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.