EPISODE TRANSCRIPT
JESSE: About two years after I was first committed, things had gotten worse, much worse. I had lost more weight and developed massive edema, which basically means that my body was producing a lot of excess fluid that accumulated in my head while I slept and then flowed down to my legs as I moved about during the day.
At one point, I ended up in the ER because my legs were so swollen with edema that I couldn't bend my knees and fell down the stairs of a bus. I went to my physician, Dr. Weitzman, to get blood drawn for tests. Primarily to try and figure out what to do about the edema. When Dr. Weitzman spoke with me about the results of those tests, he said that I needed to be admitted to a hospital immediately.
So I admitted myself to Cooley Dickinson hospital. Not long after arriving at the hospital, I was transferred to an intensive care unit because my potassium levels had dropped to 2.1. I don't have a lot of context to really comprehend what that number means, but from what I understand a potassium level indicates a significant risk of heart failure.
Here's my brother Tom, talking about what he remembers from seeing me at Cooley Dickinson.
TOM: I remember at the time that you were in there, I had never seen you looking worse. I had never been more scared of how frail you looked, not just thin, but frail. Pretty much every time we visited while you admitted that things were rough, you always tried to play it like, you were like,
“I'm okay, you know, I'm sure It'll all be sorted out soon. It's not that bad.”
There was like a mountain of denial. Whether you yourself were convinced of it or were trying to convince yourself by saying it, I'm not sure.
JESSE: I admitted myself to the hospital on a Friday. I was transferred to the ICU by Saturday. By Sunday, my potassium levels stabilized and I was transferred out of the ICU and placed on another floor for medical observation. And on Monday morning, I awoke with a horribly fluid-filled face and looked up to see Dr. Weitzman sitting next to my bed, looking down at me.
Weitzman essentially communicated that he was worried that I might die and that he no longer wanted to be responsible for my treatment. So he had coordinated to have a psychiatrist come and commit me. He began communicating all of this literally within seconds of me waking up. And then he left.
Not long after Weitzman left psychiatrist Killian O'Connell arrived in my room holding up two forms; a conditional voluntary in his right hand and a section 12 in the left.
After a brief introduction, Killian held up the conditional voluntary and said,
“Either you sign this one.”
He then held up the section 12,
“Or I sign this.”
Killian then said that he didn't have time to wait for my answer, so he handed both forms to someone who had entered the room with him and said,
“If he doesn't sign the conditional voluntary, then you sign the section 12.”
At the time I didn't really understand how a conditional voluntary worked, but I knew for certain that I never wanted to be section 12’d again. So I signed the conditional voluntary...and I have always wondered. I have always wondered, how is that allowed? How is it acceptable to walk into a hospital room, threaten someone with involuntary confinement and then leave before the ultimatum is even answered?
How is that okay? How is that legal?
LAUREN ROY: Well I think it's misleading, it's coercive, but if they were to say,
“If you don't say the conditional voluntary we could commit you.”
That statement would be true.
JESSE: To try and better understand situations like this Committable producer Jim McQuaid spoke to Lauren Roy from the Mental Health Legal Advisors Committee.
LAUREN ROY: My name is Lauren Roy. I'm a staff attorney at Mental Health Legal Advisors Committee in Boston, Massachusetts. I have been working with the committee for a little over 17 years.
JIM: Could you give a little bit of background about mental health legal advisors?
LAUREN ROY: Sure. So, Mental Health Legal Advisors Committee is a state agency organized under the Supreme judicial court of Massachusetts. It's the only state agency of its kind. And our mission is to represent indigent clients in the Commonwealth that have mental health concerns and/or are perceived to have mental health concerns. So our phone number for our office is posted on inpatient psychiatric units. So we get calls from clients wanting to know about their discharge rights, their admission rights, their privileges, you know, all kinds of questions.
JIM: So when people first reach out to you, I'm curious about the degree to which they understand the situation that they find themselves in, as well as their state of mind.
LAUREN ROY: So, I don't think people are commonly aware that when you go into a psych unit, the doors are locked, that you're not free to leave, right?
This is why due process rights trigger. This is why you have a right to an attorney. You know? So, clients used to say when we would bring them up to the unit when I worked in hospitals and clients still say this now, some are shocked by that. They're shocked that the doors are locked. They thought it would be just like any other hospital unit. And they get initially very, very scared. And it is scary, right? I think it's not like going to a medical floor cause you broke your ankle. You're not able to just get up and leave if you wanted to. You know, that's why we get a lot of calls. We get a lot of calls on that initial admission process because a lot of the papers that the clients sign, they don't really understand what they're signing for the most part. The papers are thrown at them and even if they're explained to them, even if they're witnessed by people, which they all have to be, the clients, you know, they're overwhelmed at the time. And in some of their mental status may be off anyway. So it's just a really hard time for them to understand. And they have several papers to sign, not just the legal papers. It's, you know, the regular hospital admission, it's like a stack of papers at once that they need to look through. And our frequent call is about,
“I don't know what I signed. I don't know what status I’m on. I don't know if I'm here voluntarily or not.”
And a lot of people think they're there against their will, even when they're there on a conditional voluntary because they felt like they didn't want to be there. So you'll frequently hear people who say,
“Oh, I signed conditional voluntary but I don't want to be here. They told me that if I didn't sign this they would commit me.”
JIM: So when people reach out to you, they're reporting that they're sitting in this room with all these papers. They're scared, they're overwhelmed and someone on the staff tells them,
“Either sign this or we're going to commit you.”
LAUREN ROY: Pretty much, or we'll hold you under section 12, which will follow the process of committing you.
JIM: So that just really jumps out at me is, is that legal?
LAUREN ROY: We're not there during that time, right? But that's what people have reported sort of goes on and you know, I've seen it go on that way. Cause you can't be on a hospital unit without being on one or the other. Right? So you're either on a section 12, or a seven and eight if you've been committed, or you're on a conditional voluntary. Okay. So it's either/or and I think it's presented to clients that way. Is it legal? No, but I think it's somewhat true if they say it that way, but it's not giving them the full picture,
JIM: But it is illegal to present things that way?
LAUREN ROY: Well, I think it's misleading. It's coercive, but if they were to say,
“If you don't sign the conditional voluntary, we could commit you.”
That statement would be true.
JIM: I'm just curious what the implications are for using the term “voluntary” at that point.
LAUREN ROY: I know, I think that that's hard and it's called a conditional voluntary for that reason because it's conditioned.
JIM: But does the person in the situation where they're confronted with commitment, is there somebody there that sits down and explains things to them?
LAUREN ROY: Whoever's signing the paperwork is the person who should be reviewing all that.
JIM: Should be?
LAUREN ROY: Yeah, and when you ask people, our clients will say that they never heard that, or they didn't really explain that. You know, we get complaints about that all the time.
JIM: So in theory, there is supposed to be a person who's explaining all of these rights to them, but that doesn't happen all the time?
LAUREN ROY: Right. And that's very hard to monitor, right? And even harder to prove. Because the psychiatrist is signing off saying that they've done it but we know from the outcomes and from what clients tell us that whatever was said, it wasn't said in a way that they understood it, which is why people call us. Right? And then you have the human rights that trigger once you get on the unit, which we have six fundamental rights now in Massachusetts.
JESSE: Here is Committable Contributor Michelle Stockman with the six fundamental rights of persons receiving services at inpatient mental health facilities in Massachusetts.
MICHELLE STOCKMAN: Six fundamental rights of persons receiving services at inpatient mental health facilities in Massachusetts. Prepared by the Mental Health Legal Advisors Committee.
The right to reasonable access to a telephone to make and receive confidential calls the right to send and receive sealed unopened uncensored mail.
The right to receive visitors of your own choosing daily and in private, at reasonable times.
The right to a humane environment, including living space, which ensures privacy and security in resting, sleeping, dressing, bathing, and personal hygiene, reading and writing, and in toileting.
The right to access legal representation.
The right to reasonable daily access to the outdoors.
JESSE: After I signed the conditional voluntary I was confined to a wheelchair and wheeled into a psych ward with the distinct, and now familiar, “click” of magnetically locked doors shutting behind me. My mother found me on that psych ward, not long after I was wheeled in. Here's what she remembers.
JEAN: I remember going to the psych ward. I've thought a lot about that day and that image. Walking into that locked ward and seeing you sitting there in a wheelchair on the side and the tears are streaming down your face. And I know there's nothing I can do. I want like hell to grab you and run out that door. And I know they're not going to let me, and then trying to figure it out and trying to talk to Kilian, fucking asshole. I'm trying to explain to him some of the stuff we were already doing and this and that and he's just looking at me like,
“Yeah, little girl.”
And he totally ignored everything I had to say. And I couldn't do anything.
JESSE: Those tears that she saw were from fear, from feeling helpless, and from confusion, because I didn't understand. I didn't understand, why did this happen again?
I went to Dr. Weitzman because something was wrong and I wanted to work on it. I asked for help. And when he said that I needed to go to the hospital, that's what I did. I admitted myself. I complied with treatment. So what happened? At what point in all of that did involuntary commitment become necessary?
Here is Committable Contributor Brian Patrick Williams, reading an excerpt from medical records written by Dr. Weitzman on the day that he told me that I needed to admit myself to the hospital.
BRIAN: History and physical, Robert Weitzman MD, January 11th, 2002. Assessment, severe anorexia nervosa with hyperkalemia, hypernatremia. Plan, will admit. Will recheck labs. EKG. Psychiatric consult will be obtained. I do think that once his electrolytes are normalized, psychiatric admission is appropriate.
JESSE: Dr. Weitzman asked me to admit myself to the hospital and began coordinating to have me committed before I ever got there. I was on that psych ward for five weeks. As part of my treatment I was confined to a wheelchair. I saw violence between patients. During mealtimes I was forced to sit alone, in a hallway, in front of the nurse’s station. I was committed for anorexia but multiple times logistical errors resulted in me sitting alone in that hallway without being given any food while every other patient could be heard eating behind me.
And when meals did arrive Kilian and the dietician had decided that,
“The patient was put on a restrictive plan to decrease his use of calories, to help him gain weight.”
I don't really know what that means, but I do know that they intentionally restricted my caloric intake and then threatened to strap me into a stationary chair and insert a food tube when I didn't gain weight on their plan. I spent five weeks on that psych ward, and when they finally let me go I was given a bill saying that I owed the hospital thousands of dollars for involuntary treatment.
I understand that there were legitimate, serious medical concerns when I admitted myself to that hospital. I can understand that Dr. Weitzman probably felt somewhat powerless to really help his patient. I can understand that Kilian probably perceived what he was doing as ultimately being in my best interest. But what I don't understand, what I have never understood. Is if you see a patient who voluntarily asks for lab work, voluntarily admits themselves into a hospital, agrees that they need help, agrees that they need to gain weight.
How do you see that patient and conclude that manipulation, coercion and an involuntary commitment are the appropriate response? How do you do all of that and actually believe that you're helping?
To try and better understand this type of situation, Committable producer Jim McQuaid spoke to psychiatrist Paul Puri.
PAUL PURI: My name is Paul Puri, I'm a psychiatrist in private practice in Los Angeles where I do medication management and various kinds of talk therapy. I have an assistant clinical professor position at UCLA where I teach residents how to do therapy. I write for TV. I have a mental health tech startup company called “Ootify”, which is trying to sort of create a centralized, supportive mental health-like space where people can connect to resources wherever they are in the mental health spectrum. So, a lot of stuff that we're doing.
JESSE: Jim asked Paul about what it is like to be a psychiatrist, someone who has to decide whether or not to authorize an involuntary commitment.
PAUL PURI: It's a mixed bag and most psychiatrists acknowledge it's a mixed bag. You know, we all go to medical school, some people specialize in surgery and we specialize in the brain and mental health.
And most people didn't go into that with the plan or desire to, you know, involuntarily commit people. Most people are very patient aligned and had intention from an early point in life. But then when you get into training and you work in hospitals, the state has sort of handed this responsibility to the hospitals and the psychiatrist on staff to make these decisions.
And so it becomes an individual versus States' rights kind of thing. Where the States and the psychiatrist as a proxy is deciding that this person can't make decisions for themselves, or that at least they're justified to hold them to decide on that point for a little bit and have a period of observation.
JIM: So, the responsibility comes from the state?
PAUL PURI: Yeah, state laws are a little different, you know, I'm here in California and we have a 72 hour civil commitment called a 5150. And then there's a 14 day follow up, if you apply for it, which, um, the 5150 basically is kind of a free pass. There's no hearing. A 5152, there's a hearing that has to happen where the hearing officer and the patient gets an advocate, their own kind of lawyer. And then that's a 14 day hold in addition to the three.
JIM: So when you say,
“If you fill out the 14 day.”
That means the psychiatrist?
PAUL PURI: Yeah, though, actually, um, sometimes it'll be filled out by other people. So like, you can actually have the applications filled out by police officers and then in California Park Rangers can actually do it.
Emergency physicians sometimes do it because they're the first pass in terms of evaluating people, but then typically the psychiatrist has to sign off on it because they're the ones bringing them into a psychiatric hospital.
JIM: When you say the state has handed this responsibility, is this an imposed responsibility? Is this something that the field would rather not have on its plate Do you think?
PAUL PURI: It depends on who you talk to. There are some psychiatrists who I know, who are friends, who are much more libertarian and they sort of take the view of like, the comparison I'll make is if people have the presence of mind to want to kill themselves and complete a suicide, then they should have the freedom to do that.
And, you know, there's others who sort of take the stance that basically we're dealing with brain disorders, is the alternative sort of point of view. And that these brain disorders can distort people's judgment because it distorts their thinking. It distorts their emotions and distorts their impulsivity, or impulse control. And so when you put those kinds of things together, you can get people who do things that they might regret. As well as with people with what we call thought disorders, psychotic disorders, it can distort sort of their, their senses. So they may be hearing things that are very detached from reality and maybe acting on those misperceptions or hallucinations.
And so those kinds of things, for lack of a better term at this moment, put someone not in their right mind. And so they need a sort of a substituted decision-maker. And so that sort of is put on the shoulders of a psychiatrist temporarily, and then generally, if there are people who have much more persistent problems they may end up being in a position of what's called a conservatorship here in California. Where someone, you know, might be committed for up to a year, or have the rights taken away for a year, a judge takes that away. And then the judge makes other decisions such as whether they can own a handgun. They can actually have their voting rights removed, which is kind of extreme I think. So there's a lot of stuff that goes kind of, the more someone is thought to not be able to take care of themselves.
JIM: So, if you're in a position where ultimately you're the one who signs off on a form, whether it's you or some other theoretical psychiatrists out there. It is a massive decision in the sense that to commit someone is to take their rights away on the one hand. But on the other hand, you know, you could be facing someone potentially killing themselves or committing other sorts of acts of harm. So, it's a very high stakes decision no matter which way you go. What is, just for you, that experience like? Not how you make the decision, but just, what does it feel like to be in that position?
PAUL PURI: In the beginning it's really uncomfortable in various ways. One of which is like, I never really wanted to be in that position and not just because of the stakes and like the fear of making the wrong decision. But it's sort of the degree to which it becomes a paternalistic system in terms of you as a proxy or an agent of the state, sort of making this decision to take away someone's rights temporarily. That's not something that I particularly identify with. But then as you get to see the degree of what we sometimes call psychopathology, which is, you know, the different ways that people can manifest a mental illness. You really see that some people do need the help, and they do need the protection.
When someone is really in the throws of a serious psychotic episode, letting them stay on the street is really, it's kind of neglectful. And they need more help unfortunately, then they may be able to accept at that point. If you get into more of the sort of theories around psychosis, there's things like the kindling theory, which is that the longer you let psychosis go untreated, the worse it can get there's variations and counter opinions to that. But there is some serious evidence to support basically like intervening earlier with people in that situation.
JIM: So that seems like it would make the process even more difficult because the idea is that rather than just intervening when a person is at the point where they're at this crisis, there is this pressure to intervene before that point.
PAUL PURI: It's all going to vary by state, in terms of the room you have to intervene as things are getting worse. But generally, at least in California, we side much more on patients' rights. The courts and, and in my own experience with hearings and dealing with this, you generally really have to have someone who's relatively in the throws of an illness. That threshold is pretty high to hospitalize someone. For example, if someone has a plan to complete suicide in a month from now, you can't actually hospitalize them or you're not supposed to be able to, I'm sure there's people who circumvent the law or, or press the boundaries of that, you know, or they'll say,
“You know, I'm going to do it five years from now, or I'm going to do it if these jobs don't work out.”
Or whatever the thing is, you can't actually preemptively hospitalize someone because what are you going to do? Keep them locked up for years on the possibility that something happens? The system isn't designed that way. I mean, it's hard enough to get insurance to pay for someone to stay in the hospital a week, let alone a month or longer. So, the threshold is pretty high.
JIM: Is there an official threshold in California? Is there a standard?
PAUL PURI: The criteria on the forms is basically danger to self, danger to others, or what we call grave disability, which is inability to manage; food, shelter, clothing due to a mental illness. And so the threshold in terms of danger to self is generally considered to be sort of an acute threat in both of these, an acute threat to self or an acute threat to others.
Again, Is there some room for interpretation with that? Generally it's in the situation. So, if someone has written a suicide note that's considered acute enough. If someone is saying they may do something in the future, that's generally not. And so it's kind of in the present situation is sort of the threshold.
I'm sure there's a proper, I'm not an attorney, let me see how to put this as a non-attorney from my understanding, I took a forensics course once, in terms of forensic psychiatry, and basically there is, there are decisions that can be made in different types of courts based on like reasonable doubt is a comparison. And basically these things end up breaking down to sort of percentages actually of evidence. And so I think that the threshold gets higher in terms of proof. As you get further along within the mental health system. So the degree of proof that has to be made to conserve somebody and put someone on a conservatorship is much higher than it is to say, do a 72 hour hold. And especially because the 72 hour hold is much harder to sort of challenge by the time you get into the courts, like a day or two could have passed. And so if a patient has a lawyer, for example, they could do like a writ of habeas Corpus or something to try to challenge and get themselves out immediately.
JESSE: The relationship between psychiatrist and patient is sometimes viewed as oppositional as individual versus States' rights. I think this perspective can be applied to both sides of the relationship. The psychiatrist as an individual with a very focused type of training is interacting with the legal authority given to them by the state and the patient who is not necessarily a type of person, but as better defined as a person in a particular type of situation.
The patient experiences, the legal authority exercised by a psychiatrist through the buffer of legal protections, granted to patients by the state. So in theory, there is a balance legal authority and legal protection. Unfortunately, in my experience, it doesn't really matter what legal protections I have.
If the psychiatrist attempting to commit me, isn't aware of those protections. Here is Steve Schwartz from the center for public representation, discussing some of the complications that can arise when people involved with involuntary commitments have different understandings of the law. I think what you often see is.
STEVE SCHWARTZ: And this is a common problem in all mental health legal interactions, whether it be around drugs and involuntary treatment or hospitalization or anything else, is that all go conceptually, there are three separate findings that have to be made and each finding is. Independent and distinct. Does the person have a serious mental illness?
Is the person a serious risk to themselves or to others or unable to take care of themselves? And three, is there a less restrictive alternative? What you often see is that. Instead of being three independent findings that they become intertwined and interdependent. You see lots of situations where what's really happening is they're starting at the back issue.
The person has no place to live. They're homeless. Uh, they're not willing to go to a certain shelter or something else like that. So there's a concern that there's no alternative, meaning no safe place for them to even sleep. So that shows that the person's not able to take care of themselves. So you, you meet the third standard and you meet the second standard cause you can't take care of yourself.
And if you can't take care of yourself enough to even know like where to sleep or where to eat, that must mean you have a mental illness. Cause you must be confused and disoriented. So although the law reads, you go in the opposite order. So if you don't find the person has a serious mental illness, you don't ask the next question, because if they don't have a serious mental illness, even if they were dangerous to themselves, you know, because they had a terminal illness and they were not willing to continue to you don't take cancer treatment.
But they were quite mentally capable, but they said, you know, I just kinda had it. I'm going to in my life or not take this or not do that. That person should never get committed because they don't have a mental illness. They may be dangerous to themselves. They may be in that sense, in fact, articulating an intention to take their life, but they're not mentally ill.
They wouldn't get, shouldn't be committed.
JESSE: The law is often viewed as separate from the relationship between patient and psychiatrist. But when it comes to involuntary commitments, the law is not separate from the conversation, the law is the conversation. Because without the law, I simply say,
“No, thank you.”
And get to go home.
Here is committable producer, Jim McQuaid speaking with psychiatrist, Paul Puri again.
JIM: And so when you are in the position where you are in the presence of someone who may fit into one of these three categories; danger to self, danger to others, or grave disability, what's that decision making process like? How do you go about assessing a person in a situation?
PAUL PURI: Those are pretty different situations, and it depends on the context. So I've worked in private hospitals, academic, VA, as well as some County facilities, County emergency rooms, County urgent cares. And basically those sort of end up creating situations on how someone is presented to you.
So one version, let's say I was when I was working in a County ER, is pretty common. Is the police bring someone in and so they'll bring someone in they'll fill out the basic paperwork and their situation might be a person was running in traffic, screaming at traffic without any clothes on, and then shouting about God.
And so, you know, they're not mental health professionals, but they say this person seems “crazy” to me. And so we're going to bring them into a psych facility for evaluation. What our job then is to do an assessment of the degree to which the person can communicate and degree to which we can get information about them to understand what's going on.
And so that might mean that this person is intoxicated. They could be on meth, or cocaine, or something that can cause hallucinations. So we're going to get a toxicology. I'm going to talk to them to the degree to which they'll talk back to us and answer questions. And then if we have collateral sources, we'll try to get those.
So we’ll see if we can get ID on them, and if we can talk to family members or friends, we'll get that information so we can get a fuller picture and then sort of decide. Based on all this information, is this a problem that is actually impairing their ability to take care of themselves?
So, you know, you could make an argument in that case for danger to self, because they're running in traffic. That's dangerous behavior. Was it intentionally to hurt themselves? We'd be trying to determine that. And then inability to manage food shelter, clothing would be made as an argument that they're not dressing themselves in public, that they're running around naked.
So that would be an argument for that aspect of grave disability. So was that based on a psychotic process? Such as, I had a patient who used to run around naked because he thought he could escape the devil faster. That way you'd be faster without clothes on. That was his thought process which had an internal logic.
JIM: Yeah, it makes sense, there's a logic to it.
PAUL PURI: Exactly, and that's true with most psychotic disorders, there is an internally consistent logic. So basically, is this something that is temporary and that can be treated, you know, immediately, or that will abate as their intoxication goes away? Or is this more of a persistent problem such as schizophrenia, where we have concerns that they're going to need a longer period of hospitalization or at least a longer period of observation.
So sometimes we're in a position of not knowing, you know, we're acting on incomplete information. They're clearly psychotic. They won't answer any questions. Their urine toxicology was negative. We can't get any other information on them. Okay. We're going to need to hold them for a few days to try to figure out what's going on.
Give them maybe a little bit of an anti-psychotic if they'll accept it, and then see what happens. So that's sort of a process for that danger to self and danger to others are their own unique situations because danger to self is like, who decided that they are there? Did a family member have concern about them?
Did they bring themselves in? We get people all the time, and I don't work in the hospital full-time anymore I just consult or teach, but people will come to check themselves in and they'll do it on these very loose terms. Such as,
“I'm worried I'm going to do something.”
And so it's very sort of incomplete. And generally, if those people are hospitalized at all because there's usually bed shortages at hospitals all over the country, then they'll get admitted voluntarily, not on a hold involuntarily. But then, you know, sometimes people will get brought in because they are planning something, but they're denying it.
And so, you know, you get all these variations and situations. And so if you don't quite know, so let's say somebody got brought in with an overdose, but they denied that they actually tried to kill themselves. They said,
“Oh, I only wanted to go to sleep, but I did take 20 sleeping pills.”
Now we're in a situation of saying, okay, That doesn't quite seem plausible. It's concerning. I probably need to hold this person to evaluate longer and maybe to medically stabilize them too. So I'm going to hold them to try to get more information and see if they'll open up about what happened. But there's enough evidence here that they took 20 pills and not two or three that I can say, okay, this is worth hospitalizing, someone for a few days, for further observation to see, are they going to try to do something else to hurt themselves?
And can we try to get to, is there underlying depression and things like that.
JIM: When you are in the position to make these kinds of assessments, do you feel self-doubt sometimes? Do you feel relentlessly confident? I mean, what's the experience like just for you?
PAUL PURI: I'd say it varies.
So sometimes, you know, you say like, this is what the law was written for. This is a slam dunk sort of situation. It's very clear that they need to be held. And sometimes, you know, the patient will challenge that. And they'll get a hearing and you'll lose. Even though you think it's a slam dunk, like it's so obvious that this person isn't together. You know, they're paranoid and they've been building, you know, a shelter inside of their apartment to shield themselves from microwaves and aliens and whatever else, but they're really articulate.
And so they're able to convince like a judge or a court advocate that they shouldn't be held and they win. So sometimes feeling that you’re right doesn't really matter. And sometimes there's situations where you say, I really am not certain, but I think there's a danger here. If I let this person out right away, there's too much uncertainty.
And so I'm going to hold, in California the 72 hour hold is intended to be an observation period. It's intended to sort of gather more data to really see is this person ill enough that they need more help from the system? And where they can't take care of themselves, or that they're a danger. There's a lot of uncertainty that can happen with this.
And sometimes you talk it out with colleagues and sort of get their perspective on it and try and get also like, are other people on board with this? So sometimes the family is really in support of it. That can sort of help your case. And sometimes the family really wants to take them home and sometimes that'll soften the decision and say, okay, you know what? I think I'm okay sending them home because there's 15 people that are going to be watching them. So if they need to be brought back in, they will. And sometimes the family is very encouraging to bring them home, except they're very naive and they don't really understand what they're dealing with. Those cases could go either way.
JIM: Seems like the role of the 72 hour period and the potential 14 day periods are a combination of crisis management, observation and preparing the person to reenter life. It sounds less like there is a focus on, god, I hate to use this term but for healing the patient or it's, you know...
PAUL PURI: Yeah, the system is most definitely not designed for really creating a healing environment.
I mean, there are exceptions to that and you know, if people are in sort of private pay situations, if they can pay out of pocket and they go to, you know, Sierra Tucson or one of these very prestigious places, then they can go for months at a time. And then basically you are able to sort of address like deeper issues and really manage it.
But the larger psychiatric hospital system isn't really designed for that anymore, which is a really lamentable thing. I have a mentor who, he said,
“You know, back in the day…”
This is like the sixties.
“...you know, we could put someone in the hospital and insurance would just pay for it for months and you could really get somebody better and we wouldn't have to worry about how long we can keep them and all of these other issues.”
It's not really designed to deal with the deeper problems and really heal the person or get them all the way back to whatever we want to call normal. I don't even use the term normal, but...
JESSE: To understand where we are in this conversation about involuntary commitments, it can be really important to understand how we got here. Here is Steve Schwartz again, discussing some of his experiences working as an attorney focused on mental health law in Massachusetts.
STEVE SCHWARTZ: So it's important Jesse, when we started our work, which was in the early seventies, many States had no provision at all for what was called emergency detention. In fact, they even had no serious protections for long-term commitment. But as a result of some civil rights cases that were brought in the late sixties and the early seventies, that you could not deprive a person with psychiatric disabilities of their liberty without a hearing, without a good reason, without the right to a lawyer.
States began to reform their laws. Massachusetts was one of the first to do so and when it did it, it actually required a fairly in-depth process and a pretty rigorous standard for long-term commitment. Long-term commitment was for six months or a year or longer, which was novel across the country because there were no protections in many, many States.
So Massachusetts was one of the States that set up these more rigorous standards and procedures to safeguard the inappropriate deprivation of freedom.
JESSE: When Paul recounts a perspective from his mentor, that in the sixties and seventies psychiatrists could keep people in hospital for long periods of time and really focus on getting that person better. From a certain perspective, that could be true.
But from another perspective, In the sixties and seventies people could be held in hospital for psychiatric treatment for potentially indefinite periods of time, because there were virtually no laws protecting them. This perspective could also be true.
But when it comes to a difference of perspective, this is not a debate.
This is not a simple disagreement.
Because when it comes to involuntary commitments one side of the conversation has virtually unchecked legal authority to detain the other.
Here's one last segment from the conversation between Jim McQuaid and Paul Puri.
JIM: This is the fascinating, but also it seems like an impossible challenge, that you guys face is that you are making decisions based not on what's actually occurring in the person's head, but what signals are they presenting? Right? So, somebody is composed. Then they have that social skill cause they know how to navigate the situation. They know how to hide their symptoms versus someone who isn't composed and doesn't have those capacities. And so to see past the mask, or to just the parce out the signals that you're dealing with…
PAUL PURI: in some ways it seems very subjective, I would imagine, to other people. And there is a degree of subjectivity to it, absolutely. But I think, you know, we aren't mind readers, but the more sort of skilled you get you can get better at sort of pattern recognition and understanding what certain patterns mean.
I have seen psychiatrists who get a little too cavalier with that in terms of assuming that something means something about someone's internal state when there are alternative explanations. But generally what we do is something called the mental status exam. Which is sort of what we call the psychiatric equivalent of a physical, and that looks at various domains of someone just on an interview.
So there's; appearance, behavior, attitude, speech patterns, thought process, thought content, insight, judgment and cognitive functioning. And so you're looking at all of these different domains for signals about, you know, based on the clinical picture and everything else to sort of be suggestive of something.
And so what we're looking for is sort of inconsistencies, or consistencies, with the story. What supports it and what goes against it, based on the observations and certain things fit into certain patterns. So someone's saying that they, you know, have a million dollars in the bank and that they live in a big mansion, but they're like in totally disheveled clothes. And apparently haven't bathed or showered in like two weeks and are rambling periodically. There's an inconsistency there with their story. And so we're looking at how things fit or don't fit together to try to make sense of it.
JIM: And what about the environment itself that the patient finds themselves in?
PAUL PURI: So, they enter into this situation and they are confronted with all these other people who are committed as well. It's an unfamiliar environment. I'll give different perspectives on it. Hospitals do what they can in terms of trying to create a relatively comfortable environment. So, whatever, like pleasant lighting and painting and all of that stuff.
But from the patient experience, yeah, it's terrible. Because they're going into an environment typically they don't want to be in. They're being held against their will. They can't leave. Generally most psychiatric hospitals that I've seen, and bigger ones are different, they're a mixed population.
And so you have a mix of all of these different psychiatric populations together. So you have people who are depressed, next to people who are hallucinating, next to people who might be having alcohol withdrawal or various other issues, or be potentially, and we generally don't try to, but they could be psychopathic. Which could be people who are dangerous in that way.
And generally we shouldn't be hospitalizing people who are psychopathic, but that in the acute sense of someone who is threatening other people, sometimes they do end up in hospitals for various reasons.
So, basically, if you're a depressed person that's really scary. Like, it's incredibly scary to go into that environment. If you are psychotic and paranoid, you're already scared. Generally people are, you know, in that state of mind, that's a scared state of going into the world and you're going into this environment that's unfamiliar. So no, there's nothing necessarily conducive about it, but there's a mix of constraints here. And I assume you're going to get into the deinstitutionalization and, you know, starting from Reagan, because there's sort of a sociological component to that in terms of defunding hospitals and that had a big impact where as there's less and less funding the systems have only room for basically this crisis management and it's not really in any way designed to accommodate the individual patient's experience and what's best for them.
JIM: I guess my last question is just, is there anything that we haven't talked about that you think I should know? Or that we should know?
PAUL PURI: I appreciate that Jesse's had like a difficult experience, and I don't know his particular background or reasons for it, and I'm sure I'll hear it on the podcast. But I've had to do work with people who were willing to come into therapy to sort of repair their relationship to mental health afterwards. And sometimes it's really sort of tiptoeing because I mean, I had a patient who had very severe bipolar disorder and he was traumatized by being hospitalized against his will and had so much anger at the system because of it and very understandable, like, it felt horrible for him, but he was also doing incredibly dangerous things.
He put himself into situations where he actually got very physically hurt because he was manic, you know, he was driving recklessly and, you know, his family was very concerned about him and he only got hospitalized once. And then we found ways to work around it without him having to be hospitalized, but it was pretty understandable, his perspective, and yet still necessary for his own protection.
And that sort of quandary that even though we are sentient, aware beings that seemingly should be able to make all decisions for ourselves, that our own brain can betray us. Our own senses can betray us. That we can't know and see everything the way that we think we can and that sometimes other people might see better than us. That we all have blind spots basically, is a tough thing for, I think, all of us to reconcile.
JIM: The way you phrase that I think applies, he is pretty suspicious of things like therapists and getting treatment and things. Whereas I have encouraged him to. I see a therapist and all that. But yeah, I know that kind of lingering effect is there. And I think some of what you said, I think he could find heartening.
PAUL PURI: I think it's just a matter of, hopefully he can find someone that he can trust and if you can build that relationship, then it can go from there.
JIM: Right. Right. Exactly.
JESSE: The last part of this interview has stuck with me.
If you have asked for help and been harmed by the treatment you received, how do you repair that relationship? How do you feel safe asking for help again?
What options do you have when you know, for certain, that you are committable?