My phone flashes a news report that tells me another shooting has happened, this time in Maine. The suspect appears to be a man who has an extensive history of mental illness and hospitalization. He’s reported to have been hearing voices, and I immediately understand why he did this, why the mental health system failed him and the public, and why this will happen again and again until we find the political will to fix the problem.
It was late on a Sunday night, and I was working at the emergency room doing psychiatric evaluations. I’m the mayor of El Cajon, California, but like most public servants, I also need to make a living, and I have always done that as a mental health professional with a Bachelor of Science in Nursing and a doctoral degree in Psychology. My patient was a man in his 50s who was brought in on a 72-hour hold for danger to others, established by the police.
He had been home with his family and wanted to go to the casino to gamble. The problem was that he had no money, but he knew his young adult daughter had some saved for college. He demanded it, and when she refused, he went into his bedroom, brought out a gun, placed it to his daughter’s head, and pulled the trigger. Fate would intervene, and there was no bullet in the chamber, giving the girl time to flee while he attempted to reload.
Upon my evaluation, the patient was obviously in the throes of a manic episode, and I upheld the 72-hour hold. He did stay in the hospital and was treated for three days, but at the end of that time, he was released back home to his family.
I disagreed with his release, but there was little to say or do because the system we navigate is so affected, so underfunded, and so burdened by state law that I knew that this would be the case. I also knew that similar scenarios were being played out hundreds or perhaps thousands of times a day in California.
If a person is to be detained in a psychiatric hospital against his or her will, the first step is a 72-hour hold. The criteria for this are being a danger to self, being a danger to others, or being gravely disabled.
A person who is a danger to self has made an attempt or had an idea to seriously harm oneself. This includes serious suicide attempts or plans but doesn’t include reckless behavior, minor harm such as cutting, or drug or alcohol addiction, even if it’s potentially leading to death. It must be a result of a mental disorder—for example, a patient who didn’t want to accept treatment by dialysis, even if it meant they would die, wouldn’t be holdable.
Being a danger to others is similar in that there must be a threat, ideation, or attempt to kill or seriously harm others.
This gets tricky because it’s difficult to hold people longer than three days. After all, if the patient, after the three days, says he no longer hears voices telling him to harm people or he says he no longer wants to harm others, then usually that’s enough for release.
Grave disability means that someone is so psychotic or confused that he or she can’t access food, clothing, or shelter, even if that’s provided. Most people who end up in long-term conservatorship meet this criterion.
At the end of the 72-hour hold, if the criteria continue, then the psychiatrist can place the patient on an additional 14-day hold, but this triggers a hearing and must be upheld by a judge or magistrate.
At the end of the 14-day hold, the psychiatrist may apply for conservatorship of the person. This means that for one year, the patient’s rights and decisions will be subjugated to a conservator. This can be a family member or a professional conservator, usually one working for the government. This, unfortunately, rarely happens. The process requires a hearing at the municipal court building in front of a judge. The psychiatrist must testify, which means half a day away from seeing patients. The hospital also must send security staff, and of course, there are few locked long-term beds for the patient to go to if the conservatorship were granted.
The most frustrating part is that the judge is usually very invested in giving the patient every benefit of the doubt. No matter how psychotic, the patient may be able to pull it together for a few minutes, and the judge will usually deny the application for conservatorship.
Reports from Maine suggest that their mental health system is overwhelmed, underfunded, and inadequate. I know that this is true for California. It’s important to protect patients’ rights, but it’s my opinion that these laws are crafted in a way that makes it nearly impossible to protect patients or the public. In practical effect, if a patient attests that the impulse to hurt him- or herself or others has passed, then the patient will be released.
The hospitals are overwhelmed. In my area, every emergency department is overwhelmed with psychiatric patients. Trying to get into an emergency department for treatment of a moderate-level injury or illness is difficult because of the flood of disruptive and dangerous psychiatric patients. In my county, there are 100 county beds for 3.5 million people. The private hospitals take on the rest of the burden, and they aren’t equipped to handle the load. My hospital had daily morning meetings to talk about each patient who was admitted, with a significant emphasis on getting patients discharged.
Of course, there’s always the issue of money. Like most industries, medical treatment is closely linked to the revenue that’s associated with it. Though it’s hard to accept, a lack of funding correlates to a lack of treatment. This is significant when talking about severe mental illness in that these patients often use a state insurance plan, rarely private insurance.
It’s easy to throw up our hands and cry that nothing is to be done, but we can fix much of this if we can find the political will to do so. Each state needs to develop a realistic plan to deal with our national psychiatric crisis.
We need to build psychiatric facilities.
We need to fully fund treatment options that last much longer than three days. We need to reevaluate the laws that work against families and clinicians who seek to treat the mentally ill, who, by and large, eschew treatment. We must be willing to find the money to fix a system that has long been neglected or ignored. We must work with nursing schools, medical schools, and psychology schools to make education more affordable and encourage public service in exchange for paying off school loans and providing internship opportunities.
Yes, it will cost a lot, but instead of wringing our hands in helpless surrender or pointing the finger to bolster our political narrative, we might try having an honest discussion about how we aren’t properly treating our friends, family, and neighbors who are suffering from a severe and dangerous mental illness. The outcome will be less suffering and death for all of us.
