Involuntary Commitment – A Case Study

Years ago I was director of a county mental health center in an Eastern state.  Shortly after taking the position, I became concerned that clients were being involuntarily committed too readily and without exploration of other options.  I issued an instruction that all such activity had to be approved by a middle manager before it could proceed.  This measure aroused enormous resistance from the front-line staff.

There was one client – let’s call him Charlie – who was committed to the State Hospital every year, usually in July.  Every July, he would become “agitated,” would scream profanities at his elderly mother, and break things around the house.  He carried a “diagnosis” of schizophrenia.

Mother would call the intake worker at the mental health center; the intake worker would visit the home, fill out the papers, get a judge to sign them, and take them to the sheriff.  Ten minutes later a squad car would pull up at the house; Charlie would walk out – generally calm – get in the car; and be driven to the State Hospital, where he would be kept for about three weeks.  Mother would breathe a sigh of relief, clean up the house, and take a well-earned rest from the burden of caring for her adult son.

Under the new system, the intake worker had to involve the middle manager.  He visited the house and found that Charlie was “freaking out” and mother was nervous and apprehensive.  So he suggested that mother come with him to the domestic violence shelter.  She was hesitant, but agreed.  There he explained the situation to the shelter staff, who welcomed mother with open arms.

The intake worker was furious.  It wasn’t fair, she said.  Charlie was the one who was being difficult – why should mother have to be “thrown out” of her own home.

The reality was quite different.  Mother was thrilled to find a safe haven and staff who listened to her and offered support and encouragement. Charlie had no one to scream at and was having to take care of himself (a new experience).  The manager visited him twice a day to confirm that he was OK.

When mother had been at the shelter for four days, Charlie sent her a message asking her to please come home, that he missed her, and that he would not be aggressive or violent.  With encouragement from the shelter staff, mother sent back a message to the effect that she was very comfortable at the shelter, and that she planned to stay at least a week – maybe two.

In fact, she returned home after nine days – to a situation the dynamics of which had been altered in fundamental ways.

The moral of the story is that the knee-jerk mental health response of shipping clients to the State Hospital at the first sign of trouble is not always necessary, and usually provides only a temporary fix.  The dynamics underlying and driving the problem behavior remain unchanged, and the problem behavior tends to recur.

  • John Grinwald

    I’m curious regarding Charlie’s situation. Under classic skitzophreniac explanations, wasn’t he under the risk of killing himself if left alone, hence the need to intern him in a hospital under high scrutiny?

    Was the decision to leave him alone based on the lack of evidence pointing to suicidal thoughts and actions?

  • Phil_Hickey

    John,

    Thanks for coming in.

    In the case of Charlie, he had no history of suicidal activity and was visited by the manager twice a day. You are correct, though, in your observation – had Charlie been at risk in that regard, we couldn’t have taken the steps we did. But not all individuals who attract a “diagnosis” of schizophrenia are suicidal – nor violent for that matter, popular perceptions notwithstanding.

  • John Grinwald

    Yes I understand, I was just curious about the sucidal variable, given that in the case of my friend, it is present and constant. I find the approach you took towards Charlie’s case very profound and interesting. Charlie is lucky to have stumbled upon a logic&care driven psychiatrist as yourself…

    Come out of retirement please haha 😉
    Thanks again for everything
    Cheers

  • Adam Martin

    I have a meeting with the psychiatrist tomorrow. I plan on telling him that this is my last visit. My mother thinks I should tell him in person. I think that if I tell him I do not believe that I have an illness, and medication is harmful, he will commit me.

    What do you think I should do?

  • cannotsay

    Be extremely careful. Do not forger that shrinks can make your life very difficult. Don’t show any aggressive behavior whatsoever. Be extremely gentle with whatever you do.

    No need to bash a psychiatrist in his/her face. You have survivor groups where you can use psychiatrists as punch bags.

    So whatever you do, be very, very gentle and peaceful.

  • Francesca Allan

    Speaking from personal experience, Adam, please consider just going to your appointment and saying nothing that might concern him. If you say that you don’t have an illness and that medication is harmful all that will happen is that he will add “lack of insight” to your chart. Nothing good can come of it.

  • Phil_Hickey

    Adam,

    Because I don’t know you personally, I can’t give you specific advice, other than what I said earlier: don’t stop the drugs abruptly. And I’m not talking about a few days or weeks. Months and even more than a year are sometimes needed, depending on how much your body has habituated to the chemicals.

    You are going to need a supply of these drugs during the withdrawal period. Presumably you get them now from your psychiatrist. Have you an alternative source lined up?

    Would you consider asking your psychiatrist to help you taper? Some psychiatrists will help with this, and if you’re comfortable talking to him, this might be preferable to looking for someone else.

    I think it’s commendable that you’re planning to retake responsibility for your
    life, but don’t underestimate the grip that psychiatric drugs can acquire on
    your body. Sometimes when we try to move too fast, things can go badly.

    I also endorse completely the advice that cannotsay and Francesca have posted for you here. You’re an intelligent person, so be smart.

    Best wishes

  • all too easy

    Are you court ordered to take meds as prescribed? Have you engaged in criminal behavior, that resulted in your arrest? Did that lead to an examination by a psychiatrist who diagnosed you with a mental illness?