This is crazy!

Over the past few years I have had occasion to observe the workings of several mental health care facilities. I have learned a few things in the process, and I have seen some things which cause me some concern. Most of my experience in this area is in the state of California but I imagine that other legal jurisdictions are similar.

Some of the facilities I am familiar with are privately-operated, both general medical hospitals with a mental health unit and private free-standing mental health care facilities. These tended to be smaller (up to about 25 beds) and to be open (rather than locked) units.

Others were government-operated units, again both connected to a general medical facility and separate free-standing units. These were predominantly locked units, and it sometimes seemed that it would be easier getting into and out of a minimum-security prison than these places.

Most jurisdictions have some procedure for admitting patients to a mental health care facility against their will in order to protect against their causing harm to themselves or others. I was with a friend who had taken an overdose of medication and was sent involuntarily to the local government-operated mental health unit by the emergency room staff after they ensured that the medical emergency was resolved.

My friend was "evaluated" by the mental health care professional at this facility and admitted to the unit under California Welfare and Institutions Code Section 5150, which allows the person to be held for 72 hours for observation and treatment. My friend, if given the option, would have signed forms to be admitted for care as a regular, self-admitted, voluntary patient.

I discussed briefly with the technician conducting the evaluation for admittance what criteria were considered in making the decision that involuntary confinement was required. He advised me that the patient was expressing suicidal ideation and was considered to be at risk of self-harmful behavior. I asked if the patient had been given the option of voluntary admittance and was told “no”. I asked why the patient had not been given that option and was advised that it is not usually done. Since the admittance was done late at night I postponed any further questions until I could speak with hospital officials.

Since this experience was disturbing to me I returned to the facility the next day and asked to speak with the administrator. This person was kind enough to see me without an appointment and I was able to get answers for some of the questions which had been bothering me. I learned that more than 80% of the patients in this facility were "medically indigent" -- they had no means to pay for their care directly and had no insurance coverage to pay for the care, not even government insurance like Medicaid. The local government unit which operated the facility pays for the costs of their care out of its general funds.

As I thought about this experience I decided that I would like to see some changes made to the laws which govern this process to help protect against possible perceptions of abuse. First, I would like the law to require that patients be given the option of a voluntary admittance. The facility staff might object that this could lead to unnecessary game-playing by patients who want to leave the facility prematurely (before they are stable enough to not pose a risk of harm). My response is that if the patient wishes to leave the facility against medical advice the staff still has the option of using the 5150 72-hour hold. What they gain is a patient who is potentially more cooperative and committed to working with the program (after all it was their decision to be here).

Second, I would like the evaluation process to be completed by a mental health professional who is not connected in any way with the facility the patient would be admitted to. In the case of my friend, there is the real possibility that the staff member performing the evaluation might have been influenced by the fact that the census of the unit was low or that this patient had insurance to pay for their care. Requiring an independent evaluation reduces any appearance of conflict of interest. In smaller jurisdictions this may not be practical and some exception may be necessary but most areas of California have enough mental health professionals available to make this work.

A third concern may be more difficult to resolve. More and more frequently the insurance providers seem to be influencing the decisions made about who gets health care and under what conditions. I asked the admitting staff member at another hospital why my friend was not admitted voluntarily even though they had come to the hospital on their own to seek admission. The response was that it was difficult to get the insurance campany to pay for a voluntary admission but if the person was admitted under section 5150 the insurance company more readily admitted that the services were necessary. This certainly seemed to be an abuse of the power granted under the law. Since the law provides for involuntary confinement of a person who has committed no wrong and has had no trial or legal hearing it should be used only in the cases for which it was intended: as a last resort to protect persons from harming themselves or others.


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