Bipolar 2 From Inside and Out

Posts tagged ‘involuntary commitment’

Mental-Illness-and-Drug-Abuse

One thing I’ve noticed about all the political rhetoric about plans to deal with mental illness is that they always lump it in with drug abuse. Like the two were the same thing. Like the solutions are the same. Like the causes are the same. Like the two are somehow related.

It’s true that many people with mental illness have substance abuse issues. And lots of drug abusers also have mental disorders. But people with varicose veins also have acid reflux. That doesn’t mean they’re related.

Of course there are similarities. Drug abuse seems to be controlled by the pleasure or addiction centers of the brain. And mental illness has to do with a malfunctioning brain. But just because the same organ is affected doesn’t mean the causes – or the treatments – are related. The causes and treatments for the lung ailments cystic fibrosis and asthma are not the same.

The various conditions that we call mental illness may be centered in the brain, but we’re a long way from knowing exactly where. Serotonin receptors? Maybe. Other neurotransmitters? Possibly. Drug treatment seems to work by trial and error, at least in my experience. Every time I’ve asked a psychiatrist how a psychotropic medication works, the answer is invariably “We don’t know.”

Treating drug abuse with other drugs is counterintuitive. Besides, it largely doesn’t work. Antabuse merely makes alcoholics so sick when they drink that they prefer to remain sober. Narcan can pull an opioid abuser back from an overdose, but it does nothing to prevent the next one. And methadone has its problems as well, especially since it’s an opioid too.

Many people break the chains of alcohol or drug addiction with the help of 12-step groups. Such groups have no effect on serious mental illness. Even therapy groups have limited results with people who suffer from psychiatric brain disorders. Support groups can help some of them cope with the problems associated with mental illness, such as loneliness, frustration, fear, and, well, lack of support. But healing is a hard thing to come by, and seldom is found in a circle of people with similar severe psychiatric conditions.

Part of the 12-step approach to addictions is surrender to a Higher Power – not technically the Judeo-Christian God, but the functional equivalent for most. God has not proven to be a reliable cure for mental illness, though of course prayer can help sufferers deal with their suffering and find comfort amid their troubles.

So why do politicians make the assumption that what will be good for one condition will be equally effective for the others? That funding directed at mental health problems and drug abuse can be used for the same types of treatments and treatment centers? Admittedly, politicians are not generally well educated about either mental illness or drug addiction. That’s why they have advisors, who should be able to explain the differences and the nuances to them. And that’s why there are organizations with members who have studied the problems – or who struggle with the conditions themselves – who can inform those who control the pursestrings as well as the general public about what is needed.

It’s convenient to want to deal with mental illness and drug addiction in the same way. Treatment centers, hospital beds, and halfway houses may play a part in dealing with both problems. But hospital beds for detoxing, for example, are different from hospital beds needed for those with serious mental illnesses such as schizophrenia or psychosis, which may necessitate a long, difficult stay.

This is not the place to discuss involuntary commitment or AOT (assisted outpatient treatment, also called “outpatient commitment,” a form of involuntary treatment in the community) for severe mental illness, except to say that involuntary commitment is not an option applied to drug abusers, however much the conditions are conflated. They are complicated issues, and ones that I am not qualified to speak to.

But until we can convince people, and especially those who pull the political strings, that alcoholism, drug abuse, and mental illness are separate subjects that need different kinds of attention and support, we won’t make sufficient progress on either problem.

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Mental Health

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Systemic Breakdown and Involuntary Commitment

I don’t often review books in this blog, but Lynn Nanos has written one that has caused me to think long and deeply about an important topic, so I felt compelled to share my take on it.

The book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, deals with the involuntary commitment of people who experience schizophrenia, psychosis, some mood disorders, and anosognosia (lack of understanding or awareness of one’s own mental condition). Nanos lays out her thesis logically yet compassionately, with lots of references to back up her opinions.

What Nanos says is that involuntary commitment should be more widely available and easier to accomplish. Her experience as a clinician in Massachusetts involved many instances when she was involved with administering “Section 12” orders for involuntary commitment.

I’ll confess my bias up front. I’ve always been leery of involuntary commitment. As a person with bipolar disorder which was long untreated and un- or misdiagnosed, I have suffered with the fear that I might be committed at some point in my life. I’m a great believer in civil rights and believe that patients should have the right to refuse treatment.

Nanos is changing my mind, at least in the case of psychiatric disorders which prevent victims from knowing their own needs and taking care of themselves. She makes an excellent case that schizophrenic and psychotic patients, especially those with anosognosia, are the most likely of all psychiatric patients to commit violence and be victims of violence. This she refers to as “dying with their rights on,” a powerful phrase.

As it currently works – or doesn’t – forced commitment often leads to a revolving door of hospital emergency department stays, early release from psychiatric units, and the patients who most need help being discriminated against by psych units that turn them away because of their potential for violence and the difficulty in treating them. This results in homelessness, overuse of emergency services, release to relatives ill-equipped to handle a schizophrenic or psychotic person, and other potential dangers.

Nanos thoroughly discusses Assisted Outpatient Treatment (AOT) and other versions of court-ordered therapy and medication. Though these strategies are not without their flaws, Nanos indicates that her experience with them is that they are substantially beneficial and reduce violent behavior significantly.

Breakdown does not imply that there are simple or one-size-fits-all solutions to the serious problems with emergency psychiatry. The part insurance companies and hospitals play in not supplying adequate treatment is not ignored.

Lest one think that this is a dry, academic tome, though, Nanos fills the book with empathetic and sometimes searing stories of people that the system has failed – both patients themselves and the victims of their sometimes violent behavior.

How has Nanos’s book affected my opinions on involuntary commitment and related areas? The criteria she recommends for the procedure are far from superficial: She posits that involuntary commitment should be used only for those who are actively schizophrenic or psychotic and are unable to recognize the nature of their disorder and are unable to care for themselves – especially if they have shown signs of violent behavior or serious threats. (“Unable to care for self” takes the place of the older “danger to self” and includes conditions like homelessness, malnutrition, etc., not just being suicidal.)

Do I now think that involuntary commitment and/or AOT should be easier to accomplish? Yes, with the understanding that easier does not mean easy. We’re still talking about people’s civil rights, and those should not be broached with serious thought and safeguards in place. But my own fears of being involuntarily committed are revealed to have been irrational, a product of my bipolar disorder.

Has the psychiatric “system” broken down to the point where involuntary commitment is a necessary and even a beneficial thing? The answer, sadly, is yes. Lynn Nanos’s Breakdown has convinced me of that.

 

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Mental Health

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Young Children and Involuntary Commitment

Involuntary commitment. In California, it’s a 5150. In Massachusetts, it’s a Section 12. In Florida, it’s the Baker Act. But right now, we’re talking about Florida. Whatever the Baker Act was meant to do, it wasn’t meant to do it to six-year-olds. Yet in Florida, a six-year-old girl was involuntarily committed for two days of psychiatric evaluation after a temper tantrum at school. The child has attention deficit hyperactivity disorder and a mood disorder.

According to CBS News, a sheriff filed a report, and a social worker stated the girl was a “threat to herself and others,” “destroying school property” and “attacking staff.” Duval County Public Schools told CBS that “‘the decision to admit a student under the Baker Act is made by a third-party licensed mental health care professional'” and that the response was “‘compliant both with law and the best interest of this student and all other students at the school.’”

Florida’s Baker Act was established around 50 years ago and allows authorities to “force such an evaluation on anyone considered to be a danger to themselves or others.” Danger to self or others has long been the standard for involuntary commitment, but until recently, it has seldom been used on young children, especially without immediately notifying their parents.

“The number of children involuntarily transported to a mental health center in Florida has more than doubled in the last 15 years, to about 36,000,” according to a 2019 report by the Baker Act Reporting Center. In another such incident, a “12-year-old boy with autism was taken to a facility in a police cruiser. It was the boy’s first day in middle school and during a meltdown, he scratched himself and then made a suicidal reference,” according to CBS. The boy’s mother says that the school had a plan to follow if the boy made threats, but the plan was ignored.

It’s certainly true that six-year-olds have threatened suicide and some, unfortunately, have completed the act. And 12-year-old boys definitely have the potential to harm themselves and others. But for schools – with the help of law enforcement personnel and mental health professionals – to “Baker Act” children is an extreme interpretation of the law. “The law specifies that minors can only be held for 12 hours before [a mental health] examination is initiated. For minors, notification must be provided as soon as the child arrives at the facility,” according to the Family Center for Recovery. The law does not say that parents must be notified when the child is taken away from the school.

The Family Center adds, “The statute specifically calls for ‘substantial’ evidence, which is [a] much higher bar than simple suspicion. As a result, people cannot be involuntarily institutionalized simply because they’re acting strangely, refuse to seek psychiatric examinations, or have occasional mood swings or outbursts.”

Need I point out that all children, not just special needs children, experience occasional mood swings or outbursts? School personnel are supposed to be trained to handle these situations.

But “zero tolerance” policies for “acting out” and threatening school property have led to such excesses and others, such as the use of in-school restraints and seclusion. Restraints and seclusion are now being called into question, especially since they have been used capriciously and brutally, especially on children with special needs. IEP plans that specify procedures to follow if a child has a meltdown, as with the 12-year-old, and in schools that supposedly have staff trained to handle special needs children, like the six-year-old, are too often not communicated to staff or simply ignored.

Of course, such treatment is the exception rather than the rule. Some states are beginning to enact laws regarding restraint and seclusion. And many well-trained special needs educators would never countenance such treatment of mentally ill or neurodivergent students. But 36,000 children is a lot. Two-day commitment away from parents is excessive for a six-year-old. Police officers taking children away in cruisers before notifying parents is unconscionable. The law specifies that minors can be held for only 12 hours before [a mental health] examination is initiated. For minors, notification must be provided as soon as the child arrives at the facility.

Florida state lawmaker Jennifer Webb has introduced a bill to reform the Baker Act. It includes training for school officials and resource officers and establishes rules on when a parent should be notified that their child might be committed.

“[The Baker Act] should only be used as a last resort,” she told CBS.

 

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Mental Health

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