Category: Lessons

Recall in the second scenario the man who was throwing his furniture out of his apartment due to concerns that someone or something was trying to take over his room. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

There isn’t compelling evidence that he wanted to harm himself—if anything, he suggested that his behaviors were attempts at self-preservation.

Though he never said that he wanted to harm someone else, his behavior was inadvertently putting other people in danger: He had already thrown stuff out the window, where it could have injured people on the sidewalk. He also threw a guitar in your direction, though, thankfully, it didn’t hit you.

2. How imminent is this risk of harm to self or others?

Imminent. He does not appear to be responding to direction to stop throwing things and perhaps it is only luck that the items he has thrown has not hurt anyone.

3. Are these behaviors due to a psychiatric condition?

Probably.

Given what we know about his history and the timeline of events, it seems likely that these behaviors are due to a psychiatric condition. However, these behaviors could feasibly be due to drug use or medical problems.

Related: Will hospitalization help treat the underlying psychiatric condition?

Probably. Hospitalization has historically helped this man recover from his acute symptoms.

What actually happened?

After the guitar crashed into the wall, other people—neighbors, staff—arrived. The man had retreated back into his room and continued to shout: “People don’t UNDERSTAND none of this is MINE how did this even HAPPEN why did I think it was OKAY I won’t let it happen again I won’t let it happen again—”

After tucking myself around the corner, I shooed away the neighbors; they needed to get out of there for their own safety. A social worker used her hands to mime making a phone call, her eyebrows raised as if asking a question. I nodded.

“Hey,” I said in a quiet voice[1. The next time you’re trying to lower the volume of someone else’s voice, try lowering the volume of your own voice. It’s hard to yell when the other person is barely audible.], “I’m sorry you’re feeling overwhelmed. Just so you know, though, we’re calling 911. I’m worried about you.”

He grabbed the clock off of the wall with one hand and a framed photo of his sister and him with the other and threw both out the window. Both shattered when they hit the sidewalk.

“I DON’T CARE you can do whatever the F@#$ you want I just NEED to get rid of all this SH!T—”

The rest of us waited.

Before the police and paramedics arrived, he had thrown a floor lamp, more silverware, and much of his clothing out the window. Papers were scattered on the floor. He smashed all the mirrors in his apartment. He tore the curtains from the walls. He threw several pieces of fruit, one remote control, and his pillows out into the hallway.

I braced myself as the police appeared in the hallway. Please cooperate… please cooperate… I hope the cops won’t be jerks…

The social worker had already briefed the police and paramedics about the situation.

“You Dr. Yang?” an officer asked. I nodded.

“And that’s the guy?”

“Yes.”

“We’ll take it from here. Can you write an affidavit?”[2. An affidavit is a written declaration that is used in court, in this case to hospitalize this man against his will. The police were asking me to write the affidavit because of my credential and because of my relationship with the patient. This affidavit included my opinion that he was a danger to others, given that he had thrown a guitar at me and had continuously thrown items out of his window.]

He was rummaging through his closet when the officers knocked on the door. He looked over his shoulder and paused as the officers greeted him. A few beats of silence followed.

“OH GOD WHY WON’T THEY LEAVE ME ALONE?” the man suddenly bawled. He fell to the ground and began to weep. After glancing at each other and then me, the officers and paramedics walked in.

He initially balked at their overtures about transport to the hospital, though he ultimately agreed. He choked on his sobs on the gurney as the paramedics wheeled him down the hallway.

He was in the hospital for over a month.

At our next appointment, he sat in the chair, his eyes glazed over, his body twenty pounds heavier.

“I’m sorry about what happened that day,” he said.

“That’s okay,” I murmured. “I’m glad you’re here.”

Involuntary commitment refers to hospitalizing people against their will for psychiatric reasons. It is a controversial topic because this is where medicine and civil liberties intersect: Physicians have the ability to take away the rights of fellow citizens. (I suspect that few people who become psychiatrists realize that making recommendations about involuntary commitment is part of the job. I certainly did not know this. I also did not appreciate the ramifications until I was well into my residency training. It is the worst part of my job.)

Involuntary commitment laws differ in each state. In general, there are three criteria to consider prior to hospitalizing someone against their will. In a just world, all three criteria must be met for involuntary commitment to occur.

1. Does this person want to harm himself or someone else? The legal language often refers to this as “danger to self” (often suicide) or “danger to others” (often homicide). The “danger” could also refer to inadvertent harm—not only purposeful intention to harm self or others. For example, consider a man who believes he is Superman and wants to fly off of a roof or someone who believes that he will prevent the next nuclear war by destroying a high traffic bridge.

There is also a concept of “grave disability”, which refers to individuals who cannot attend to basic needs. Consider a woman who refuses to eat because she believes that, if she eats, she is eating her internal organs.

2. How imminent is this risk of harm to self or others? If the risk of dangerousness is high and there are concerns that harm will come to self or others “soon”, this strengthens the argument to hospitalize someone against his will. (Note that the word “soon” is not defined. “Imminent” could refer to minutes or hours, though generally not days.)

No one, however, can predict the future, so no one knows for certain who will actually hurt themselves or other people. We can only assess risk of dangerousness. This includes evaluating known factors, such as past history of violence, current symptoms, demographics, etc.

3. Are these behaviors due to a psychiatric condition? If this person is a danger to self or others, is this due to a psychiatric condition? Or is it due to something else (such as a medical condition, drug use, etc.)? Depression, substance use, and psychotic disorders increase the risk of suicide; social support, cultural beliefs that discourage suicide, and a sense of hope decrease the risk of suicide. Some people argue that the wish to kill self or others is always due to a psychiatric condition (“there must be something mentally wrong”), though others (such as Thomas Szasz) argue that psychiatric conditions do not exist or that they are irrelevant.

To further complicate the issue, sometimes it’s not clear if behaviors are due to a psychiatric condition. For example, some people argue that substance use disorders are not psychiatric conditions.

Another question to consider: Will hospitalization help treat the underlying psychiatric condition that led to the imminent danger to self or others? This last point is often not considered as strongly as the others.

This explains why some people go to jail instead of to the hospital. We don’t have effective treatments for people with antisocial personality disorder (“sociopaths”) or pedophilia. If hospitalization doesn’t appear either indicated or helpful, then involuntary commitment may not be an option.

The three cases I presented prior to this post (1, 2, and 3) are all based on true events. Let’s go through them again and, applying the above criteria, consider how to proceed. I will also share what actually happened.

“What should we do?” the outreach worker asks. “He slapped a woman at the laundromat yesterday.”

The police know him well. For at least ten years, he, along with a cadre of other homeless individuals, has spent his days in the park and nights in empty lots in the neighborhood. He limps to the right when he walks; he reportedly fractured his leg many years ago while drunk and it never healed properly.

These days, the police frequently see him before 9am because the two 40-ounce cans of beer he finished earlier in the morning have led him to call 911.

“I just wanna die,” he bawls to the dispatcher. “I’m gonna kill myself, I’m gonna jump off that bridge, I’m gonna be dead, I just wanna die.”

The police are exasperated with the hospital: “We bring him there because he has tried to kill himself when he’s drunk. Less than three hours after we drop him off, he’s right back here again and drinking! They don’t do anything, so we don’t even bother taking him there anymore. If we arrest him, he’s in jail for a few days, but he doesn’t get any help. Then he’s out and back here again.”

You’ve looked at some recent hospital records for him; he’s had numerous visits to the emergency room. His blood alcohol level is usually around 0.3%[1. A blood alcohol level of 0.08% is considered the legal limit.] and he often says that he wants to kill himself. As the alcohol leaves his system, he retracts these statements: “Nah, I’m fine. I don’t wanna die.”

He was psychiatrically hospitalized over a year ago. At that time, he said that he heard voices and drinking alcohol made them go away for a while. He started taking medication. He said he felt better. The rest of his hospitalization was uneventful. He didn’t attend the appointment scheduled for him one week after he was discharged from the hospital. He returned to the park.

“The woman in the laundromat called the police and they knew exactly who she was talking about,” the outreach worker said. “He was napping in the doorway of the laundromat and the woman asked him to move so she could get her stuff inside. He got up, followed the woman in, slapped her across the face, then left. The police couldn’t find him when they showed up.”

After speaking with you, the outreach team goes to the park to find this man to talk with him about what happened. They also intend to discuss housing, something that he continues to decline.

“I don’t wanna follow somebody else’s rules,” he has said during moments of relative sobriety. “I wanna do what I wanna do.”

The outreach team is back in less than half an hour.

“He was really pissed off,” the outreach team says. “He chucked a can of soda at us.”

“He chucked a can of soda at you?”

“We were trying to talk with him and he wasn’t having any of that. He told us to ‘f@ck off’—the usual when he’s drunk—so we said we’d come back later to talk with him. We were probably about ten feet away when an open can of Dr. Pepper flew past our heads. We got a little soda on us, but we didn’t get hit. It would’ve hurt if his aim was better.”

Does this man have a mental illness? Does he need to be sent to the hospital for psychiatric evaluation? If he doesn’t want to go to the hospital, should he be forced to go to the hospital against his will?

His sister helped him move into the apartment about three months ago. She told you that he has a long history with the mental health system: His first hospitalization, which was over six months long, occurred when he was 19 years old. Since then, he’s been hospitalized close to a dozen times—often against his will—and each hospitalization has lasted weeks to months. Sighing, she said that because of his symptoms, he’s been evicted from nearly every apartment he’s ever lived in, fired from the few jobs he’s been able to get, and unable to complete his schooling to earn his college degree, something he’s wanted to do for many years now.

“When he starts to get better, he stops taking his medicines… then we start all over again.”

He had left the psychiatric hospital the day before you met him. His eyes looked flat and dull; he hardly blinked. Saliva was oozing from the right corner of his mouth. His head was tilted to the right. Though his arms trembled when he shook your hand, he spoke with a steady voice: “Nice to meet you.”

He understandably did not like the side effects from the medications he took.

“I feel so tired. I can’t think,” he said. “I can’t play my guitar.”

Because of his listlessness, you gradually reduced the doses of several of his medications. The drooling stopped. He showed more facial expressions. The tremor nearly resolved. He started playing his guitar regularly.

“I don’t think I need the medicine anymore,” he declared about four days ago. “They don’t help me. I’ll be fine. You’ll see.”

With the knowledge of his past history, you try to negotiate with him: How about taking this medication, but not that one? What about taking this medication right before bed to ensure sleep? Let’s try—

“No, I’m fine. You worry too much, doc! This time will be different. I can feel it. Everything is clear now. I won’t end up in the hospital.”

He begins to deliver monologues about his masturbation habits. He has taken an interest in a woman who lives down the hall… and the woman who lives upstairs and the visiting nurse for the man who lives in the corner unit. He spends his nights writing 1000-word poems of love and lust to each of these women. He plays his guitar for hours. The neighbors become annoyed, especially when he starts bawling and laughing at 3am.

It’s only been four days! He’s now dragging all of his furniture out of his apartment.

“NONE OF THIS IS MINE!” he roars. “GET THIS SH!T OUT OF MY APARTMENT!”

He’s thrown some of his belongings out of the window, as it is apparently easier and more efficient to clear out his apartment that way. His iron, toaster, and most of his silverware are scattered on the sidewalk below.

His brows are furrowed, his teeth are bared, and his hands are clenched into fists.

“SOMEONE is taking over MY room THEY plan to take over my body THIS is all MINE YOU can’t make it stop so I have to make THEM stop—”

He’s struggling to push a chest of drawers towards the door. Yelling, he yanks the top drawer completely out and throws it across the room.

“Please stop for moment—” you begin.

“YOU can’t make me stop no one can me stop YOU don’t understand THIS is an EMERGENCY SOMEONE is trying to make ME go away and NONE of THIS is MINE the furniture MUST be KILLED it tells to me to DIE—”

You see him reach for his guitar and you thank your instincts a few seconds later when you hear the guitar crash into the wall behind you.

Does this man have a mental illness? Does he need to be sent to the hospital for psychiatric evaluation? If he doesn’t want to go to the hospital, should he be forced to go to the hospital against his will?