The Rights Versus Treatment Debate

 

Just yesterday I coauthored a brief opinion piece on the issue of civil commitment and the issue of rights versus treatment (2). My co-author Mark L. Ruffalo had the great idea to initiate our commentary based on a letter from the late Darold A. Treffert, MD who was then the Superintendent of Winnebago State Hospital in Wisconsin. Dr. Treffert was also an expert on autism and savant syndrome.  I heard him speak on that topic about 15 years ago at the Door County Summer Institute.  His letter (2) was both a statement about the need for legal intervention and a call to action. In the final line, he attempted to solicit negative experiences from other physicians about a civil commitment process that erred on the side of rights rather than recognition of severe problems and treatment and the resulting problems.

Historically this letter came around the time that antipsychiatry forces were building and one of their main talking points was that there was no such thing as a mental illness.  People simply had “problems in living” and therefore no medical or legal intervention was necessary.  Certainly not a legal intervention that resulted in the deprivation of civil liberty.  The antipsychiatrists and liberty advocates failed to recognize the problem of severe mental illness and the associated lack of problem recognition and impaired decision making.  Those impairments greatly compromise any person’s ability to negotiate the world safely and take care of their self. The usual examples include suicidal or aggressive thoughts and behavior.  They can also extend to routine medical care and activities of daily living.  As an example – a person with severe mental illness may no longer see the need to take insulin for diabetes, or blood pressure medications, or anticonvulsants. That can precipitate a medical emergency in addition to any existing psychiatric emergency.

In Dr. Treffert’s letter, he mentions that the Wisconsin Supreme Court set a new commitment standard of “extreme likelihood that if the person is not confined he will do immediate harm to himself or others.”  Imminent likelihood became an impossible standard in many cases. Even if a patient had attempted suicide or assaulted someone, at any point during a one or two week court process – they could make the argument that the imminent danger had resolved – even if they were refusing treatment and continued to have severely impaired judgment. In that case what frequently happened was that courts experimented with rapid dismissals of commitment petitions – until there is a catastrophic outcome.  At that point they become as cautious as the physicians involved in assessing and treating the patient.

The dangerousness standard for commitment has additional unintended consequences. It functions as a de facto hospitalization standard. It is common that managed care companies deny payment for admissions or even continued stays in the hospital based on the imminent danger statute even in patients being treated on a voluntary basis. The applicable standard in this case should be an adequate treatment standard – also a quality standard.  It is highly likely that any patient admitted after a suicide attempt or episode of severe aggression will continue to have that problem if they are discharged without adequate treatment. Adequate psychiatric treatment generally takes much longer than typical 2-to-3-day crisis hospitalizations. As a de facto standard in the managed care era, it is also easy to discharge a patient who is uncooperative with care by documenting the resolution of the imminent crisis and discharging them rather than working on relationship building and a plan based on a therapeutic alliance. The adversarial legal standard becomes an adversarial medical process. 

Imminent danger standards also fail to recognize forensic populations, the subgroup of people with severe mental illness who have a pattern of violent crimes and have a chronic risk of violent and aggressive behavior. This group of patients often cannot be treated in the same setting as other patients with severe mental illness, and require treatment in forensic settings with adequate staffing and protections for both patients and staff. That segregation can also occur at the community hospital level, where just a few hospitals have psychiatric units and fewer have units that are designed to contain aggressive behavior. Aggression and violence in psychiatric settings is so stigmatized that its existence is commonly denied unless someone is trying to make a political argument that involves blaming societal violence on psychiatric patients.  Even then there are counterarguments that it does not exist. I have been advocating the position that violence and aggression secondary to mental illness are public health problems that should be addressed at that level for at least 20 years.  During that time, I have not seen a single public service announcement with that message.  Instead, the political and legal system continues to ignore that approach by flooding the country with firearms, closing many if not most community mental health centers, closing supported housing, and failing to provide affordable housing.

The response from journalists is not much better – ranging from overt misinformation about psychiatry and mental illness to the occasional human-interest story. The people who know the most about the problem – psychiatrists, social workers, and case managers are left out of the loop in favor of the most convenient critic. Journalists seem unaware of conflict of interest of many of their recruited experts and do not apply the same standard that they would for a psychiatrist.  Journalists and politicians also promote widespread cannabis use and in some cases legalization of many drugs that all pose serious health risks to psychiatric populations.  It is as if saying that out loud is bad for business and tax revenues.  

The humane aspects of involuntary treatment are often turned on their head in the rights versus treatment debate.  Is it more humane to keep persons with mental illness circulating between short term hospital with minimal to no treatment, jails, and homelessness because they do not recognize the problems they are having and fail to come up with solutions, or is it more humane to offer involuntary treatment?  Context is very important.  In my experience, during involuntary treatment – therapeutic alliances occur as it becomes evident that the treatment providers are helping the patient survive better. People with impaired insight and judgment require evidence that they are being helped and that is generally a turning point in the process. If a person is homeless, the evidence has to be provided right where they are – on the street.  That requires active outreach by treatment teams. Ideally that can happen before any crisis occurs that may lead to civil commitment and involuntary treatment. But even if the patient is committed active intervention to support them outside of institutional settings is possible.  This method of community psychiatry and community support has been around since it was invented by Len Stein, MD and Mary Ann Test, MSW in the 1970s. I was fortunate enough to have been supervised by Dr. Stein during residency and one of the key concepts was “the money has to follow the patient.”  In other words, the money used to finance extended state hospital stays had to be used to treat people in the community and provide them with their own housing.  This was a model to maintain people disabled by severe mental illnesses in their own housing.  The other elements included active outreach and 24/7 availability of staff to help them resolve any crises. That basic model has been around for 50 years and it is rarely implemented and only recently discussed in mainstream medical journals.

The primary reason we have a problem with both homelessness and untreated chronic mental illness in the United States is economic. The managed care model of health care administration showed how easy it was to deny and ration psychiatric care to make money.  That model was sold based on increased efficiency and cost containment – but at this point it is obvious that it does neither. It does reroute funds to pay for a massive increase in the number of administrators at both the private and public levels.  These administrators are largely focused on enforcing the rationing of care instead of providing quality care. In fact, the real onset of managed care heralded the total disappearance of quality metrics in medical care. Quality was no longer monitored by external agencies.  It was internalized in managed care organizations. The focus went from adequate treatment of a problem to how quickly a person could be discharged to maintain profitability under an unrealistic reimbursement system.  That approach is a disaster for acute care psychiatry, community psychiatry, and it makes involuntary treatment more likely from the resulting chronicity. It has also been a major frustration for outpatient psychiatrists trying to get hospital access for their patients in crisis. But the economics are generally swept under the rug or discussed at a superficial level by the critics.

At the community level, rather than active outreach by trained mental health staff most communities end up using law enforcement or other first responders with minimal to no mental health training. In most communities they are the only staff available on a 24/7 basis and that is also a funding issue. There are situations where the police do need to be involved in a mental health crisis, but that is far less common than the need for mental health intervention.

What are the solutions? I have written about many on this blog over the years. At the top of my lost today is just moving past the rights versus treatment debate. It has been a stalemate for 50 years while the entire system of care has collapsed due to rationing. The rights have been adequately safeguarded for decades and arguments about abuses before that time are irrelevant. What do I mean about adequate safeguards? In the state where I worked, there was a prepetition screener, a prepetition screening team (to discuss the merits of commitment and whether the patient met statutory requirements), 2 court appointed examiners, a defense attorney, a country attorney, a probate court judge, and if necessary, a substance use assessor.  That is about 7-10 people independent of the treating staff and any one of who could disagree with the commitment process.  I am not aware of any legal process that provides more safeguards.

On the treatment side, there is a legal concept called least restrictive treatment. That simply means a treatment setting where the person is free to come and go as they please rather than being in a facility where they either can’t leave or have to ask for permission.  The goal of the Stein and Test model was to maintain people in their own apartment – the least restrictive of all. That is a goal that any functional system should aspire to.  When we hear about the homeless problem only a fraction of those folks have severe mental illnesses.  Another fraction has substance abuse problems. The obvious solution is a housing first option that may include social support or in the case of mental illness case management services with active community psychiatry outreach.  The first step is not transport to emergency departments and admission to psychiatric units.   

Another unmentioned dimension on the treatment side is well trained and motivated staff.  Police officers do not choose a career in law enforcement because they are interested in communicating with and treating people with severe mental illnesses. Mental health staff do.  Communication and relationship building goes a long way toward defusing a crisis and preventing involuntary treatment.

Addressing the dilapidated psychiatric infrastructure is the final step. The issue of psychiatric beds is a chronic problem with the ongoing political rhetoric that no more are needed compared with needs analyses based on bringing the length of stay (LOS) of psychiatric patients in the emergency department to the same LOS as medical and surgical patients. On that basis – there are very few places in the US with adequate psychiatric beds.

By far – the single most detrimental factor has been the managed care model of rationing in health care systems and by the states. Denying care will always be more cost effective than providing care.  It is also a good model for generating profits. Much of that early profit was made by shifting the cost of effective care for serious mental illnesses away from subscriber-based health care systems to state funded systems – at least until the states adopted the model for themselves. Any serious discussion of the rights versus treatment debate needs to start at that point. Involuntary treatment and civil commitment will never be a solution to the problem of homelessness or the revolving door of people with severe mental illnesses getting inadequate treatment.

I wish that I could end the year on a more positive note but things seem very grim out there. We are still in the midst of a pandemic that has showcased how susceptible the public is to misinformation and political manipulation.  I can't help thinking that this has been the state of affairs in psychiatry for the past 50 years and this post is some of that evidence.  I am hoping that we can see the rise of some leaders in psychiatry to counter these trends - just as we have seen experts in virology and engineering counter the coronavirus misinformation.  But it seems like it will take a lot more than that.

Here is hoping for a better year in 2023 and beyond!

 

George Dawson, MD, DFAPA

 

References:

1:  Ruffalo ML, Dawson G.  Still Dying With Their Rights On, 50 Years Later.  Psychology Today December 30, 2022 Link

2:  Treffert DA. "Dying with their rights on". Am J Psychiatry. 1973 Sep;130(9):1041. doi: 10.1176/ajp.130.9.1041. PMID: 4727765.

Photo Credit:

Eduardo Colon, MD with thanks.

Additional Posts Relevant To This Topic:

 1:  The Problem With Inpatient Units:  Link

 2:   Are There Any Good Jobs Left for Psychiatrists?  Link

 3:  The Bureaucratic Takeover of American Psychiatry: Link

 4:  There Is No Identity Crisis In Psychiatry  Link

 5:  Holding Tank or Psychiatric Unit?  Link

 6:  Medical Care of the Seriously Mentally Ill - The Way It Should Be Provided Link

 7:  Governments and Psychiatric Beds  Link

 8:  The New York Times Steers The Mental Health Conversation in the Wrong Direction  Link

 9:  Bedless Psychiatry and  Recipe for Remaining Bedless  Link

10:  The New York Times Article on Why Mental Health Can't Stop Mass Shooters  Link

11:  My Opinion on Community Mental Health from 1989  Link

12:  Minnesota's Abandonment of the Severely Mentally Ill - Nearly Complete  Link

13:  Treatment setting Mismatches - The Implications  Link

14:  Why There Are No Bipartisan Solutions to Exorbitant Health Care Costs in the USA  Link

15:  A Circular Ethical Argument About Psychiatric Services  Link

16:  The EMTALA Paradox  Link  June 11, 2017

17:  Managed for Mediocrity - Corporate Medicine in the 21st Century  Link

18:  Remission Before Discharge?  An Un-American Concept  Link

19:  Do Businessmen Dream of Medicine Without Doctors?  Link

20:  Americans Can't Do Basic Health Care Arithmetic  Link

21:  The Largest Psychiatric Hospitals in the USA Link

22:  Hospitalists...  Link

23:  A Better Analysis of the Psychiatrist "Shortage"  Link

24:  Just When You Thought American Healthcare Could Not Get Any Worse  Link

25:  Newsflash from the StarTribune - Psychiatric Patients Have Nowhere to Go  Link

26:  Medicine to Psychiatry to Parking Lot:  The Evolution of Detox Over the Past 30 years  Link

27:  Admission, Discharge, and Readmission Policies: No Better Example of Business Driven Pseudoscience  Link

28:  How To Ruin You Life Without Being Dangerous  Link

29:  How the Ruling Class Impacts Your Health Care and Why They Need to be Stopped  Link

30:  Trauma In Psychiatric Hospitalizations  Link

NEJM Three Part Series - Severe Medical Illness In the Context of Severe Mental Illness

Lisa Rosenbaum, MD has written a three part series in the New England Journal of Medicine that should be read by non-psychiatric physicians, family members, patients, and policy makers.  It is focused squarely on providing medical care to patients with severe mental illness and all that involves.  It is really impossible for psychiatrists to avoid the issue.  At some point in your career you find yourself in a situation with a patient who has a severe medical problems and refuses to address it because of the way that their decision making process has been impacted by mental illness.  If you are an inpatient or ACT team psychiatrist - it is usually up to you to come up with a plan to address that problem,  Several of the scenarios she describes across this series are directly from those settings.  Like any other specialty, psychiatrists will all migrate toward a certain niche.  For many reasons being that person who has to confront mentally ill patients about the fact that they are seriously ill or dying is not a position that is in great demand.  But mostly it is because inpatient and ACT team positions are rationed and none of the payers or administrators want those psychiatrists to do what they are capable of.

This series is part of an overall increase in psychiatric topics that are discussed in the NEJM.  So far this year there have been three Case Records of the Massachusetts General Hospital and a review of the basic science of addiction and a number of other articles on addiction and mental health policy.  Although I have not attempted to quantify it, there does seem to be a general increase in the coverage of psychiatric topics that include reviews of diagnostic groups, basic science mechanisms, clinical trials, and articles of general interest from the field.  The search function of the web site allows for grouping according to specialty and there are generally 20-30 psychiatry references per year over the past 5 years.  Lisa Rosenbaum is a cardiologist and is a national correspondent for the NEJM and in that field has probably seen a number of cases of people with severe mental illnesses and cardiac problems.

In the first article in the series she discusses the issues of informed consent and coercion in treating patients with severe mental illness.  It is well known that this population is undertreated from the perspective of primary treatment that is focused on the mental illness.  She uses an estimate of 9.8 million people with severe mental illness and only 60% of those people receiving treatment.  She cites the systemic problems of a lack of bed capacity 11.7/100,000 currently compared with 337 per 100,000 in 1955.  The contrast is more striking if per capita health expenditures for health and the number of psychiatric care beds per 100,000 population are compared.  For OECD data per capita expenditures for healthcare rank the USA at the very top by far and the per capita number of psychiatric care beds near the bottom compared with other countries.  The article discusses how deinstitutionalization was supposed to be linked to more community resources and not less.  The underfunded systems is portrayed as somewhat of a mysterious problem rather than system-wide rationing of psychiatric services.  The author in this case ties the underfunding to problems that it can't fix namely severely ill patients not seeking treatment  and antipsychotic drug side effects.  The high discontinuation rates in the CATIE trial are cited as proof of this problem.  I think that underfunding due to rationing is the problem.  With adequate resources comprehensive care is possible when the focus is comprehensive care more than medication.

The philosophy behind ignoring psychosis due to a psychiatric disorder compared with other physical illnesses is discussed.  The author points out that given the severe disability of these illnesses they cannot be ignored and that unlike other illnesses there are no major campaigns focused on prevention or treatment.  From there she transitions into the issue of intervention against the patient's wishes.  She discusses Stone's theory of paternalistic intervention if the affected person is likely to be grateful after they have been stabilized.  The flaw with that theory is that in many cases only a degree of psychiatric stabilization can be achieved.  In many cases it is likely that the person will have continued problems with insight and medical decision making and will continue to disagree with any suggested treatment.  She discusses the flaws with "dangerousness" as a component but does not take that discussion to its logical conclusion.  Dangerousness is of course not a psychiatric concept.  It is used by the courts as a basis for the initial stages of civil commitment and by managed care companies to decide if they will pay for psychiatric hospitalizations.  Any inpatient psychiatrist has found themselves talking with an insurance company reviewer - usually many states away who wants to know "where's the dangerousness?" and who is quick to deny payment for the treatment of a severely disabled person on that basis.  Dangerousness is probably the single word in the English language responsible for shutting down psychiatric care bed capacity and driving skilled psychiatrists away from the treatment of severe psychiatric disorders.

Rosenbaum makes the mistake of overemphasizing the importance of stigma.  She accepts as a given that stigma causes "countless harms" when the real harm is caused by systemic discrimination by the government and insurance companies.  The dangerousness concept as a justification for no treatment has done far more harm than the stigma of mental illness.  She also connects the attempt to counter stigma with illness minimization behaviors such as treating a person with a severe mental illness and impaired decision-making capacity as a competent decision maker.  Stigma is of course tied in with the recovery movement and policy that flows from the Substance Abuse and Mental Health Services Administration (SAMHSA).  Overmedicalization and disregard for civil liberties is cited as a need for this recovery based model.  That cannot be reconciled with the fact that for at least 40 years, all states have had civil commitment and guardianship/conservatorship laws in place that are in place to assure the civil liberties of anyone where there is a suggestion of coerced treatment.  When people "die with their rights on" they are generally dismissed by courts and end up dead as the result of untreated mental illness.  Only psychiatrists are generally bound by these laws and not other physicians and that part is left out.

The other significant group left out of course are the antipsychiatrists and their considerable allies whose raison d'etre is basically to bash psychiatrists and make them look bad.  That group frequently uses the term overmedicalization and pretends that there has not been decades of legislation to protect the civil rights of the mentally ill.  She is patronising in suggesting that "most psychiatrists" recognize "peer support, structured activities, psychotherapy, employment assistance, and case management" might be useful -  ignoring essentially a century of research by psychiatrists on these elements of treatment.  It also ignores the truth that every psychiatrist knows and that is - people recover and people with severe illnesses recover.  I don't need a recovery movement to tell me that.  I have people walking up to me on the street who I treated decades ago who tell me that they are married, they have children, and they are working.  Despite that severe shortcoming, I give her credit for pointing out how recovery proponents "twist data to advance their agenda".  There is currently a lot of twisted data out there.

She ends the first discussion with commentary on whether a living will for treatment of psychiatric disorders, innovations like a "one-time autonomy violation for forced treatment", or civil commitment as usual is the best approach to forced treatment of severe mental illness.  That assumes that some innovation is necessary and that it will be universally applied.  Both assumptions are incorrect.  It is possible these days to look at the editorial pages of any major medical journal and of course the non-medical media and read endless suggestions about how "the system" of medical care should be changed.  The reality is that there is a loose system of medical care and for psychiatric care the system is non existent except in the minds of antipsychiatrists.  As far as I can tell the only thing wrong with mental health law is that it is subjectively interpreted and that interpretation is clearly affected by the attitudes of attorneys and judges and the resources of the county that is financially responsible for treatment.  That skews undertreatment more severely to the counties with fewer resources.  There is nothing wrong with the law as it is written.  Civil rights are protected and the decision about rights is made by the legal system and not psychiatrists or physicians.

The second article in this series (2) is focused on the mortality gap between persons with mental illness and those without.  Unlike recent authors Rosenbaum points out that the problem was first identified by a psychiatrist in 1932, long before there were any effective treatments or treatments that allegedly cause medical complications.  She almost avoids the accusation of some recent extremists that psychiatrists and psychiatric treatment are responsible for this increased mortality rate but does bring that point up.  Nobody can argue that a lot of this mortality is based on pessimism in dealing with the mentally ill.  I can still recall the obsessing about the decision go to smoke-free inpatient psychiatric units.  One of the arguments is that it would lead to much more aggression among patients and toward staff.  The  other argument was that smoking was "all they had" and it should not be taken away from "them."  Both arguments were advanced by trained mental health staff and are extremely demeaning.  It is not surprising that patients with mental illness have lower rates of guideline recommended care or disease altering interventions.  I have contacted many primary care physicians who were surprised to hear that their patient was still alive.  I have also found myself in the position of treating people with sustained very high blood pressures or people who were actively bleeding because the patient was refusing treatment.  The only advice I got from consultants was to call them back when something bad happened and in some cases it did.

The medical rather than psychiatric assessment of capacity to consent is discussed.  A study is presented that shows  that on a typical medical service 40% of patients lacked capacity to consent and the treatment team was aware of only 25% of those cases.  This implicit consent on medical and surgical services is widespread.  It is generally questioned only in the case of high risk procedures or if a patient illogically refuses routine care.  In hospitals with psychiatric consultation-liaison services - they are typically consulted with the question.   Rosenbaum suggests that in contested situations forced treatment results in brutal seclusion, restraint and forced medication.  That is an unlikely outcome in these situations.  Most people no matter how delusional agree to care if a judge orders it or they realize that just leaving is not an option.  The suggestion is made that more time and training for capacity to consent evaluations be considered.  That is not going to happen.  There is a reason that people avoid going into psychiatry.  Talking to patients and making these assessments is one of them.  And there is no way that hospitalists are ever going to have the time it takes to do this job in addition to their medical evaluations.  It is just another psychiatric resource rationed out of the system.

Rosenbaum concludes with a valentine to integrated care models.  She has access to some of the few internists who are adept are treating people with severe mental illness, including one internist who specializes in it.  The recent MGH Case Reports have discussed similar models.  The main model that was invented in 1974 by Len Stein, MD, Mary Anne Test, MSW and  others is never mentioned.  Since that time there are ACT teams that coordinate medical care for people with severe mental illnesses and help them stay healthy outside of hospitals.  As a psychiatrist trained in these community psychiatry interventions there was nothing about patient care in these three articles that was news to me.  There are plenty of psychiatrists trained in these interventions but very few settings to implement them.  That is because the rationed care approach has split psychiatric care off from managed care organizations and placed it under the purview of the state - usually as a way to justify shutting down state hospital bed capacity.   In states where the resource becomes state-run managed care poor outcomes can be expected to follow.  Since ACT treatment was originally focused on deinstitutionalization and quality of life it is easy to dismiss based on typical cost effectiveness arguments.  I can still remember Len Stein showing us the reason why ACT was invented.  It was a single slide showing a gymnasium sized room full of cots that were placed edge to edge.  The patients were all men wearing the same uniforms off to one side.  His question to the residents was whether it was better to help all of those men live independently or let them live in those state hospital conditions?  Unlike today - incarceration and homelessness were not acceptable options.      

The final article in the series suggests that inaction on the part of physicians in addressing the problem of medical illness in people with severe mental illness is a result of learned helplessness.  That refers to a well known animal model of depression where test animals are subjected to some insurmountable stressor and generally give up and stop trying.  That model alone provides an interesting disconnect between psychiatrists and the rest of medicine.  Since the days of German asylums, psychiatrists have wanted to talk to their severely ill patients - even before there were any effective treatments.  That drive is one of the most  compelling reasons for medical students to go into psychiatry in the first place.  I don't think that properly trained psychiatrists view these problems as hopeless situations, even though some of the inpatient units they work on are clearly repositories for problems that other physicians consider hopeless.

I have no problem at all talking with anyone who has a severe psychiatric problem, understanding them, and discussing treatment options for both their psychiatric and medical problems.  I have no problem understanding that the only reason I am the one offering help is a matter of genetics and good luck.

Any psychiatrist that I know can do that.      


George Dawson, MD, DFAPA



References:

1: Rosenbaum L. Liberty versus Need - Our Struggle to Care for People with Serious Mental Illness. N Engl J Med. 2016 Oct 13;375(15):1490-1495. PubMed PMID: 27732817.

2:  Rosenbaum L.  Closing the Mortality Gap - Mental Illness and Medical Care.  N Engl J Med. 2016 Oct 20; 375 (16): 1585- 1589.

3:  Rosenbaum L. Unlearning Our Helplessness - Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016 Oct 27;375(17):1690-1694. PubMed PMID:27783917.

Psychosis Idealized

I thought I would provide a counterpoint to the New York Times editorial entitled "Medicating A Prophet" written by Psychiatrist Irene Hurford (1).  The opinion piece is available free online and I encourage anyone interested in the topic to read the article rather than accepting my summary here as adequate.  I will say from the outset that I am not a stranger to any of the issues that Dr. Hurford discusses either clinically or personally.  The bulk of my career was spent treating people with severe mental illnesses and addictions.  Once you have worked in that setting, it is clear that many people who are severely ill need involuntary treatment and that is one of the decision points that she addresses.

In her essay, Dr. Hurford describes an early call experience during her residency.  She was asked to assess a man in the emergency department (ED) who had been delusional for 30 years.  The delusions were religious and grandiose in nature.  He was a college graduate but was homeless living on the street in Philadelphia.  He also had AIDS and the complication Kaposi sarcoma.  His reason for being in the ED was "to preach".  Dr. Hurford encourages him to come in for voluntary treatment but he refuses.  At that point she ponders involuntary treatment but in the essay decides to discuss the patient's right to psychosis. Later we learn that she made the decision but has decided to analyze that decision in retrospect based on factors that she has encountered since.

One of those factors was the influence of a professional colleague who based on her own experience with psychosis and that colleague's mother's experience suggested that thoughts about living "in psychosis" and outside of psychosis need to be challenged.  She basically states that the problem may be within the beholder rather than the identified patient. Following that logic, it makes sense to show up in an ED to preach while ignoring serious health problems.  It also makes sense to make decisions about the person's "in psychosis" experience knowing so little about them.  In my experience, nobody in the ED calls the parents or family of a 50 year old street person, to get a clear picture of how the psychosis has truly affected him.  When I have treated these people on an inpatient unit and made those calls, I have never heard that the patient was well served by the psychosis.  Not a single time.  In many cases, family members were surprised to hear that person was still alive.

Dr. Hurford advances a number of other arguments that I call into question.  She uses a very loose definition of insight as a "failure to accept an alternative view of reality".  She turns this around to suggest that anyone who does not accept this premise (implicitly the treating physician) also lacks insight.  I don't think that you can practice psychiatry and not be comfortable with alternative realities.  I would suggest a more appropriate definition of insight as a decision-making process.  Can I accurately assess how I am doing in the world?  Am I making decisions in my best interest?  Are those decisions consistent with my ability to survive?  If I realize that I am not doing well can I get help?  Pretty basic decisions.  Not a question of lifestyle choices.  To have a lifestyle you have to live.  That is the kind of insight that I am used to dealing with.

Dr. Hurford discusses a case of a young patient with a psychotic disorder who stopped taking his medications and started using cannabis on  daily basis.  He dropped out of college and became progressively incoherent and then mute.  She is concerned about traumatizing the patient by "enforcing" treatment even though he cannot "eat, sleep, and talk."  I don't follow the logic that some treatment intervention - even basic detoxification from cannabis is somehow more traumatic than not eating, sleeping, or being able to communicate.  How is that a preferred alternative existence?

At that point she digresses to a very brief overview of the usual comments about mental illness being only peripherally associated with violence and the lack of evidence that forced treatment led to fewer hospitalizations, arrests, or a better quality of life.  She cites a meta-analysis of three randomized-controlled studies of more than 700 people.  There are a lot of reasons why meta-analyses are not superior to the actual trial data.  There are also a lot of reasons why truly clinical samples with these problems cannot be ethically randomized or included in the studies.  There are also reasons why I would expect the entry points into these studies to be highly variable as well as the treatment resources that are involved.  In Minnesota, we have 87 counties and the rule is that there are 87 interpretations of the commitment act for involuntary treatment.  There are two corollaries operating here.  The first is that the courts will be very liberal in terms of dropping commitments until something bad happens.  At that point the pendulum swings back in the direction of more frequent commitment.  The second is that only the wealthiest counties in the state can afford to provide adequate resources to treat the severely mentally ill.  Even then there is no assurance that the counties that can afford it will actually provide the care.  Some currently function like managed care companies and ration the care.  They can end up rationing care and commitments in order to save the county money.  The lack of evidence that forced care does anything may be more of an indictment of the lack of quality or consistency in delivering care and interpreting the law  and rationing care more than anything.  I have personally treated many times the number of people with forced treatment than in the meta-analysis and there is no doubt that the outcomes were better than with no treatment.

The outcome variables cited by Dr. Hurford are also dreadfully lacking compared with what can be seen routinely in clinical settings.  They include very adverse outcomes in encounters with the police including getting shot, dying from a treatable illness, suicide, loss of relationships with spouses and children, loss of a job and income, and acute loss of life due to poor insight and judgment.  In Minnesota, all that takes is going outside in the winter time without adequate protective clothing and you are dead or in the Burn Unit with frostbite.
     
Right now we are in the midst of a sweeping cultural change that idealizes psychosis and suggests that hallucinogens and cannabis are therapeutic drugs.  That will put the next generation or two of people with psychoses, mood disorders, and substance use disorders at risk for chronicity and every possible negative outcome.  A point that should not be lost on anyone is how no care for psychosis is "cost-effective" care when the total impact on the patient is ignored.  My point in writing this rebuttal is really advice for the people in these generations.  Ask any psychiatrist treating you or your family member where they stand on this issue.  

Especially if you value psychotic symptoms a lot less than your psychiatrist does.



George Dawson, MD, DFAPA





References:

1.  Irene Hurford.  Medicating A Prophet.  New York Times.  October 1, 2016.

Will Changing The Commitment Standard Decrease The Rates Of Mass Shootings?

A colleague sent me an e-mail this morning about a story that focuses on changing the commitment standard to a need for treatment rather than dangerousness.  She asked me if I thought it would be an effective measure so that more people with psychosis are treated decreasing the risk of mass violence perpetrated by psychotic persons.  As a background, most states have civil commitment statutes that involve imminent dangerousness.  That literally means that the person in question has already done something dangerous or they appear to be at high risk for doing something dangerous in the near future.  My first reaction is that it would not do a thing and here is why - states routinely ignore lesser standards and default to dangerousness because it limits court and treatment costs.  At least until there is a "bad outcome" and then for a while the standard is broadened again.

Let me illustrate what I mean by using the statutes that pertain to civil commitment in the state of Minnesota.  The following are the statutory definitions of a mentally ill or chemically dependent person who could be considered for civil commitment in the state:

Subd. 13.Person who is mentally ill.

(a) A "person who is mentally ill" means any person who has an organic disorder of the brain or a substantial psychiatric disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or to reason or understand, which is manifested by instances of grossly disturbed behavior or faulty perceptions and poses a substantial likelihood of physical harm to self or others as demonstrated by:

(1) a failure to obtain necessary food, clothing, shelter, or medical care as a result of the impairment;

(2) an inability for reasons other than indigence to obtain necessary food, clothing, shelter, or medical care as a result of the impairment and it is more probable than not that the person will suffer substantial harm, significant psychiatric deterioration or debilitation, or serious illness, unless appropriate treatment and services are provided;

(3) a recent attempt or threat to physically harm self or others; or

(4) recent and volitional conduct involving significant damage to substantial property.

(b) A person is not mentally ill under this section if the impairment is solely due to:

(1) epilepsy;

(2) developmental disability;

(3) brief periods of intoxication caused by alcohol, drugs, or other mind-altering substances; or

(4) dependence upon or addiction to any alcohol, drugs, or other mind-altering substances.

Subd. 2.Chemically dependent person.

"Chemically dependent person" means any person (a) determined as being incapable of self-management or management of personal affairs by reason of the habitual and excessive use of alcohol, drugs, or other mind-altering substances; and (b) whose recent conduct as a result of habitual and excessive use of alcohol, drugs, or other mind-altering substances poses a substantial likelihood of physical harm to self or others as demonstrated by (i) a recent attempt or threat to physically harm self or others, (ii) evidence of recent serious physical problems, or (iii) a failure to obtain necessary food, clothing, shelter, or medical care. "Chemically dependent person" also means a pregnant woman who has engaged during the pregnancy in habitual or excessive use, for a nonmedical purpose, of any of the following substances or their derivatives: opium, cocaine, heroin, phencyclidine, methamphetamine, amphetamine, tetrahydrocannabinol, or alcohol.

The first thing that should jump out at any reader is the fact that "dangerousness" most commonly defined as a "danger to self or others" is only one of several relevant criteria (see bolded sections).  A significant part of the statutory definitions for both mentally ill persons and chemically dependent persons has to do with self care.  Can they provide food, clothing, shelter, or medical care for themselves?  Can they manage their personal affairs?  I would suggest that the majority of people in this country with psychotic disorders and both substance use and psychotic disorders who are acutely disabled by those disorders meet this standard rather than threatening or aggressive behavior.  Suicidal ideation and behavior is also less common than deficits in functional capacity or self care.  There are also a number of important legal interventions that are as important as civil commitment to address these issues among them conservatorship or guardianship that provides substituted decision making for the person with impaired cognition due to mental illness.  I worked with an even better option in the State of Wisconsin and that was a parallel system of protective services and protective placement that could be used in place of civil commitment to assure that the person had adequate resources for their day to day needs and medical care.

The article I received today talks about mental health being the default position for legislators who do not want to take on the firearms issue.  The politics of this situation and the deadlock  are quite obvious so I won't belabor the point.  The legislator in this reference wants better training for the police and a commitment standard based on treatment considerations rather than "imminent dangerousness."  I have already demonstrated how imminent dangerousness is a de facto standard that the courts and managed care systems collude with, but it really has nothing to do with existing statutes on the books.  I will take a page from the gun advocates who claim we have enough gun legislation on the books it is just never enforced.  We have enough commitment standards on the books - they are never recognized or followed.  To say that the commitment standard is "imminent dangerousness" is simply false.    

The politics of civil commitment is always an interesting process and it does shed some light on why the standards are ignored.  It actually happens at all levels.  In Minnesota, if a person is on a 72 hold in a hospital they need to be seen during that time frame by a pre-petition screener from their county of residence. Pre-petition screeners come from many counties and they vary considerably in their clinical acumen and political orientation.  It becomes fairly easy to predict which counties will proceed with commitment and which will not.  Some counties have pre-petition screeners who actually consider themselves to be civil rights advocates and they will fight any suggestion of commitment.  That fight should occur at the next level and that is the county attorneys who represent the county in the commitments and the defense attorneys.  Outcomes vary with the personality of those attorneys and some of those outcomes are not good.  The final step is the probate court judge, commissioner, or referee responsible for making the determination of commitment.  The quality and experience at this level varies considerably ranging from judges who are consistent and handle cases very well to those who clearly make wrong decisions to judges who overstep their authority and start to make medical decisions such as ordering a specific medication or quantity of mediation per court order.  As far as I can tell there is no uniform training or standards for any member of the commitment process so variable outcomes should not come as a surprise.    

With the issue of civil commitment laws that use a treatment standard, they are already on the books but  they are rarely followed.  That has to do with the culture of rationing mental health services as much as anything.  How do I know this?  I have been part of conversations where staff involved in a commitment were told by a county bureaucrat that they were doing "too many commitments" and it was "costing the county too much money".  I never really understood that argument because all of the people involved are there, on salary, and show up every day whether there is anyone in commitment court or not.  The cost should be the same if one person shows up for a hearing or 20 people show up.  At 5 o'clock everybody goes home, so there is no overtime.  I have never seen the court so saturated that they could not move through the necessary hearings and decisions.  The only thing that this false economic pressure creates is a change in the way the commitment statute is interpreted.  Suddenly the ONLY rule is "dangerousness to self or others".  That also translates to "imminently dangerous to self or others".  Notice that the statute says nothing about "imminently" and any form of the word danger is limited to a special section at the bottom about "Mentally Ill and Dangerous".    

I conclude the changing the commitment standard and expecting that to have an impact on mass violence will not work, basically because that treatment standard is already on the books and it is routinely ignored.  In Minnesota, the entire chemically dependent person statute is frequently ignored and I often hear "we don't commit anybody for chemical dependency."  There are a number of financial, avoidance of work incentives, and lack of quality standards that have facilitated that process.  It is readily observable by any psychiatrist who sees their patient back, realizes that they did not receive any care in a hospital, and notes the patient was discharged at his or her request because "they were not imminently dangerous".  The financial interests of managed care systems and the counties involved overlap perfectly at that point.

Once again I keep coming back to the old term "quality".  Quality care never involves discharging a disabled person because it is convenient to do so and it can be rationalized by a "community standard" that is determined by everybody except the experts involved and in this case the state statutes..

The focus of psychiatric professional organizations should be on defining what that standard of care should be and how to optimize treatment instead of throwing in with a managed care model for rationing care.  Rationed care has resulted in a non-existent system of care for the patients with psychosis.  And as long as that system remains non-functional, the small percentage of people who are violent and psychotic will also not get the care they need.

The prevention of violence by individuals with psychosis starts with improving the standard of care for everybody rather then trying to pick the violent individuals out of the crowd. 

George Dawson, MD, DFAPA 

More on Homicide Prevention – LA County Style

I have been developing a theme of how to prevent homicide and mass killing for more than a decade.  As previously posted, I think that this needs to be done independent of the firearms issue with a public health focus on both primary and secondary prevention.  There have been a couple of developments recently that I would like to highlight and whether or not they are consistent with the public health approach.

The first is an article in the NY Times today on a unique approach to school threat assessment and intervention.  The article describes LA County’s School Threat Assessment Response Team.  Several threat scenarios are described that trigger a multidisciplinary response from team members representing law enforcement, school officials, and mental health.  The way the program is described it is unique in terms of engagement.  Threats at school generally result in one dimensional and fragmented approach to the problem.  The school has a protocol that may result in suspension.  Referral to mental health providers is frequently a limiting step due to the lack of appointments, insurance problems, or debate over whether the school system or the health care system is responsible for assessment and treatment.  This patchwork system is a set up for people with severe problems falling through the cracks.

The LA County response is for the team to make a rapid same day assessment at the point of the threat and at the student’s home including looking at their room.  How many times have we read about the marginal teenager who is thrown out of school for threatening behavior and they end up sitting in their room focused on the same thought patterns or watching other forms of violent activity on the Internet or in video games?  Getting right into that environment seems like a powerful intervention to me and one that is likely to yield better results.  The main reason for failure in situations where a threat has been identified is that lack of follow up.    People who are threatening and aggressive are not likely to care if they are thrown out of school and they are not likely to follow through with mental health interventions.  The response team also spends time educating people about how to communicate in emergency situations where there are many misunderstandings about confidentiality.

The LA approach is innovative and exactly what is needed to assess and intervene in crisis situations involving threats and dangerous behavior.  In situation after situation, tragedies occur when people people come to the attention of someone and there is no clear map for assessment and treatment.  That is true in the school system, in colleges and universities, in the workplace and in family situations.  I have personally talked with people who said that they either did not know what to do or they actively tried several resources and were told that there were no appointments available or that the person was not dangerous enough to treat and unless they agreed to a voluntary assessment and treatment that nothing could be done.  But it doesn’t stop at that point.  I am also aware of situations where there clearly was enough evidence that the person was dangerous enough to meet criteria for an emergency assessment but it was not done of the person was released for the emergency department.  In many of these cases there was an adverse outcome.  What is the problem?

There is a significant bias against aggressive and violent people.  To some extent that bias is self protective.  Any reasonable adult knows the obvious advantages of avoiding conflicts or even irrational behavior.  There are always plenty of stories in the news about the lack of Good Samaritans in situations where an aggressive act is being perpetrated in public.  Many psychological explanations of this behavior are offered but I think the obvious motivation is avoiding the conflict and possible injury.  That same code of silence often applies in cases where there have been sudden changes in behavior and the person involved has a treatable problem.  A second level of bias is the moralistic approach to aggressive and violent behavior that equates this behavior with bad moral conduct.  That applies in situations where criminals use aggression to intimidate people and get what they want.  It does not apply when the aggression is a symptom of mental illness.

The bias extends beyond members of the general public.  The health care system is activated by a legal concept called “dangerousness” or “imminent dangerousness”.  Every state has different statutory requirements and those statutes are interpreted on a highly variable basis across every county in the state.  In some counties it comes down to some of the public officials involved seeing themselves as protectors of people’s rights.  In other counties, assessment and treatment are more of a priority.  At the level of the health care system there is another layer of bias.  The overwhelming bias these days is that people should not be assessed or treated in a psychiatric facility for more than 4 or 5 days and any assessment or treatment should be kept to the bare minimum.  It is easy to find different clinicians make entirely different decisions when presented with the same potentially dangerous patient.  The end result is a patchwork of acute care settings where people can go for help.  Because of all the biases involved unless an aggressive act has been committed the likelihood of an intervention occurring is basically a coin toss.

That is why the LA County response is so important.  It is an intervention that activates a rational response to threats from people who are likely in distress and possibly mentally ill.  There is no dangerousness standard initially and that is a critical departure from the current nonsystem.  The goal of the LA County response is to engage the person and their social network and not make a one-time assessment and decide to admit or discharge the patient based on a dangerousness concept.  The LA County response is unique in that it is based on behavior and the goal is to help the person involved rather than decide on whether or not they should be committed.  The overall approach is very similar to community psychiatry case management teams except LA County teams seem to have more latitude because they are not limited initially by commitment standards.

The is an excellent approach to the problem and I hope that it is researched, expanded to mental health crisis teams and widely adopted if effective.  I don’t know why it would not be effective.

George Dawson, MD, DFAPA

Erica Goode.  Focusing on Violence Before It Happens.  NY Times March 14, 2003.

NYTimes on Involuntary Treatment

The New York Times somehow let an all too true story about the treatment of mental illness slip through today instead of one of their more typical speculative pieces.  It is a story of a family desperately trying to get their father and husband assistance after he develops acute bipolar disorder with psychotic symptoms.  It is a reasonable discussion of some of the issues behind deinstitutionalization, involuntary treatment, and the sad state of affairs that currently exists in trying to get treatment for those with severe mental illness. 

Probably the best quote in the article follows:

“The lack of resources has triggered a devolution of the standard,” says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. “Twenty years ago, ‘imminent danger’ meant what most people think it means. But now there’s this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there’s no place to send them.”

I will refrain from the typical term applied to the situations whose definition is: "a particularly bad or critical state of affairs, arising from a number of negative or unpredictable factors".  The reason I will refrain is that it is not exactly accurate.  The entire debacle has been totally predictable.  It is the predictable result of applying managed care rationing techniques to the private and public mental health sector and denying care to those people with the most severe forms of mental illness.  When your only perspective is rationing care to make money - there are no standards.

So  what are the solutions?

They are fairly straightforward.  First off, there needs to be reasonable commitment standards with a more appropriate balance than "imminent dangerousnessness".  From the article it is clear that even that standard is interpreted widely.  There needs to be a three part standard for danger to self, danger to others, and gravely disabled and not able to care for oneself.  Some states accomplish the same goals by separating civil commitment from protective services/protective placement statutes.  The latter approach has the advantage of avoiding the use of commitment courts for issues that come up in the course of Alzheimer's disease and other dementias.

Secondly,  the statutes need to be uniformly interpreted.  My experience working with probate courts from a 3 county area illustrates that no two judges would make the same decision on a particular case.  In many counties, the social workers screening the cases had much different philosophies.  The only time that changed was when there was a bad outcome.  That outcome was typically a person released by the court who attempted or committed a homicide or suicide.   

Third, there needs to be recognition that state hospital beds are not the only solution.  The main reason that state hospital beds don't work is that there are no local resources.  Once a person is ready for discharge, there is no place to send them.  More and more people accumulate at the state hospital and nobody is discharged.  There needs to be housing resources and community teams to actively work with people to facilitate discharge and maintain them in the community.   Just building state hospital beds has the predictable outcome of building more state hospital beds.

Fourth, financial conflicts of interest must be eliminated.  They exist at multiple levels and are the predictable outcome of rationing techniques that originated in the managed care industry 30 years ago.  The basic premise of managed care is that a "medical necessity" standard can be developed that will be subjectively interpreted by the company in order to ration care and save the company money.  One of the major loopholes has been any person that needs involuntary treatment.  The managed care company can simply say this care is no longer "acute" or "medically necessary" and transfer the financial burden of care to the taxpayers.  Huge cost savings to the managed care company.  That doesn't happen if you need a heart transplant.

The financial conflicts of interest occur at every level in the system.  Another example is the interpretation that at an aggressive or self endangering event has to have occurred in order to meet the commitment standard.  The author here does a good job of providing examples.  What is not obvious is the financial conflict of interest that is present in these situations.  In almost all cases - the hearing occurs  at the county level and the judge presiding knows the county's financial status and access to resources.  That significantly biases decisions especially in the case of counties where there are limited resources.

The only solution to avoiding these pure conflicts of interest is to have the money follow the patient and have it in a dedicated fund.  It is too easy to move funds around that should be designated for the treatment of severe mental illness if they move in and out of a general fund.  

Fifth, there need to be better managers of the systems responsible for the care of patients with severe mental illnesses.  Managed care companies clearly do a very poor job.  On the other hand every state generally has a large Department of Human Services and second to education they are usually the largest budget in the state.   Despite significant constant and high demands they are generally managed like any other state agency.  If there is a revenue shortfall and everybody has a 6% across the board spending cut, DHS also has a 6% spending cut.  These departments usually employ cost  center accounting that is also a detriment to coming up with an adequate plan of care across treatment settings.  Finally it is also common these days in both managed care and state systems to see managers with no clinical experience attempting to hold clinicians accountable to subjective standards and implementing plans to change care delivery - even though they have no expertise.

These are a few changes that would make a world of difference for families and patients like those mentioned in the NYTimes article today.  I am not very hopeful that they can happen because it would also involve changing a culture that has been the most insidious aspect of managed care.  That culture is quite simply - bureaucrats and business people telling psychiatrists what to do and restricting the resources needed to provide adequate care.

George Dawson, MD, DFAPA

Jennen Interlandi.  When My Crazy Father Actually Lost His Mind.  NYTimes June 22, 2012.