as well at every stage of that and that's pretty much what they said to me, is exactly what you said. Well, you know, I don't know, I'm not qualified, so I'll pass it to the next person. And so then you finally end up in the psychiatric hospital and often that's what they're saying too, is, well, I don't know if you will or won't kill yourself, but I think it's safe then that you just stay here.

And so they often incarcerate people for days, weeks, until whatever, something happens that makes them go, okay, we're just gonna get rid of you. Maybe they need the bed for someone else who they clearly think is worse off than you, or whatever it may be. Or they convince themselves that you start telling them and assuring them that you're fine. You know, you're no longer suicidal, whatever it is, something will get you freed. 

Just the outcome issue, right? As you're saying, it really is a problem. And I would say that that's across the board, in all of the mental health system right now. There's a stunning lack of actual real world outcome tracking.

Jesse: With the rollout of 988 the federal government is spending about 400 million dollars to help set up and support the network of local call centers that are working with Vibrant. All of these local call centers are contractually obligated to utilize some form of risk assessment that allows for the possibility of a forced intervention, but that is not the only type of hotline.

There are hotlines committed to never initiating a non-consensual intervention. And because of that commitment these hotlines are not able to access any of the funds being distributed.

To better understand this type of hotline, and how they might be impacted by 988, I spoke with Yana Calou. 

Yana Calou: So my name is Yana Calou, I use they/them pronouns, and I'm the Director of Advocacy at Trans Lifeline. Trans Lifeline is a peer support and crisis hotline that offers crisis and peer support to trans people. We’re run by and for trans people, so that means every time somebody calls they will be speaking to another person who identifies as as trans or non-binary. So, somebody with shared lived experience. 

And we've been doing this since 2014 without the use of any partnerships with 911 or police because of a couple of different reasons. One, because we know that police often make situations worse and shouldn't be the people who are responding to situations in which people are experiencing difficulty, suicidality, mental health crisis.

And secondly, because we also know that criminalization, or corrections, or police, aren't the answers. Also, there are many trans specific things that can happen to people within these contexts, and we know that in general forced treatment around suicidality makes things worse, it doesn't make things better.

So in our effort to get cops out of crisis calls, we also really include force hospitalization in that effort. It's not just no police, but also really giving people agency over the kinds of supports that we either refuse or or accept. 

Jesse: I started the conversation with Yana by asking about what trans-specific concerns, or trans-specific impacts, should people be aware of when discussing these sorts of forced intervention policies.

Yana Calou: I guess I'll start by saying, you know, I really believe that forced hospitalization hurts a lot of communities and people with intersecting lived experience and identity. So a lot of the things I'm gonna share do apply to other folks. But there are some trans-specific, oftentimes unintended, consequences of forced hospitalization that impact trans people really intensely.

So, one of the things is just thinking about disabled communities, trans communities, communities of color, where employment discrimination is so high, meaning that people from our communities are more likely to be unemployed. And since health insurance is tied to employment, often in our country, sticking somebody with an ambulance bill, or an ER bill, or a psych hospital bill, who's uninsured can often cause more stress. Especially since debt and financial instability are huge indicators or huge reasons why people are in crisis in the first place, right? So for trans people, 14% of trans people are uninsured, and so this makes this a massive financial burden for support that we didn't ask for. 

In terms of what happens inside of facilities, oftentimes trans-affirming healthcare gets withheld. People who have been forcibly hospitalized, who are trans, have reported having their hormones taken away, or not having access to those, or not not being given those. When often trans-affirming healthcare is really preventative in terms of suicidality. And then, I think oftentimes when we're not looking at the structural causes of suicidality and we're not treating it as actually a very, very normal response to not having the safety, belonging, financial stability, safe houses, schools that are affirming, families that are affirming, all of these kinds of things. Suicidality is actually a really normal response, or feeling suicidal to not having what we need to survive.

And so oftentimes when people are misdiagnosed, or forcibly medicated, for just going through those things, when in actuality it's some of those structural factors. Or experiencing a lack of gender affirming care, right? So diagnosing somebody as something else, prescribing for them rather than saying, Oh, like maybe you need trans-affirming supports, or potentially medically related transition care if that's something somebody wants. 

So unfortunately trans people are often placed in solitary confinement in hospitals and psych wards. And oftentimes it's said that that's for safety from others, or their own safety, despite solitary being considered a form of torture. So trans people are more often put there or they're put in the wrong gender facility, right? So when there's gender segregated psych wards in hospitals, putting a trans person on the wrong gender unit can also be really, really distressing. 

Certainly if somebody is trans and under 18 and discloses the fact that they're trans to a clinician, sometimes those clinicians can, in those kinds of settings, can out those youth to unsupportive parents. At a time when anti-trans legislation is so incredibly high across the US and the supports that we need outside of our homes are being eroded in schools and healthcare. Than outing youth who might be suicidal because of having really unsupportive home, outing that youth to an unsupportive caregiver can be really, really dangerous. 

And trans people are at higher risk for both sexual and physical assault within hospitals, there's a lot of data on that. In terms of what this means, I think there's studies showing that trans youth who are involuntarily hospitalized are less likely to seek support in the future. And post-hospitalization, we're gonna be less willing to disclose feelings of suicidality. So if we want people to reach out for support when they're really struggling, we want to be support that people can trust isn't gonna lead to further harm or trauma. So if you want people to reach out, you need to be really transparent and open about what support you're providing. What kinds of things might be triggered if things are shared. And we really want people to be able to share how they're feeling and be able to say how terrible they're feeling without the fear of that triggering something that they might not know about or might not want. 

Jesse: An often underemphasized aspect of crisis hotlines is not simply the opportunity to acknowledge someone's distress, but to talk about the sources of that distress. To identify a person's needs and explore the possibility of connecting that person with community based resources that might help address those needs.

So, I asked Yana, are these the type of things that a person can ask about when they call Trans Lifeline? 

Yana Calou: Yeah, absolutely, you know, sometimes a phone call isn’t all that somebody needs, right? Sometimes we do need an in-person response, and we do need local resources, we need local community. And if people are wanting that we absolutely connect people with the kinds of, you know, whether that's healthcare, whether that's peer support group, whether that's housing, whether that's finances, all of those kinds of things in their area.

We also recognize that sometimes the most important help that somebody can receive in crisis, aside from emotional support, is financial help. That's often, you know, some of the reasons people are in this. So we run a micro granting program that puts money directly into trans people's hands for different types of needs. And we also trust trans people to use those funds as they need. And so we don't ask people to like, provide a receipt saying this is what you spent it on, but really trusting people and knowing that some of these structural factors are actually what's at stake. 

And oftentimes the harm that we see happen specifically on crisis hotlines that do engage emergency responders, that then can mean force hospitalization or police violence, or criminalization, right? The kinds of harm that people are experiencing aren't necessarily on the crisis hotline themselves, right? It's the emergency infrastructure that we have in our country that is oftentimes making things worse. So it's the agencies that people interact with afterwards, whether that's police or EMS, or emergency room staff, or psychiatrists, or doctors. This is what we have in this country are police, jails, emergency rooms, and psych ward, right? That is the infrastructure that exists. And so for crisis hotlines to actually be able to provide more options in terms of resources for people, than those resources really need to be funded in order for them to exist, right? So really thinking about the need to fund more peer-based supports, peer respites, peer-based support groups, and things like this, as part of suicide prevention. Aside from just dumping money into emergency responders for this kind of work. 

Jesse: Those are all of my questions, is there anything else about 988, about Trans Lifeline, or about this issue that you think people should know? 

Yana Calou: I think it's really important that we as people who might seek support services have all of the information we need about what kinds of services we're gonna access. And really push 988 to be really transparent about these practices. Whether they're geolocating themselves or they're just doing that through 911, right? That's still happening on those calls. And also about their requests to the FCC to be able to do this. 

I think it's important that people advocate for funding for these alternative peer based models, if that's the kind of care people want.

One of the things that we are doing at Trans Lifeline is gathering stories from survivors. You don't have to be trans, from anyone who has survived a non-consensual emergency responder intervention. Can be on a hotline, can be not on a hotline. But we're really looking at what does it mean to bring together all of those survivors and center that expertise and advocate for the kinds of safety and transparency and agency that we need?

So if people are interested they can go to translifeline.org and click on Safe Hotlines, which is our campaign that's really trying to get police out of crisis care and ensure the safety and transparency that people need. And hopefully urge more hotlines to shift those policies and practices and show them that that's possible.

And I think it's really important for survivors to be the ones leading the way in terms of what's actually helpful in crisis situations. As a country we just really need to look at our emergency infrastructure in general and really get to the underlying issues of why we're in crisis to begin with.

And the best thing that we can do for suicide prevention is to give people money, and houses, and jobs, and safe schools, and supportive communities, right? That's what's actually gonna prevent suicide, not just not just having a line. You know, as somebody who works in an organization that provides a listening ear, that emotional support is really important. And it's also not gonna get to the underlying reasons why somebody might be having a really, really hard time 

Jesse: When we began this series, we were trying to understand one person's experiences with police intervention and involuntary psychiatric detention. Our questions quickly led to broader interlocking systems, systems not clearly designed around evidence, at least not evidence of positive outcomes for the people being pushed through them.

And we learned of all too common practices, laws, and systems that routinely bring a serious risk of harm to people who may be in one of the most vulnerable moments of their life.

And now we're left with more questions than when we started. 

How do these systems operate? What protections are you supposed to have? How do you make sense of a system this complicated after you've been forced into it? And is there anywhere where you can feel safe knowing that someone else views you as Committable?

Coming up in season three of Committable.

KC Lewis: Aid and Assist is not a restoration to health, it is a restoration to competency. They get to the point of being able to aid and assist, they send them back to the county that they came from, where often they will wait in jail for weeks or months to be able to be taken to trial. Then once they get back to the courtroom, they're not able to aid and assist again because their mental health has been deteriorating in jail.

Luciene Parsley: I don't believe that forcing them into treatment is gonna solve the problem. And there's no way that individuals are going to engage in treatment if they're forced. They'll probably do it for the period of time that they're in the hospital until they figure out what they have to demonstrate to get out.

Elizabeth Satchell: They're usually put in solitary confinement, which makes things worse. Sometimes they're stripped down and put into what's called a pickle suit. Sometimes they're strapped to a chair. So really they can be tortured, in my mind, it's torture. 

Ian Pettycrew: They're just in like a high school cafeteria, and there's no separation between the men and the women usually. And that's, you know, where people sometimes spend three to four to seven days. They're given like a blanket. That's it. Maybe a pillow if they ask for a pillow, but they wanna make it as safe an environment as possible. So pillows are sometimes not deemed to be safe. 

Nancy Murphy: Life doesn't stop because this is happening. It's not planned, so they're just plucked out of their life and put in a hospital with no idea of how long they're gonna be there, when they're gonna get out, what their rights are. It's not that they don't have a voice, it's that nobody's listening. It's not always the voice that's the problem, it's the ear. There’s nobody there to hear it.

Jesse: This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid, and me, Jesse Mangan. All music is from the song Reasonable, by Christopher G. Brown.

S2 Episode 4: Looks Like Criminal Detention

Jesse: Previously on Committable.

Cassidy: They eventually said that they had to hold me, and this was extremely distressing to me because the thing that I had said, like cited as traumatic during the call with the counselor, was an experience on a psychiatric ward. And now I was being like sentenced that I was going to be held in a psychiatric ward again. 

So, like the exact like environment that I had said was traumatic that I didn't wanna be in. I told them like, this is like the worst possible thing that you can do for me. It's very, very gray what your rights are, and I think that's in part intentional, cuz if you don't know what your rights are the more they can get away with.

Like, I was very frustrated by it cuz I'm like this isn't about care. This is about you guys protecting yourself from liability.

Jesse: The first time I was detained for evaluation, it felt like having a foundational illusion of security torn out from under me. All I had done was ask for help. The clinician acknowledged that they didn't think I was suicidal, but told me and my family that I had to be strapped into a gurney and transported to an unnamed facility for insurance reasons.

I have spent over 20 years trying to tiptoe through society while every moment, of every day, in the back of my mind is the very real fear that nothing in the laws has really changed. It would be just as easy and just as legally acceptable for someone to detain me like that again. So why aren't we talking about this more?

Why isn't this viewed as a civil liberties issue? 

Molly Linhorst: Generally speaking, civil commitment raises serious Liberty issues, which are foundational to our constitutional rights.

Jesse: This is Molly Linhorst. 

Molly Linhorst: My name's Molly Linhorst, I'm a staff attorney at the American Civil Liberties Union of New Jersey. I've been there for a couple years and I actually primarily work on immigrants rights issues, but broadly speaking all of us at ACLU New Jersey work on a lot of different things and much of our work comes from constitutional rights and advancing individual rights, generally speaking.

Jesse: So civil commitments, the process changes from state to state but broadly speaking, in what ways might involuntary civil commitment be considered a civil liberties issue? 

Molly Linhorst: So in a lot of ways, right? Generally speaking, civil commitment raises serious Liberty issues, which are foundational to constitutional rights. That, you know, includes bodily freedom, personal autonomy. A lot of privacy rights, which are grounded in several different constitutional provisions and address really all different sorts of aspects of your life. So generally speaking, liberty interests and privacy is kind of a component of that.

Jesse: I think one things that might set this apart from other issues is that  it is a civil process. So, what bar has to be met in order to justify possibly superseding these liberties issues in a civil process. 

Molly Linhorst: Yeah, that's a great question and it's also one that raises, I think a lot of the issues that are at the crux of why civil commitment is a constitutional issue. Because you have a lot of these characteristics of civil commitment that look like criminal commitment, that look like criminal detention, but you don't have the same sort of protections. 

So there are different standards and different states have different processes, different procedures, different standards that you have to meet. But by and large, even though the courts have interpreted civil commitment, because it poses a risk of indefinite commitment, as a very serious constitutional issue. You don't have to meet the same standard in most states that you do for criminal detention. Which in both cases, the state holds the burden, but for civil commitment, they just don't have to have as high a showing. And part of that is because the courts have said, well, it's not really possible to get to that beyond a reasonable doubt standard. Instead it has to be by clear and convincing evidence. Which is still a fairly high standard, but you don't have the same sort of intense protections that you do in the criminal process. Which itself, as we all know, has a lot of problems and is not really sufficiently protective, but for civil commitments in particular, You have this lower standard, you don't have the same sort of evidentiary protections.

You don't have some sort of equivalent to the Miranda rights. You don't have the protection against self-incrimination. And I don't think a lot of people realize the immense power of the state to take away your liberty in what is a civil process. And I also, because I've mostly worked on immigrants, rights issues, and a lot of my work has been focused on immigration detention, right? Which is also a civil process. In both of these cases, you have the state saying we have an immense interest in making sure these people, for immigration detention go to their proceedings, right? In civil commitment they're talking about danger to yourself, danger to others.

And in some cases, the state is saying, well, these people need treatment, this is the only way they're gonna get treatment. So you have noncriminal sorts of reasons, but then in actuality, when you see how commitment plays out, or how immigration detention plays out, It holds a lot of the same characteristics as criminal detention.

So it's this uneven sort of application of what it looks like on the ground, and the sorts of protections that are in place.

Jesse: Involuntary detention for evaluation and civil commitment exists in an often unexamined area of society. They are legal forms of confining someone against their will and all that is required to authorize this sort of confinement is an opinion. Often that opinion is coming from a clinician with some sort of training and experience, but in many states, any adult in the community can go to a court and apply to have someone else detained for evaluation. 

That is all it takes for police to be sent to your home to involuntarily bring you into a facility where you will be detained.

There isn't reliable evidence that these practices are actually helpful to the person being detained, but there does seem to be a significant amount of evidence that these practices bring the potential for serious harm. So why don't we question these practices? Why isn't there more attention given to the effects of this sort of coercion?

To better understand the state of research around involuntary detentions and civil commitments, I spoke to Nev Jones. 

Nev Jones: My name is nev Jones. I'm an assistant professor in the school of Social Work at the University of Pittsburgh. I operate from kind of a survivor researcher space and over the years  I have focused on a number of different issues. But I think I would sort of describe as an organizing theme, really trying to zero in on areas where there are particularly kind of pronounced disconnects between how people on the ground; service users, people with lived experience, are just experiencing these systems and services and interventions. As well as other ways in which power plays out in these spaces, and sort of where research is at, and kind of clinical development. 

That's quite long.

Jesse: That's totally fine.

So, it seems clear that coercion is an important component to look at and understand. This process inherently involves coercion. Do you have a sense of why there wouldn't have been more focus on understanding the complexity of that coercion? And how it impacts the person experiencing it?

Nev Jones: I mean, I think there's many reasons, right?

There's pervasive ableism,  sort of discrimination, stigma and social exclusion, and marginalization of people with “mental illness”. There's underlying racial and structural dynamics, as well as this sort of larger in a way, societal disregard for people who fall into sort of this category. You know it leads to, involuntary holds and civil commitments lead to automatic reporting to the police for example. Mainly because of firearms laws that render people who have been involuntarily committed ineligible to purchase firearms. And then again, the specifics vary by state. That in a way should be a major civil rights issue. And I'm, you know, I'm like an anti-gun person for sure but here the problem is not whether one is anti-gun or not, it is all about the discrimination. Serious discrimination  completely out of keeping with evidence that we have on the likelihood of people who have been involuntarily hospitalized committing gun involved, firearm involved violence in the future. And yet there's been very little societal conversation or controversy about that.

So, I think it's just suggestive of a population, a group of people, that is extremely marginalized. Issues that are extremely marginalized, that we as a society don't care a whole lot about. And then there are, I think real kind of complications when it comes to power dynamics in this space that are very, very obvious to people who have been, for example, involuntarily hospitalized, that are not necessarily as apparent to kind of folks who have not. And there's huge underrepresentation of researchers with personal experience of hospitalization, involuntary hospitalization. And there are in turn huge barriers academically for people with psych disabilities and these kinds of histories of systems involvement.

So, I think there's a lot of things converging to sort of prevent research happening that otherwise would have. And there's something very uncomfortable to a lot of people also about the whole topic of coercion in psychiatry. Because certainly politically this has been, the big picture issue of like coercion, a huge point of contention, right? Between activists for many, many, many decades, and kind of clinical administrative policy research representatives or leadership. So, it is a contentious issue, and I think sometimes people just see it as easier to just sort of avoid, sidestep, not talk about for that reason. 

Jesse: So there's a lot of disparity, a lot of systemic problems. And diagnosis can have an impact on the type of treatment you receive and things like coercion. Is there any research indicating how reliable an initial diagnosis might be? 

Nev Jones: Very unreliable, especially if we're talking about, so first of all. I think there's a real need to carefully distinguish reliability and validity. So validity being, is there a valid, underlying condition or syndrome that is being captured?

Reliability is do two different clinicians even agree about what it is? And so there's underlying problems of validity. So just within the psychosis spectrum, or across “psychotic disorders”, there's tremendous disagreement, even among researchers about how to sort of divide or parcel things out. Whether that makes sense, whether there's a continuum, multiple continua. So there's huge disagreement. 

So there's contestation about validity, and then there's also problems with reliability. And some diagnoses have incredibly low levels of reliability, especially in real world settings. Meaning more likely than not one clinician is gonna disagree with the next clinician about what's even wrong with somebody.

Some of the work I was previously doing, looking at youth who were referred within a court circuit for competency assessment. So there's some suspicion that there are mental competency issues in the context of whatever they were charged with, and they have to be assessed by multiple psychiatrists. And really shocking how three different psychiatrists, three completely different conclusions about what the diagnoses, usually plural, of the youth in question are. 

Even in research settings where there's sort of hardcore training and reliability meetings and checks depending on the diagnostic category, right. Reliability can be low, but boy is it low when you're not even talking about those kinds of research constraints and it's just real world clinicians deciding on, you know, a DSM or ICD code to assign, or codes plural.

Jesse: Mental health laws in the US exist as a sort of disparate collection of complicated, localized systems. Not just in relation to the letter of the law, but also in relation to the clinical culture that surrounds those laws. For the person being forced through these systems, the differences in policy and practice can be shocking. Not just from state to state, but from county to county, from facility to facility.

Sometimes it feels like the only thing you can rely on in these systems is the potential for trauma. 

So I asked Nev, if someone has been forced into one of these systems before, and been traumatized by it. Is there any research that indicates how clinicians should engage with that person if they're being forced into one of those systems again? 

Nev Jones: There's very little work that's actually looked at the sort of deeper impacts that involuntary and coercive experiences have in terms of undermining trust and faith in the system. And internalized stigma, and I don't love the word stigma at all, but often what people, I think, experience and report, and certainly in the qualitative research I've done this is incredibly pervasive. Is a sense of sort of blaming and shaming in the context of involuntary everything; initiation, transport, hospitalization. And that can be deeply internalized. So how do we help people then who have sort of experienced these things to not just sort of process, but actually heal from. And I think we have very little research there. We have on the ground experience.

And in the last qualitative project I did, I systematically asked people about this and everybody said that they would deeply appreciate opportunities to actually talk through what had happened to them inpatient, their interactions with the police, all of it. And what was really shocking to me though, is that in my last kind of qualitative study out of like 40, you know, youth and young adults, only one, possibly two depending on how you would define this, was ever subsequently asked or given an opportunity to process what they'd been through. Which I found really quite shocking. And in one case, the young person had explicitly reached out to a third party source just to get that. So even for, you know, good portion of the people going back into mental health services, no processing of what happened to them in the hospital. And that to me is really quite shocking. 

And I think there's really a lost opportunity we have to recognize, and I would say the same thing for re-entry for people who are leaving the prison system, which is just some massive, massive trauma, especially depending on how long they were there, whether they were in solitary or restrictive housing. We really need to start treating institutionalization as a major source of potential trauma and harm, maybe not a hundred percent of the time there, but a major potential source for a lot of people. And then actually responding to them as if they have been through something that could have had many negative impacts on them that they need to process and come to terms with.

And I think the whole idea of, kind of, sanctuary trauma, institutional betrayal comes into play too. What does it even mean for your whole outlook, much more broadly, like on society when ostensibly helping institutions end up being experienced as a source of real kind of harm? And I don't think it's just that that necessarily just applies to attitudes towards the mental health system. Do you start to distrust the government more? Do you start to feel politically demoralized and disengaged? And we just have essentially no research again on kind of looking at those impacts. And from an intervention standpoint or a support standpoint, what do we do? How do we help people process these experiences and end up in a place where they don't feel sort of disenfranchised more globally?

Jesse: On a Saturday morning, Cassidy was experiencing distress related to traumatic experiences from a previous inpatient hospitalization, so she called a hotline for help. That call resulted in police officers coming to her home, handcuffing her, placing her in a police car and driving her through her community to be detained for evaluation in an ER. She was evaluated, involuntarily sedated, and detained in a second facility for days. 

The system that she was forced into guaranteed that traumatic experiences connected to her distress would be repeated.

These systems are not designed around evidence or empathy, the primary throughline of these policies seems to be protecting institutions from liability. And the access points that can initiate someone’s entry into a system like this continue to expand.

Next time, on the season two finale of Committable, we talk about 988.

Aneri Pattani: 988 has a policy that they call the imminent risk policy.

Rob Wipond: Even the National Suicide Prevention Lifeline’s own researchers admit this is so unreliable it shouldn’t be used, but they use it anyway.

Yana Calou: The kinds of harm that people are experiencing aren’t necessarily on the crisis hotlines themselves, right? It’s the emergency infrastructure that we have in our country that is often times making things worse. So, it’s the agencies that people interact with afterwards whether that’s police, or EMS, or psychiatrists, or doctors. This is what we have in this country are police, jails, emergency rooms, and psych wards, right? That is the infrastructure that exists and so as a country we really just need to look at our emergency infrastructure and really get to the underlying issues of why we’re in crises to begin with.

Jesse: This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid and me, Jesse Mangan. 

All music is from the song Reasonable by Christopher G. Brown.

S2 Episode 3: Hot Potato

Jesse: Previously on Committable

Cassidy: They said that they were gonna take me to get evaluated.They eventually said that they had to hold me and this was extremely distressing to me because, um, the thing that, the thing that I had said, like cited as traumatic during the call with the counselor was an experience on a psychiatric ward.

And now I was being like sentenced that I was going to be held in a psychiatric ward again. How can you think that this helps? This isn't about care, this is about like you guys protecting yourself from liability. I said a lot like this is not care, it's not care.

Jesse: Mental health laws in the US vary from state to state, but one thing that they all have in common is allowing for some legally authorized method of involuntarily detaining someone for psychiatric evaluation. These evaluations usually involve some form of risk assessment, a tool which seems to be built into the foundation of mental health laws. But are these types of assessments effective? Are they reliable? 

Tim Wand: That's the thing, there is no evidence whatsoever to support the idea that risk assessments reduce acts of harm. 

Jesse: This is Tim wand. 

Tim Wand: My name's Tim Wand, I'm an associate professor in mental health nursing with the university of Sydney and I have a clinical role in emergency mental health as a nurse practitioner.

So I've worked for many years in mental health, the last 22 years still working, uh, in the emergency room as a nurse practitioner in mental health. And I do a lot of research around that emergency mental health, uh, interface and teaching to undergraduate nursing degree programs and postgraduate programs 

Jesse: In the context of treatment for mental health conditions, what is a risk assessment? 

Tim Wand: Well, traditionally a risk assessment is really about interviewing an individual to identify certain risk factors they might be presenting with, or posing individually. So that might be well, the classic example of course, is suicide risk. You know, that the person has some current stresses or ongoing historical stresses in their life that are leading them to thoughts of, uh, dying by suicide. And they might have explicitly stated that, or, um, made attempts to die by suicide and that they might have risk factors that influence that in a negative way. So maybe excessive alcohol or drug use, or a lack of supports, homelessness, financial difficulties.

They might also have factors that you might identify that are protective of that. So a willingness to seek help, hope that things can improve, a support network around them, religious beliefs, faith, pets. So yeah, I think when we look at risk assessments, we do look at risk factors but we, we often are hoping to weigh those up against protective factors. And collaboration I think is really important in my work, the willingness of the person to work with me collaboratively on reducing their risk.

Jesse: So, if these risk assessment tools are sort of handed down within a culture that is teaching generations of clinicians and mental health professionals. How effective are they? If they're continuing to be passed on how effective are they? 

Tim Wand: Well, they're based on no research evidence, that's the thing, there is no evidence whatsoever to support the idea that risk assessments reduce acts of harm. So they’re not evidence based tools. And you know, when you talk about legislation being framed around risk of harm itself or others, again, no evidence for that being part of a mental health law that clinicians can use to deprive people of their civil liberties. This preventative detention component of mental health law means that we can take away someone's civil liberties in advance of them harming themselves when there's no empirical evidence to support our ability to predict acts of harm, such as suicide. There’s a published study in 2017 by Carter and college in the British Journal of Psychiatry that found that 95% of people who are designated as high risk of suicide, don't go on to die by suicide. So imagine the large numbers of people who are hospitalized against their will for suicides that were never gonna happen.

Jesse: Is there anything that is demonstrated to work? Is there any evidence of a different system or a different method that does have evidence?

Tim Wand: A lot of the recommendations that have come out of the risk assessment literature showing that risk assessments are not effective. And this is, you know, from a large number of psychiatrists and other mental health clinicians who have explored risk assessments and considered alternatives.

One of the things that I'm always interested in is needs assessment. So rather than focusing on people's risks, why don't we explore their needs? And by addressing people's needs, you might reduce their risk. And there's evidence for focusing on needs having a reduction in suicidal acts of harm.

The foundation I work from is a strength based approach and there's evidence for strength based approaches in mental healthcare. And that is, as I said, not just looking at people's risks, it's more about focusing on their abilities and their strengths and their assets and their resources and supporting people to eventually gain greater self mastery over their situation.

Risk fluctuates as well Jesse, I think that's the other thing we have to take into consideration that assessing or determining someone's risk at a certain point of time is one thing, but that could change in half an hour. You know, I see in my work people coming to the emergency room who are acutely suicidal and intoxicated four hours later when they're sober and you've had a good conversation with them, they walk out much lower in their risk.

You know, two days later they could be back in a terrible fraught state again. So there's no, there's no predictability around this. 

Jesse: Within a clinical setting, there is a culture; Ideas, norms, practices passed from one generation of clinicians to the next. And when a person in distress is brought into that clinical culture, it can be far too easy for the complex influences that make up the identity of that person to go unacknowledged, or misunderstood. So I asked Tim, is there any way for the methods and tools used by clinicians to accommodate for the differences between the culture taught to the clinicians and the identity of the individual? 

Tim Wand: Well, yeah, I think we need a bit of a paradigm shift really, to one that embraces more of a recovery approach, a collaborative approach, and a therapeutic approach.

You know, I keep telling my colleagues and my students, you know, assessment is the easy bit. Having conversations with people about how to go about transforming their lives is far more important. You know, I don't think any patient has ever thanked us for an assessment they received. But a lot of the research that we've conducted in the emergency department from people who have seen a mental health nurse has emphasized the therapeutic value of being listened to and understood.

You know, it's not rocket science, but someone walking out of an emergency room having seen a mental health clinician feeling that they've been heard and validated is bound to, I think, reduce risk than just being assessed with some sort of tick box style approach. 

In fact, one of our patients in the research study that I always quoted chimed back at us, when we asked about what could have been better about their emergency room experience was that,

“I came to the ED to be assisted and all I got was assessed.’ You know, I think that's really telling, you know, people don't come to emergency to be assessed. They come for some kind of therapeutic assistance.

And I think that's the cultural change that needs to occur. We need to dispense with our over-emphasis on assessment, put more of our attention into listening to people, discussing options with them and collaborating with them on ways that we can help them move forward. So, more recovery oriented, more trauma responsive.

You know, we know that the majority of people who access mental health services have a trauma history and we need to be sensitive to that and not run the risk of re-traumatizing them by exposing them to coercive practices that might even increase their risk. 

Jesse: What is a strategy for figuring out if someone is not really in imminent danger right now, how can I send them away and have some sense of confidence or hope that they're either going to get better, or know they can come back and ask for help if they need it?

Tim Wand: Yeah. Well, I guess that's some of the anxiety that mental health clinicians and organizations have been trying to address by developing these risk assessment tools and practices. I think it's more about addressing anxiety rather than being in any way clinically useful. And I think being blunt, it's a bit of ass covering from a medical/legal sense as well. Many times over I've said goodbye to someone from the emergency room and also feeling a bit anxious for, you know, what might happen for them over the next couple of days. Cuz I'm not a mind reader, I'm not a lie detector, I'm not a fortune teller and I've just gotta rely on the person being up front and I'll be upfront with them. And I talk very openly about living and dying and, like I've mentioned earlier on, my focus is really with people on discussions around options other than suicide. 

You know, I have to accept that there may be people I see, and this happens very rarely, who do die by suicide. Not every person involved with the cardiology service survives their heart attack. Not every person involved with the oncology team survives their cancer. And unfortunately in mental health we do have people who will ultimately choose to die by suicide, even despite our best efforts.

You know, it's an uncomfortable thing to have to sit with. And I think clinicians often do these risk assessments, giving themselves a false sense of security that they've addressed a risk when there's no evidence that they have. But organizationally, there's this idea that you are addressing the organization's concerns about risk.

There's a culture of blame in mental health services that you're supposed to be able to identify with some accuracy that this person is gonna act in that way, despite no evidence that we can do that. And I think that humanity is what saves us most of the time, is making sure that we develop a human to human connection with people so they don't feel like they're being rejected or not being heard. I think there needs to be options given to people so they can make informed decisions.

Jesse: Mental health laws leverage a great deal of coercion to funnel people in distress from their communities and into a facility where they can be assessed.

That assessment is, in many ways, the safeguard designed into these systems to make sure that whatever coercion is being used is appropriate. But if there is no evidence that risk assessments are effective, then why do policy makers continue to design these systems around them? 

Morgan Shields: So I'll answer that question and then I'll also respond to where I think it's coming from. 

Jesse: This is Morgan shields. 

Morgan Shields: My name is Morgan Shields and I have a PhD in Social Policy from Brandeis University and I have a Master's in Public Health from Harvard University. I'm currently an NIMH T32 postdoctoral fellow at the University of Pennsylvania, and my research program has really been focused on understanding how quality of care is both defined and how it varies across different types of inpatient psychiatric facilities and across different patient groups. And then also figuring out what we can do to improve quality systematically and to hold provider organizations accountable. 

Jesse: So if there isn't good evidence to suggest that these tools, and they vary but that in general, these tools are not very reliable. What is the value of designing systems around these tools? 

Morgan Shields: I don't know what the value is, I guess it depends on who you're asking. Because the thing is, organizations, and I'm talking about outpatient community providers, as well as schools and law enforcement. They're interested in discharging risk. They use these tools not just to figure out how can we best serve this individual, but it's also how can we best protect ourselves from risk and liability? What can we do to make a decision to basically transfer this risk to a different entity, which might be the emergency department, and then let them make a decision.Right? But then the emergency department's not very well equipped to be able to make that decision. And there are a lot of issues there. So it really depends, you know, what is the outcome that you're looking for? And what's the utility of it? Because these risk assessment tools, you know, sometimes they're used to protect an organization like that's the outcome. It's not necessarily only just to serve the patient and the patient's best interest, right? 

With that caveat, I don't know what the benefit is in designing systems around it. I will say though, and this is my inference of where the question is coming from, our system isn't designed around these risk assessment tools. Our system isn't evidence-based. Inpatient psychiatric care doesn't exist because it's this evidence-based service. And commitment laws were not designed because they make sense. These are all policies that have just evolved over time as revisions to our society’s attempts to manage social issues, either the best that we could or within the existing, you know, power paradigms at the time.

And so it's just these tweaks to an underlying system that is not necessarily the best foundation to begin with. I view inpatient psychiatric care in general as just this like hub, whereas I mentioned of discharging risk, It's like we don't know what to do, it makes us uncomfortable, we're not equipped.

Community providers don't necessarily have the skills to manage suicidality. And also they don't necessarily have the resources, the flexibility, like there's all of these reasons why. So we’re just gonna move it to the next stage and let them figure it out. But there is no evidence that it's actually helpful to the individual patient. And it was never built based off of any sort of evidence. 

Jesse: Voluntary or involuntary? Civil commitment or psychiatric hold?

The law defines each of these statuses differently but for me, when I was inpatient, these were questions that I didn't even know I could ask. And yet a lot of power was being given to whoever controlled the answers.

So I asked Morgan if she has a sense of whether or not people who go through these different types of interactions, experience them as distinct. 

Morgan Shields: That's a great question, it's a great question for folks who've experienced this. What I have found in my research where I've surveyed and interviewed patients is no, it's all very messy. And it's one reason why in my surveys I don't ask,” were you involuntarily admitted?”, because they often don't know what their legal status was. Which is really, really frightening that someone can be hospitalized on an involuntary basis and not even know it. Or voluntary but think that they have no freedom or rights.

And the reality is that they might not, because it's not like you can just easily say I'm a voluntary patient and I wanna leave now because there's a whole process, right? And as I mentioned, they might come back and say “Fine. You can fill out this paperwork to be discharged.” But then the doctor's gonna evaluate you.He might decide that he wants to commit you, you know, and do you really wanna take that risk? Why don't you just stay for a few more days? So even still, you know, you can't just easily walk out of the door. So, yeah, my very brief response to your question is from what I have found, patients do not make these distinctions.

And I'll just say, it's really tough when you're trying to understand the effects of these different mechanisms, right? Like the effect of what happens in the ED, or the effect of the use of coercion by police versus the ED. And then what happens in the inpatient facility. Folks are experiencing this all as one big intervention. And so the way that the ED staff treats them at hospital A, which might be terrible, then hospital B where they actually get their inpatient treatment is actually not that bad and may be really good. But if they're then asked to evaluate their hospital care, they might be evaluating the entire experience together.

So it just makes it, yeah, it's just a very messy thing to study and to assign responsibility. Ultimately it's messy to study, to talk about, and then what are the policy implications? Who is responsible at the end of the day? How do you hold these different entities accountable? Who is holding the ball at the end for patient outcomes? Right? Because of that it also is easy for all of these different entities to, in the same way that they can easily pass the patient around, like hot potato. They can pass responsibility around like, well, that's not us. That's the responsibility of the outpatient provider. For example, if the patient dies by suicide when they're discharged, that's not our responsibility, right? Like you can just keep passing the hot potato around. 

Jesse: Do you have a sense of whether or not clinicians view patients differently on these different statuses? Would they view a voluntary patient differently than an involuntary patient?

Morgan Shields: I can't say that we have excellent data on that. There has been some research and there is some evidence that potentially there is bias and, to circle it back to the risk assessment. You know, there are not just risk assessments for the individual patients, but something that's happening also behind the scenes is that the receiving psychiatric hospital is trying to determine whether or not they want a certain type of patient, right? And so they might use heuristics to do their own assessment. And we can swap out the word risk for just like, the desirability of a certain patient. And some of it could be justified, and some of it not. Like the justified reasons could be well, if this is a patient that's really experiencing acute psychosis, maybe we're a unit that specializes in depression and anxiety. And maybe we're not the most appropriate unit, we don't have the clinical skills. But that often is sort of used as a cover for various other reasons for not wanting a patient as well. Maybe there's fears that the patient who has acute psychosis will be more difficult to manage. If they're experiencing homelessness, they'll be difficult to place. Which, there's financial implications for that if you can't easily place them and if there's regulations that you can't discharge them to the street, and then insurance cuts off. Then that can be like a cost to the facility. And then that brings me to the next, you know, sort of characteristic, which is facilities might select patients based off of who their payer is, Medicaid and whatnot. 

And so voluntary status, how an individual arrives to the facility, whether or not they arrive by police. These all are characteristics that could be used in these heuristic decisions by the receiving facility as to whether or not they want to accept a patient.

So there isn't good data on this at the individual level. Like, how do these different classifications impact the interpersonal relationships between the providers and the patients, but also where people get sent. So I did one study and to my knowledge, this is the only study that's been done looking at who are the people who go to “Low safety” psychiatric facilities. And I did this in Massachusetts. So facilities with high rates of complaints, high rates of restraint and seclusion. And in the data, I don't have any information on voluntary status, but what I find is that the people who are going to the low safety facilities, it's not because they live closest to the low safety facilities. It's actually not even just because they have public insurance that plays a role, but if they are experiencing homelessness, If they have a diagnosis of schizophrenia, racial and ethnic minorities across the board are more likely to be sort of channeled towards these low safety facilities. So just to bring up this, I know that your question was more at the interpersonal level, but structurally these interpersonal biases, like in the ED, they play a role in how people are being triaged and the sort of, like, other form of risk assessment that the receiving facilities are doing in deciding who they wanna give beds to or not. 

Jesse: I have always thought of risk assessments from the perspective of a patient. My focus, my fear, was always about which of my rights might be taken away. But to an institution, all of these different elements may simply be data points.

Voluntary may be viewed as easier to manage than involuntary. An anxiety disorder may be viewed as less of a liability than schizophrenia. A person with identifiable resources may be seen as less of a financial risk than a person perceived to be homeless. I hadn't previously considered that the primary function of a risk assessment may not be to protect the individual, but to protect the institution.

But Morgan had mentioned research identifying low safety facilities and high safety facilities. So I asked, if people are being involuntarily detained in these facilities based on the determination of unreliable methods of assessment then, at the very least, are these facilities safe? 

Morgan Shields: That study I did, when looking at low safety facilities, it's really just, I had two groups and I called them low safety versus high safety. But in actuality, there was no evidence to suggest that the “high safety” facilities were even high safety. It's just that they didn't have as many indicators of egregious safety events. So these complaints that I used as a proxy were things like sexual abuse, physical abuse, death, and then the rates of restraint, seclusion. That's pretty extreme, that's a really low floor. So, we would hope that a safe psychiatric facility would be physically safe, not just safe from sexual abuse, right? But safe from misdiagnosis, right? Or being given the wrong medication and having a variety of different adverse clinical events that would not necessarily be captured in those types of levels of complaints. And psychologically safe. 

These are people experiencing psychological distress. You know, it is frustrating to me to even have to make this point, but I find that I do. Which is of all of the places in a hospital you would hope that the psychiatric unit, or a psychiatric facility, would be the most mindful of psychological safety, of trauma, of interpersonal relationships. That of all of the places this would be a place where they really understand and know how to implement patient centered practices, trauma informed care. And I have found that is really not the case.

Patients consistently report terrible interpersonal experiences. Of course, with this variation, as I mentioned, some places it's not that bad. But the stories that I hear from patients are really terrible. Like not being able to see a doctor for more than five minutes throughout an entire one week stay, for example. Being sexually assaulted by a staff member and then the way that the unit deals with it is to just to send the patient to a different unit. Rat infestations. I mean, the stories I hear can be very dehumanizing. And as I mentioned that there's not strong evidence for the benefits of inpatient psychiatry. The only thing that actually does exist is evidence for harm.

So, when we're talking about these risk benefit analysis, and as you mentioned, like the risk assessment and trying to understand the net benefits to patients. There's not evidence of benefits and there is evidence for harm. So just looking at these being documented in medical charts, it's something like 20% of patients have some sort of adverse event. And these exclude experiences of restraint, seclusion.

The everyday dehumanization of the interpersonal exchanges, the erosion of trust, all of that isn't necessarily captured either. And we know that the risk for suicide is astronomical following discharge from inpatient psychiatry. So the biggest predictor of suicide is recent discharge from inpatient psychiatry.

And, you know, you might suspect that some of that is just because these are folks who are already at baseline more likely to be suicidal. But we do find increased risk for suicidality, even among those who are not actually hospitalized for suicidality. And so there's reason to make us as sort of a society really suspicious to the benefits of this service and worried. You know, quite frankly, I think there needs to be way more scrutiny and critical thinking around the use of this as a method for treatment in improving people's lives. Cuz for some people it could be helpful, but for a lot of people it's actually left them with PTSD. Psychological treatment should not give you PTSD. And also can lead to, I have found in my research folks, then not wanting to reach out for help. So it could have these really long term cascading effects on folks. 

Jesse: Cassidy was detained in an ER for 37 hours and at some point during that time, someone did a risk assessment. That is all the law required to justify that detention, and to justify transporting her to a second facility for further detention and evaluation.

But neither the assessment, or a forced inpatient stay, offer reliable benefits to the patient. The only part of being forced inpatient that does seem reliable is the potential for harm. So why is this form of detention legal? Why aren't policy makers looking more closely at the potential for harm?

Next time on Committable.

Molly Linhorst: You have a lot of these characteristics of civil commitment that look like criminal commitment, right? That look like criminal detention, but you don't have the same sort of protections. And don't think a lot of people realize the immense power of the state to take away your Liberty in what is a civil process.

Nev Jones: We really need to start treating institutionalization as a major source of potential trauma and harm. What does it even mean for your whole outlook on society? When ostensibly helping institutions end up being experienced as a source of harm?

Jesse: This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid, and me, Jesse Mangan. 

All music is from the song Reasonable by Christopher G. Brown.

S2 Episode 2: Precisely No

[00:00:00] Jesse Mangan: Previously on Committable...

[00:00:03] Cassidy Wilson: On Saturday morning, I woke up and I was still feeling really distressed. So I called student counseling services. It was a long call, but at some point in the call, I heard this banging on the door and it was the campus police. And then another officer came and told me, like, stand up and turn around. And they handcuffed me and took me down to a police car. And I think they said that they were gonna take me to get evaluated.

[00:00:44] Jesse Mangan: When Cassidy made that call to Student Counseling Services, a process was triggered, a process that led to police officers showing up at her home, handcuffing her, and transporting her to an ER for evaluation. This was all in response to a person who was experiencing distress, asking for help. So where did this practice come from?

[00:01:06] Have police always been connected to crisis hotlines? To better understand the history of these sorts of hotlines, I spoke to Hannah Zeavin. 

[00:01:15] Hannah Zeavin: Hi, I'm Hannah Zeavin. I teach at UC Berkeley in the Department of History and I'm the author of The Distance Cure: A History of Teletherapy. 

[00:01:23] Jesse Mangan: When was the first suicide hotline created?

[00:01:26] Hannah Zeavin: So this is an interesting question, and I'm gonna answer it two ways: incorrectly, but mythologized and then correctly. So the first suicide hotline was understood to be for quite some time in the historiography, a suicide hotline pioneered by the Los Angeles Suicide Prevention Center. Now, that center is very famous because it really pioneered the field of suicidology at mid-century.

[00:01:55] You know, they became especially famous when they diagnosed after death... Marilyn Monroe, with likely having died by suicide. And this was the kind of grand debut of a new theory of thinking suicidality in the US context, really after much stagnation in that area after Durkheim say, you know, who famously gives a, a theory of dying by suicide. Who is most likely to, why, when et cetera. And that center was set up by a triad of two psychologists and one psychiatrist. It was highly medicalized and had a lot of funding.

[00:02:32] And so it, it galvanized sort of the nation as having made the first ever suicide hotline, except this wasn't the case. The first suicide hotline was not started by two psychologists and one psychiatrist. It was started much earlier in London in the early 1950s. The first suicide hotline was started by Chad Varah and Viviana Prosser in the UK in London.

[00:03:01] And as I write about in my book, Varah had been attuned to suicidality in his work as a vicar since the very beginning of his life in the church. The first act he ever did as a man of the cloth, so to speak, was to preside over the funeral of a 13 year old girl who had died by suicide. She had taken her own life thinking that she'd contracted what we would now call an STI.

[00:03:27] But in fact, she had begun to menstruate. 13 years old. And this heartbreaking story stuck with Varah. He wondered what he could have done if his first act had actually been to be a pastoral counselor rather than to preside over a funeral. And what it would've taken, he assumed, was something like the destigmatization, right?

[00:03:47] That's already, we can hear opera around sexuality and after World War II Varah had the opportunity to think about this further because unfortunately, suicide rates in the greater London area were skyrocketing. He wanted to figure out a way to have his parishioners again... right… this is in the church context... have a different form of care because every time he counseled his depressed or suicidally ideating parishioners to go seek help of a psychiatrist, they never did. 0% of any of his parishioners went to the psychiatrist.

[00:04:26] So he began to think about how people were being helped at mid-century in the UK context. They were being helped ostensibly by psychiatrists, but no one seemed to want that form of care. And additionally, they would call on the phone. But the options were the police and the fire department. And Varah's point was, well, suicide was a felony as was quote unquote, attempted suicide.

[00:04:51] We don't use that term anymore, but that was the term of then. Suicide was a felony as was attempted suicide. So calling the police was gonna be a no go. So no one wanted to talk to psychiatrists. No one wanted to call the cops. Well, there needed to be a third thing and that's what he made. So he started a new church in a former bombed out rectory of St. Stevens Walbrook in London that hadn't yet been rebuilt fully after the blitz, after the war. So there was no congregation. He started a brand new church, just made out of essentially telephone wire with Viviana Prosser who helped him triage calls. And he became a full-time counselor, pure counselor in the sense that he wasn't being paid.

[00:05:34] He never met the people who are calling in and the service was immediately greatly desired and needed and successful. So he quickly had to train many more counselors, but instead of training fellow clergy, that bit came later he trained peers. And they became known as the Samaritans and were just there to provide a kind of simple consoling non-judgmental interaction called befriending.

[00:06:01] And that is still the world's most greatly used suicide hotline today. And it exists in many, many, many countries around the world. And that was the first one, not this Los Angeles Suicide Prevention Center. 

[00:06:14] Jesse Mangan: Is there a, a direct connection there between the end of World War II, a rise in suicidal ideation and I guess a need in the community? Is there some connection between all of those factors? 

[00:06:28] Hannah Zeavin: Yeah, I mean, so we could sit here and talk about that for hours, right? The Durkheimian idea would be something to do with big social upheaval will bring an increase in suicidal ideation and, and in ways that's been borne out. But also it's not just that it was post-war, right...

[00:06:44] What happened next is also really interesting. And part of why the Los Angeles Suicide Prevention Center is misremembered in the US context as being the first suicide hotline, which is that, of course, the reason you wouldn't wanna go see a psychiatrist to talk about shame at mid-century had to do with psychiatry's increasingly heteronormative stances at midcentury. 

[00:07:09] So if Freud in fact was quite anti-normative. Everyone is bisexual according to Freud. In the US and the UK, there was a conservatizing impulse, especially in the US, amongst psychiatrists who at this period include psychoanalysts, right... So psychoanalysts are in this moment, almost exclusively psychiatrist.

[00:07:29] And the Diagnostic Statistic Manual, the DSM had just been published in this period and it included, you know, a horrific quote unquote personality disorder called homosexuality. So in the US also in the 1950s, there was a, a for suicide hotline. Again, not the Los Angeles Suicide Prevention Center helmed by Bernard Mayes. And Bernard Mayes by his own self appelation was a closeted queer priest. He was British and had known of Varah's work in the UK context, had emigrated first to New York and then to California and he hated it here. I'm calling from the Bay Area. He hated it here because he thought it was actually rather conservative and was surprised that it was so, but also because he saw San Francisco as almost celebrating in a kind of ironic and mocking way, the fact that it had the highest suicide rate of anywhere in the world outside of West Berlin, which was completely isolated from the rest of Western Germany at the time. And he thought to himself that this also was attributable to the increased violence against the queer community in this period. It was the era of the lavender raids. And Mayes signified on, in a way Varah's system in the UK, he kept the telephone, he kept the peers, but he abandoned any idea of the psychiatrist.

[00:08:57] There was no idea that you should call a psychiatrist. In fact, it was quite the opposite and so much like, you know, Varah's hotline was not psychiatric and it was not carceral Mayes made that a kind of central convening notion of his hotline because of course non-consensual hospitalization for the queer community in that moment could have resulted in everything up to lobotomy.

[00:09:23] That was a quote unquote cure in that moment. This was life or death. So that hotline attracted some attention a little bit skeptical in the late 1950s, but was also immediately successful. So successful that it caught the attention of the Los Angeles Suicide Prevention Center. They moved to shut the hotline down because not only was it using the telephone around the clock, but it was making use of peers, not experts. And they thought that this was a double mistake. And eventually they couldn't shut the hotline down. And so they copied it. And this is why in the historiography of suicide hotlines, such as it exists, this is often a misremembering that the very hotline that tried to restrict and control the more radical expressions of community based peer to peer care ends up being given the sort of crowning name of first suicide hotline in the US. 

[00:10:22] Jesse Mangan: While discussing the history of suicide hotlines, hannah mentioned the falsity of saving a life at any cost. So I asked Hannah if there was a specific moment where the idea of saving a life at any cost became part of the hotline. 

[00:10:37] Hannah Zeavin: The idea that we have to save lives no matter what is present from the very earliest moments on the hotline, especially once you get experts involved, because then there's a whole new kind of ethical and legalistic sets of code that are overrunning a hotline like Mayes', which was interested only in what we might call prevention, but not intervention. And that's a very signal difference. That really is part of how one can think of contemporary hotlines as well is a hotline going to, no matter what, intervene? Or is the hotline seated at a place where it waits for the caller to come to them and then sticks with the caller, no matter the outcome. And so these are, you know, still ongoing massive debates. Although the intervention side has largely won, which, you know, colleagues and I are very saddened by because it often is this kind of false idea that well, you know, and it's very hard to speak back to the kind of straw person argument of, you know, something like horrific, like, well, you must just not care or want people to die. Precisely no. But that studies and studies and studies have shown that both forced hospitalization and police intervention actually increased suicidality, not just for individuals, but in communities.

[00:11:59] Which, you know, makes all the sense in the world if you sit and think about the history of policing and the history of psychiatry in the United States specifically, and, and who is most targeted by the agents of, of the state, the police and hospitals and so on. So even if there's this argument that well, you should do everything to save a person, those very means of saving a person, A) might save them today, but B) will in the long term actually harm them quite significantly. And my colleague Yana Calou, who's the Director of Advocacy at Trans Lifeline, and I have been working on this because it's actually become ever more pressing because these sort of tools and techniques of the hotline are becoming unified and will be unified this summer when the government and the FCC roll out a new number for all national hotlines 988, which is to make it like 911, but with a difference, however, as I've just sort of run through, the difference isn't going to actually be there if the hotline is a feeder to both psychiatric and carceral intervention. 

[00:13:07] Jesse Mangan: Imagine a moment where the thoughts swirling in your head seem inescapable, where the world around you feels like it's falling apart. You feel irreparably vulnerable. And you don't know what to do, but you remember a flyer or you remember a slogan. You remember that there is a hotline. So with the last vestiges of will that you have left, you make that call, you ask for help. And in that moment, who is it that you're hoping responds?

[00:13:39] Police involvement in these types of situations is often encouraged or even mandated as a matter of policy, but why do we involve police in this type of distress and what impact do those policy choices have on the people asking for help? 

[00:13:53] Jamie Livingston: I think it's really weird and unacceptable that police are involved in the first place.

[00:13:58] Jesse Mangan: This is Jamie Livingston. 

[00:14:00] Jamie Livingston: I'm Jamie Livingston. I'm a criminologist in Halifax, Nova Scotia, Canada. And the work that I do is at the intersection of the mental health, substance use, and criminal justice systems with a particular interest in understanding people's experiences at that intersection in relation to stigma.

[00:14:19] Jesse Mangan: So when we're talking about stigma and it's this identifying characteristics and sort of grouping people by perceived characteristics, one of the the bigger talking points around mental illness is the interaction between people living with mental illness and, and law enforcement. What role does stigma play in those interactions between law enforcement and people living with mental illness?

[00:14:40] Jamie Livingston: It plays a major role, especially when you view it as a structural stigma. So I think that if you look at history, but also the current context, there's been a tremendous amount of policies and social processes that have channeled people with mental health issues into the criminal justice [00:15:00] context. And those policies and practices are often rooted in stigma.

[00:15:04] So... stigma by defining people with mental health issues as being dangerous and risky, as being manipulative and untrustworthy, as people who are unable or incapable of making decisions for themselves and all of that kind of musters the state to use these coercive tools in order to impinge on the rights and liberties of people with mental health issues.

[00:15:29] So I think it's from that fundamental basis of defining people in particular ways and viewing people in particular ways that allows the state to intervene in people's lives in ways that they wouldn't for other sort of health conditions and other types of contexts. But beyond that, it's also kind of the deficiencies that have been built into our social institutions, including our healthcare system that create acceptable ways of discriminating against people with mental health issues in education and housing and healthcare, in all sorts of different realms. And that discrimination leads to the neglect of people with mental health issues. It escalates their chances of experiencing crisis and then increases their risk for their liberties to be impinged upon by the state.

[00:16:20] So the neglect of our healthcare system and by our governments to meet the needs of people with mental health issues places people in situations in which they're more likely to experience crisis, more likely to have their rights being jeopardized, and more likely to be put into contact with someone like the police. 

[00:16:40] Jesse Mangan: When a mental illness is diagnosed, it's diagnosed based on the perception of symptoms believed to be present. And throughout the US, every state has a law that gives individuals within law enforcement the legal authority to detain someone based solely on the concern that a mental illness might be present and that possible mental illness might lead to a dangerous situation. So I asked Jamie, what sort of training are police receiving to effectively interpret perceived symptoms? 

[00:17:12] Jamie Livingston: That's a great question. And it's all over the map. So there's no general kind of statement that could be made about how well prepared police are to interact with people who are in mental health crisis.

[00:17:25] I did a study like a decade ago that was on the heel of a really tragic event in Vancouver, British Columbia, where a man was shot fatally shot by police. He was clearly in mental distress at the time that he was shot. He was on his hands and knees and not capable of threatening at anyone. And that led to a lot of questions involving people in mental distress.

[00:17:52] At the time 10, you know, 10 years ago, we designed a study based on some research that had been done in Chicago around understanding the perceptions and experiences with people with mental health issues in relation to their interactions with police and, you know, people who came up with really great sort of recommendations for improving police training. And it's now 10 years later and we're still asking the same questions and the gaps that we identified 10 years ago have not been addressed. And so I've almost given up on the question of police training. And I'm more interested in doing something completely different than improving police training, because I think that the police have demonstrated that they're, they're not taking seriously these, these issues of better preparing their police officers to handle these interactions.

[00:18:44] And we're repeatedly seeing people with mental health issues being placed at risk and dying during these interactions, particularly if people are poor, are homeless, are racialized, so black or indigenous, those sort of things increase their risk of dying during these interactions. So, you know, over the past few years, certainly after the Black Lives Matter protests and after the George Floyd death, I've been more seriously contemplating how to remove police from these interactions rather than improving these interactions, redesigning systems so that police are taking out of the equation to the extent that it's possible. 

[00:19:24] Jesse Mangan: What are some examples of alternatives that might remove police from responding to someone in distress?

[00:19:31] Jamie Livingston: There's lots of examples. I think it's really weird and unacceptable that police are involved in the first place. So you have something that's clearly a health event, like a mental health crisis. And police are in many jurisdictions are the default response to these events. So someone calls 911, because they're concerned about, you know, a loved one or a neighbor or someone in their neighborhood that is displaying concerning behavior, not always threatening, you know, and not always violent, but regardless of what the circumstances, in many communities, including my own community that I live in, in Halifax, the police are the default response to these circumstances, which I think is a form of structural stigma.

[00:20:18] So baking law enforcement or police into the mental health system in this way, I think is a form of structural stigma in that it's clearly designed in ways that leverage this idea that people are dangerous, risky, and, and facilitates their criminalization. And I think that it's a sign of health systems not taking care of their clientele or the, the people that they should be taking care of, including people who are in mental distress that need a mobile response to come to them. There's now plenty of examples of communities that have redesigned their mobile crisis response systems, such that the police are removed from the equation as much as possible.

[00:21:06] And the most kind of renowned example is in Eugene, Oregon, and a program called Cahoots that have been doing this for, you know, over two decades in which they came to the kind of solution that police should not be the default response. It should be clinicians that are the default response to people who have a mental health related crisis. And so for many of the calls crisis calls, they would dispatch like a, a paramedic with a nurse to attend to these calls and more and more communities are jumping on board and recognizing that that makes the most sense to achieve a whole bunch of goals like a goal of not shooting and killing people during mental health crisis.

[00:21:56] That's an important goal, but also, you know, other sort of social goals of how to, you know, support anti-racist efforts, such that people from communities that are harmed by the police feel more comfortable for calling for help if someone's in, in distress. In Canada here, but also in the US, but strongly in Canada, you know, social movements built around anticolonial types of efforts... so how do support indigenous communities who've had historically and ongoing really terrible relationships with the police, how to support those communities to take care of the mental health needs, particularly when their community members are in, in crisis. So decoupling police, which for many communities have had really violent and harmful histories, decoupling police from a health response.

[00:22:52] So there's more and more models that have been developed and have been established, many of them in kind of a precarious pilot basis, but you see more evidence and more models being mobilized to provide alternatives to the police to people who are experiencing mental health crises. 

[00:23:09] Jesse Mangan: On a Saturday morning, Cassidy called Student Counseling Services for help. That call led to her being handcuffed, transported to an ER, and detained for evaluation. That evaluation, that risk assessment, seems to be the goal, seems to be the tool that policy makers depend on to safeguard a person in distress and a significant amount of coercion and manipulation goes into getting that assessment to happen.

[00:23:33] So, how effective is it? How reliable is this type of risk assessment? Next time on Committable..., 

[00:23:42] Tim Wand: There's a culture of blame around mental health services. You're supposed to be able to identify with some accuracy that this person is gonna act in that way despite no evidence that we can do that.

[00:23:53] Morgan Shields: Of all of the places in a hospital, you would hope that the psychiatric units would be the most mindful of psychological safety, of trauma, of interpersonal relationships. And I have found that that is really not the case. For some people, it could be helpful, but for a lot of people it's, it's actually left them with PTSD. Psychological treatment should not give you PTSD.

[00:24:27] Jesse Mangan: This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid, and me Jesse Mangan. All music is from the song Reasonable by Christopher G. Brown.

S2 Episode 1: Transcript

Jesse: This is season two of Committable, a podcast about involuntary commitments. I'm Jesse Mangan. Producing this podcast involves a lot of reading, reading research, commitment laws, policy proposals, medical journals. Often this material can be challenging to engage with but a few months ago I came across an article that instantly drew me in.

It was titled At the Forefront of Medicine: My Summer Involuntary Hospitalization by Cassidy Wilson. I immediately reached out to Cassidy to ask for an interview. 

Cassidy: Sorry, could I like, try that again? 

Jesse: This is Cassidy Wilson. 

Cassidy: Hi, my name is Cassidy and I'm a student, um, an undergraduate at the University of Chicago and I study neuroscience and Human Rights.

Jesse: Cassidy's article was about an experience that started with a phone call, a call that seemed to spiral out of control into an involuntary process that lasted several days. So I started by asking about the day of that call, what was going on that day? And what happened?

Cassidy: What had happened is, um, on a Friday, so I had like a research internship over the summer and so several like factors and like, uh, aspects of that had caused me to be having like, Flashbacks. I had a previous, um, experience, psychiatric trauma, um, having to do with a psychiatric ward. Um, and I was having flashbacks related to this experience.

So, on Saturday morning I woke up and I was still feeling really distressed. So I called student counseling services. It was a Saturday, um, so I had speak to like the counselor on call and I essentially said that I was feeling like really distraught. I described how I was having like flashbacks to a previous like traumatic experience.

And it was a long call, but at some point in the call, I heard this banging on the door. Um, and I was worried they were gonna like break down the door to my apartment. I didn't know like what was happening, so I went and answered it. Um, and it was, uh, the campus police, the UCPD. Um, and there were several officers. 

And I like, so I just like woken up when I like called. I wasn't like fully dressed. Like I, I was wearing essentially like just this like shirt that I sleep in. Um, and I was very emotionally distressed to begin with, like I had been emotionally stressed that had prompted the call and I had remained like, distressed throughout the call.

If anything, I felt like the counselor was like escalating me with the questions that they were asking. So I like was, I didn't like feel any better. I'd been like crying throughout like the whole time, I was still crying. Um, and so these like UCPD officers came in. Um, and one like told me to like, sit down. I had this like folding chair that they had me like sit down and I was like talking to them. And I was distraught to begin with, and then obviously this is a very distressing experience to have like a bunch of police officers come into your home when you're not expecting it when you're not dressed, and when you're distraught to begin with. 

Um, but I was sitting, I was talking to one of them. He was talking to me about just like, about the university about, he was telling me about like what he had studied. And then another officer came, um, and told me like stand up and turn around and they handcuffed me. And took me down to a police car.

The handcuffs were really tight, like I remember it really hurting my wrist and my hands. They said, they would like put me in the car with like the female officer but I felt like the gender of the driver of the car is like the point where the gender of the officer matters the least compared to like when I'm actually being like physically handled.

And they drove me to the ER, I remember being really scared that like, that someone would see me cuz we had to like drive past like my campus. So I remember thinking about that, but I got taken to the ER, they gave me like a hospital gown and I had to turn over the very little clothing that I did have.

Jesse: When you were handcuffed, was there any dialogue about why this is happening or what's about to happen? 

Cassidy: Well, they didn't ask me to come with them before, like, handcuffing me. They like, they didn't ask me to do anything for me to cooperate or not cooperate with. I had done everything that they had told me to do.

I had sat down when they had told me to. That was literally like the only thing that they asked me to do. Um, so it wasn't like I wasn't cooperating cause there was nothing to be cooperating with. Um, and I think they said that they were gonna take me to get evaluated. Um, it's hard to remember, like when I was told what by who.

Jesse: Um, so, you're transported by police to the ER, where you're given a hospital gown. What happens then? 

Cassidy: So I'm on this hospital bed for like a long time. Everyone that like comes in, I like ask them as much as possible, like what's going on. Um, they take like my phone, I didn't know what was happening. So I got visited by like a medical doctor, I got like blood drawn, I got like an EEG taken, this is all like very unpleasant for me.

So I have some like sensory processing issues. It was a very loud environment. Um, I feel very uncomfortable when I like can't have my own clothes. I'm also a sexual assault survivor and I don't like to be touched. Um, I don't like to be touched by people I don't know and given like, this had already happened a lot this day by the police. But also too by various like doctors, or people coming in to take like blood, or take EEGs, or any of that. 

And I ended up being in the ER for about like 37 hours. Um, and it's mostly like, sitting there. I talked to like some medical students and I tried to tell them as much as possible. And I also tried to tell 'em that, like, I feel like I was doing all the right things.

Like I have a psychiatrist, I have like a counselor,  I can create like a safety plan, which is like, what they talk about, like creating. Like, I have all of this stuff in place already. I told them all of this, but it didn't matter. 

They eventually said that they had to hold me. And this was extremely distressing to me because, um, the thing that I had cited as traumatic during the call with the counselor was an experience on a psychiatric ward. And now I was being like sentenced that I was going to be held in a psychiatric ward again. So like the exact like environment that I had said was traumatic and that I didn't wanna be in.

So I told them like, this is like the worst possible thing that you can do for me. If I think about like, what is good for like my mental health. It's when I'm engaging with stuff that I feel like is meaningful and engaging with people and like my friends and being like with my support network. And the thing that is the worst for me is if you deprive me of everything in my life that is good. And put me in an environment that is actively bad, where I just have to be alone with nothing to do with my thoughts all day and marinate in whatever had put me in crisis in the first place like that doesn't make any sense. How would that help anyone?

But they said that they were going to do that so then at that point there's like, nothing I can do. They said that they were waiting for like a bed at a specific facility. Cuz it had the same like team, the same like team that was like talking to me in the ER would be on this ward apparently. 

So this was like near the end of the day on Saturday where they, I think they said that they would like be holding me. And I ended up continuing to be held in the ER through all day on Sunday until about, I guess like 1:00 AM on what was now Monday. And I got transferred to a different room on a different floor in the UChicago hospital.

It was really surreal and ironic later on because after all this happened and I had like gotten discharged, I was still, um, a research intern in a lab and I had to walk through one of the same sections of the hospital that I had been brought through while I was detained. Which was upsetting. And also just like a very like, surreal feeling of thinking about being like I was here, that was me, except now I have clothes, now I can freely enter and exit this building. Now I'm allowed to have water. Oh, that's the thing I forgot. Um, when I was in the ER, I was sedated because I was, um, monopolizing the staff's time. I said monopolizing the staff's time because that's what one of the staff members said to me when I was asking questions and I was asking things like, can I have water? What's going on? Because I wasn't being given these things, like at large.

But someone was like, you can't keep like monopolizing the staff's time like this. So I was, um, I was given sedatives. They said, will you take sedatives orally? Or are we going to have to inject you? And I said I would take them orally.

So I was finally given water, in order to take the sedatives. Um, and then as a result of the sedatives, I was sedated. So I like slept for a long time. 

Jesse: So at this point you did not want to go to the ER, but you're brought to the ER and you're asking questions about, can I use my phone? How long am I going to be here? Can I have water? And it seems like because of those questions the staff determined that you needed to be sedated? 

Cassidy: I'm not entirely sure because I got sedated shortly after I got told that I was going to be held. And after I was told that I was going to be held, I was lying on the floor because the tile was cold, and I like found that soothing. And like the gurney was not comfortable. And I also, like, I really like lying on the floor just in general, in my life. I'm very comfortable on the floor. So I was lying on the floor and they were like, you can't be acting like this. So I got up, like they told me to and was like sitting there.

And I would try to like talk to anyone who would talk to me because it's very scary, like being there. And it's like, one way that like helps is if you have more information about what's going on. Um, so I would like ask anyone, like anything that they could like tell me. And then someone was like, you can't keep monopolizing the staff's time like this.

Um, so I think it was a combination of how they perceived me to be, and that I was also like asking too many questions. I don't understand the logic behind why they did it. And I also, because I do like read a lot on the system, I was very like frustrated by it. Cuz I'm like this isn't about care. This is about like, you guys protecting yourself from liability. I said a lot, like this is not care. It's not care. 

Jesse: So you’re evaluated, you're told you're going to be held, you're sedated. Because you're sedated it's hard to figure out exactly the timeline, but at the end of things you're there for about 37 hours before they actually take you to a facility.

Cassidy: No, I wasn't taken to a facility then, I was taken to a different room within the UChicago hospital around 1:00 AM on what's now Monday. And I'm in that separate room, so no longer in the ER. So it was like a much better environment for me. Like, it was nice that I had a window, um, which was very nice, cuz I didn't have that in the ER, which is why, like, it was very hard to have a sense of time.

We determined 37 hours cause I was able to figure out like what time I was like moved and based off of like my mom’s phone records. So that's how we like figured out that it was like 37 hours in the ER. Um, then I was in this other room in the UChicago hospital until late in the afternoon, early evening on Monday.And then I was transferred by ambulance to another facility. That was the actual like psych ward. 

I was also like, so like when I was in the ER, they were talking about like that they'll like move me upstairs, which I was really looking forward cuz I was hoping to be like less loud. And it was also like, um, In the ER, there was like a bathroom sort of, but I wasn't allowed to like close the door and there wasn't any like toilet paper or anything.

So then when I got moved to this other room in the UChicago hospital it was much nicer. It was like more private. I was allowed to shower then, which that was probably one of the lowest points is because, um, I wasn't allowed to like, hold the soap bottle myself. Like the nurse's aid had to like, hold it for me and like pump the soap.

And when I asked why, she said that, like, when you're here for what you're here for they can't take any risks. And I asked her, what am I here for? And it turned out she didn't actually know. It was just by the fact that I was there that she assumed that there was a reason for it. It was very like, it was very teleological. It was very rhetorical. Just by the fact that I was present there, that I must be a danger. Like she didn't actually know why it was just my presence there that gave her whatever information, whatever surety, to know that I couldn't, um, hold a soap bottle myself. 

So I had to shower with her staring at me the whole time, um, and like intermittently reaching out for soap. And that was a really low point. 

Jesse: So then sometime Monday, Monday evening, you arrive at the second facility. 

Cassidy: Yes. 

Jesse: What happens then? 

Cassidy: Well, they like, take my vitals again. And they give me a different hospital gown and different socks. Um, and the water was out cuz I wanted to shower or brush my teeth but they were like the water's out, I think that was just like a coincidence. Like something with the plumbing, the water happened to be out that day. 

Jesse: The water for the facility was out?

Cassidy: Yeah. They were like, if you wanna like brush your teeth you can use like bottled water. Cause they had like small bottles of water. But they were like, you can't shower and things like that because the water happened to be out.

Jesse: At this point are you shown to a room? 

Cassidy: Yeah, so I had a room, it was a very classic psych facility room. Um, I had a roommate and then you have like a very sparse like bed. At this point you're allowed toilet paper, it's very exciting. Um, they had baby shampoo was the only like soap there were these like, bottles of baby shampoo. Um, there wasn't really any other soap. I had a toothbrush then. 

I had a hard time sleeping. So I, um, in my day to day life I have to take medications to be able to sleep and I didn't have access to that. And I also, um, as I mentioned earlier, I have, um, some sensory processing issues and I also need like weighted blankets in order to sleep. So I also didn't have that. So I wasn't sleeping well. And also, um, they come into your room every 15 minutes, uh, to check on you. And sometimes they turn on the lights when they do this. So you're not sleeping well.

Jesse: Now that you're in this facility, has anyone given you an explanation of what your rights are? Of what's going to happen next?

Cassidy: No one had like spontaneously told me what the rights were, but on Tuesday morning I was talking to someone and they were saying that I needed to like sign in. Cause I was currently “under certain petition”, which I'm not entirely sure what that means, but I need to like sign in. Um, and I asked them if I had any rights, cuz I said, I like, didn't feel like I had any rights.

Um, and they're like, oh, you have rights. And they gave me this piece of paper and I read like the first one and maybe I was misreading it, but I was like, this paper makes it sound like I can request discharge right now. Can I do that? And they were like, oh, that paper's actually very misleading and they took it away.

So I didn't get to read the rest of my supposed rights. It's very, very gray what your rights are. Um, and I think that's in part intentional cause if you don't know what your rights are, the more they can get away with. 

Jesse: So Tuesday morning, you're in the facility. Have they told you a timeline? Have they told you 48 hours or…

Cassidy: No, but they did say that after five business days, I can request discharge.

So business days is important, Saturdays and Sundays don't count for your time, but they do count in terms of billing. Um, but yeah, so I know that like after five business days I request, but then when they were signing, they were like, you probably like, won't be here that long. Like they haven't like said any like timeline. It's also like, what one person says doesn't actually necessarily mean anything because it seems like there's a lot of like telephone going on or not even like telephone, you're just interacting with so many different people and they don't seem to like, effectively like communicate with each other.

So even if someone had told me something, it's not necessarily gonna hold true for the next person that talks to me.

Jesse: I want to pause here for a moment because the name of this podcast is Committable, but everything you've just heard; the apprehension by police, the detention for evaluation, the psychiatric hold.

All of that is what happens before a civil commitment. 

All of that is what happens before you get a court hearing. Before there is any legal check against whatever authority decided that you…you don't get to go home today. Or tomorrow. You don't get to go anywhere until we say.  

So I asked Cassidy, now that she's in this psychiatric facility, what happens next?

Cassidy: So I sign in because they said that it looks better if I sign in and it shows that I'm being cooperative, and that I'm willing to work, and I have to be there anyway, so I might as well sign in. So you can tell it's very coercive and, um, there's like not much, there's like essentially nothing to do the day is somewhat like blended together.

But I know that there's like supposed to be two therapy groups a day. Sometimes not all of them happen but you're like supposed to go to them and they like, say like, it looks better if you go to them. So I like go to them, but they're not very helpful. Like one of them, we read a printout of a WebMD article on nervous breakdowns.

One of them they gave an explanation of neurotransmitters and like, they're like, there are these things in your brains called neurotransmitters. Their explanation, it was completely wrong. I'm a neuroscience major. Um, the way that they explained what neurotransmitters were and how they work was just completely inaccurate.

Not that like, as a patient that you need to know that, but it's just like, if they're gonna have a therapy group on it, you would want it to be accurate. And you would also want the people who were supposedly caring for you to actually know what these things are. 

They had one on like healthy eating and exercise, um, but they were talking about like how bad processed foods are and how bad processed juices are. Which is like the main thing that they give you to drink on the psych ward. And they’re talking about how important it's to go like exercise, but we like writ large aren't allowed to go outside. 

Um, and then maybe occasionally you would talk to a social worker or a psychiatrist. And every time I would talk to anyone I would just express like how much I wanted to get out and how this was like the worst like environment for me. But it would be really annoying because I feel like every time I would like talk to someone, they would just be like, so you made this call on Saturday. And it felt like it didn't matter at all any of the things that I had said in between, like, and I didn't know if it was because that hadn't been like charted or that hadn't been told to the next person, cuz it kept being different people. Even though they had said that the whole reason that they were like waiting for a bed to open up at this facility was that I could work with the same people. It didn't seem to be like a cohesive team or that things I said were actually like being like passed in between team members. Or things that they said, so…

Jesse: So what happens the rest of the week? Like, how long are you there and what is happening every day? 

Cassidy: So what happens every day is not very much. It's really, really boring.

Um, cuz there's nothing to do. Um, there were three books in the ward. Um, one of them was Plato Republic. One of them was Anna Carina by Leo Tolstoy. Um, and one of them was, I forget what book, but it was booked by Ayn Rand. Those were the only books, uh, available. 

Jesse: How long are you actually there in the facility?

Cassidy: I'm actually there in the facility until Thursday afternoon/evening. Um, it seems like the Illinois law has the like 72 hour hold. So I I'd say like around that long. And, but it's hard to tell, like what time, like counts. Like I, I know that not business days don't count, but it's like, it's very ambiguous. It's very unclear and they make it very hard to find out.

Jesse: When you are released, has something changed? Have they told you why you're being released?

Cassidy: No. No, actually nothing has changed. Like, I feel like it's not like I suddenly had a big difference in how I was feeling. It's not like they gave me some medication and it suddenly worked super well. It's not like there was a big change in the circumstances of my life. 

The changes of the circumstances of my life had happened Saturday. So, there was really no difference in my state from when I entered to when I left. If anything I just felt much worse. Maybe like, I had like convinced them that it was bad for me to be there. Cuz literally every time they would like ask me, I would be like, This is the worst place for me to be. Or like sometimes they would ask me like, how are you feeling? And I'd be like,I feel like that's a really unfair question. Cause I haven't been sleeping, I can't do like adequate like hygiene practices. I don't have my clothes. I am so uncomfortable. I have endured all of these things. I feel like that's a really unfair question to ask me how I'm doing when I'm in like, my tailor made hellscape. 

I would tell this to like anyone who would listen about just how it was the worst thing for me to like, be there. And I think also too, like they called it gathering collateral. Like I would talk to them and I like, cuz every time I would go, I'd be like, can I get discharged? Can I get discharged soon? When can I get discharged? And they're like, we feel like we're ready to discharge you but we have to gather collateral.

Um, and I guess what that meant was they needed to, again, like talk to people. So they talked to my mother, they also said they needed to talk to the Dean in the college. And they asked me to sign this like release of information. And I was like, what happens if I don't sign it? And they're like, well, uh, it doesn't matter because they already know that you're here because you came via student counseling. So it doesn't matter because they already know, so you should sign it. So I signed it, but it was very coercive. And also it seemed likewhat information was I consenting to be released if it had already been released? I think it was a release of information, I don't know, permission for them to talk to them.

Cuz they also said that when I got discharged I would have a follow up meeting with the Dean. And I got an email about that but then they never, then they said they would email me to schedule it, but then they never scheduled it. And I never had the meeting with Dean. Which seems a bit odd because they were very much emphasizing that that was something that I needed to do to get out, but then it never actually happened.

And I think my mother really emphasized just like about how important it was that I not be there. And I think like through emphasizing this, they like eventually discharged me. I don't know. I also feel like I was like…because like also every time I move, I'd be like, this isn't care. Like how can you think that this helps?

Like I remember, like I was talking to one student and I was like, how can you do this? Like, can't you see what this is doing to people? 

Yeah. So I don't know what changed, cause at a functional level it was like nothing. 

Jesse: So throughout this process, the situation was not voluntary but was there anything that helped? Is there anything that they're doing that is actually helping your situation?

Cassidy: For me personally? No, I guess like I called the head of my program and asked if I could change labs, but that wasn't something they did. No, I can't think of anything that they did that helped. They didn't like set me up with a counselor or anything.

I thought that's a big reason cause I, I like told them like who my, like psychiatrist was, but then later when I met with her after discharge she didn't even know that any of this had happened. So I'm not sure if they communicated any of that with her. 

For me personally, they didn't do anything that was helpful. And I know sometimes like people do have like helpful detentions. Like sometimes, like it can allow you to get like medications that you need, or it can get you like set up with something or sometimes it can help. But for me personally, in this specific scenario, nothing that they did helped me. 

Jesse: So you’re released, what happens then? Do you just go back to your life? Does anything about your situation change after you're released? 

Cassidy:  Uh, no. So I get released and go just back to my life and no nothing has changed. Except for that I feel worse, um, yeah, that my mental health is substantially worse. 

Jesse: I relate to Cassidy's experience. A lot. Every time I was committed or detained in a facility it was in response to asking for help.

And to this day I live in constant fear of being pulled back into one of those systems again, because the trauma from those experiences, it didn't dissipate. It accumulated. So this season of committable is five episodes focusing on Cassidy's story. On better understanding the systems involved. 

What were these systems designed to accomplish?

Who are they for? 

What could be done differently? 

And when you really need help, what choice do you have?

Coming up this season on Committable.

Hannah Zeavin: Studies and studies and studies have shown that both forced hospitalization and police intervention actually increase suicidality, not just for individuals, but in communities.

Jamie Livingston: And we're repeatedly seeing people with mental health issues being placed at risk and dying during these interactions. Particularly if people are poor, are homeless, are racialized, so black or indigenous. Those sort of things increase their risk of dying during these interactions. 

Molly Linhorst: And I don't think a lot of people realize the immense power of the state to take away your Liberty in what is a civil process.

Tim Wand: There's a culture of blame around mental health, um, services that you're supposed to be able to identify with some accuracy that this person is gonna act in that way. Despite no evidence that we can do that.

Morgan Shields: Of all of the places in a hospital, you would hope that the psychiatric unit would be the most mindful of psychological safety, of trauma, of interpersonal relationships. And I have found that that is really not the case. For some people it could be helpful, but for a lot of people it's actually left them with PTSD. Psychological treatment should not give you PTSD.

This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid and me, Jesse Mangan. 

All music is from the song Reasonable by Christopher G. Brown.