Lines In The Sand

Roberta X said it best. Calling 911 or a suicide hotline is NOT the same as simply “mention[ing] it out loud”. It is either a cry for help, or a demand for attention. I am not willing to risk my livelihood and my family’s security for the freedom of someone whose actions are DESIGNED for them to have their freedom taken away.

If a person is So much of an attention whore that they must make their “suicide” a big dramatic production (or they’re too stupid to see the consequences of such attention) then they’ve brought the psych hold on themselves BY THEIR ACTIONS.

I’ll support someone’s freedom of self determination, not their freedom to tie up valuable public safety resources with grandstanding dramatics.

 The law is no excuse, only cowards hide behind it.

1. I’m never doing it by myself. The police are always with me. In some jurisdictions, the police transport. In ours, the EMT’s do. But the police are almost always involved.
2. You neglected to read that whole comment thread about where we DO assess the situation. I’m likely to take the word of a calm and lucid patient over some vague and shadowy 911 callers who is not on the scene and didn’t give a name. However, if the patient admits to saying it, my hands are tied. I’m not the one who gets to decide whether it was a valid threat or not. The ED doctor is.
3. In the context of “coming to take you away,” I’m more like the guy who gets to take you to the embarkation point where you *might* get taken away if the doctor is convinced you are a danger to yourself, and…
4. Your only choices in that matter ARE restrained or unrestrained. The majority go unrestrained and we have a pleasant ride and a conversation on how to best convince the ED doc that you’re not a danger to yourself, but I can and will restrain you if that is the only way to accomplish that transport.
But let’s not confuse my “fish or cut bait” speech, often given an hour or more on scene AFTER I have assessed the patient and the situation, with me throwing my weight around and being overly authoritarian. I work a 911 ambulance, and emergency calls are holding while I’m trying to convince the drama queen why she shouldn’t threaten to kill herself if she didn’t really mean it.
5. As for “who the fuck gives me the right” to do all this, it’s your friendly neighborhood Congresscritter, via the Baker Act, but I don’t look at it as a right, more like a dirty job I’d rather not have.
6. There is a simple way to keep from even needing deadly force to resist such things: don’t open your mouth and threaten suicide, even jokingly. I’d much rather not be on scene when the liberty-loving dude gets gunned down over his principles because it was his right to get good cops and medics involved in his drama play.

Another example why you NEVER give police any more info than you legally have to. 

Well, you stirred ‘em up good this time, didn’t you Kelly? Bunch of wannabe libertarians who can’t think their way out of a wet paper bag and have absolutely no idea that our founding fathers understood the relationship between rights and responsibility very well. Somehow, these guys seem to have read the Bill of Rights and not the whole constitution, which is a wonderful balance between one branch of government and another, the federal governments and the states, and any government as against the individual. Thomas Jefferson is shaking his head and saying, “No, fool, rights don’t mean you can do whatever you want so long as you don’t think anyone else will get hurt. There are obligations to citizenship as well.”

So, let’s get down to brass tacks. First, AD is absolutely right. There is nothing in this blogpost with which any well-informed, reasonably intelligent person would argue. 

There are a couple of posts from well-informed, reasonably intelligent people. The rest are deficient on one side or another of that equation.

Maybe it’s bona fides time. I am a social worker with 35 years experience. Doctoral level. I’ve worked in public and private settings, rural and urban, child protection and mental health. I’ve seen all of this from all sides: as a professional and a part of the system, as someone who has family members with serious mental health problems, and as a 24-year recovering alcoholic with infrequent bouts of depression and panic attacks (hence the efforts at self-medication, early on, which eventually led to this truly wonderful life of recovery.) 

The poster who talked about his experience with psychiatrists was right on both grounds: there really are those crooks and wackos out there, and it really is anecdotal evidence. There are far more well-meaning and competent mental health workers (not just MDs, but psychologists, nurses, social workers, counselors, etc.) The well-meaning and competent far outnumber the crooks and wackos. The crooks and wackos, unfortunately, cause negative effects way out of proportion to their numbers. Here’s the thing: even if you are brought to the goony roost on an involuntary commitment, you have the right to ask for a doctor you can work with. You don’t have to take the first Joe or Jane who comes along. If they seem hinky to you for any reason, get another. Keep trying. 

AD is right, that all too often the MDs over-rely on medication. I have helped people get off ridiculous amounts of meds. Just this month, I encountered a 12 y.o. boy whose doctor had him on Ritalin and Adderal. No kid needs two different stimulants, no matter how ADHD they may really be. I will point out that this gaffe was caused by a pediatrician, not a psychiatrist, but that is no guarantee that it couldn’t have been. I’ve seen some crazy stuff.

Without offering phony excuses, I have to say this: there are not nearly enough well-meaning, competent psychiatrists to handle the load. They do get rushed. They just don’t have the time, way too often, to really get to know the patient. That’s where people like me come in. I have good relationships with the docs in town. They know I get to spend tons more time with our patients than they do. I don’t try to tell them how to practice medicine, and they don’t try to tell me how to do psychotherapy. But we listen to each other, and when they have bungled it, they will correct it. You can’t ask for more, because you can’t suddenly concoct a huge new supply of well-meaning, competent psychiatrists.

So, you’ve got different groups of people who Kelly is talking about. You’ve got the truly depressed, who are truly having suicidal ideation, who may not want to go the psych unit, but who are so glad they did when the depression lifts enough that they are no longer suicidal. Genuine suicidal ideation is not the planned suicide Dr. Kavorkian talked about (and this is not about my opinion of Dr. Kavorkian’s effectiveness as an advocate.) Genuine suicidal ideation is irrational. It makes no sense to anyone except the person who’s got it. It is a symptom of an often deadly illness. If someone suddenly started slurring their words, couldn’t raise both arms equally, and passed out, you wouldn’t argue that they ought to have given informed consent before being transported to the ER. You get that stroke treated. Same here. People in that condition are not capable — let me emphasize that, NOT CAPABLE — of giving informed consent. Those who have not seen enough of this, have no idea how powerful and compelling irrationality can be. Shut the hell up and listen to people who do know. Period.

Then you’ve got the maladroit, of both genders. They don’t know how to handle a conflict or a bad situation, and they start to wish they didn’t have to. Or, worse, they use threats (to self or others, as the legal language goes) to force their preferred outcome on someone else. Libertarians of all stripes, get this and get it right: emotional blackmail is no more defensible than physical coercion. You wouldn’t stand by while the guy beat up his girl friend, would you? (If you would, then you have no standing in this discussion at all.)

In both of those cases, Kelly does not have the competence to decide. He knows this. He knows that I am not slamming him. I don’t do what he does, he doesn’t do what I do. With my Red Cross certification and my Scout training (kept constantly up to date as an asst. scoutmaster, training new Scouts), I know damn well when I want Kelly or his brothers/sisters there beside me. And Kelly knows when he wants me on his side. Even if he had a choice, which he doesn’t, because both the law and his licensure don’t give him that option.

The last category is the one that others have referred to: the person who really means to kill themselves. Tomorrow, my wife and I will observe the anniversary of the suicide of her son by a previous marriage. He didn’t tell anyone. He went off by himself and shot himself. How I wish someone could have man-handled him into an ambulance and taken him somewhere, where he would have had a chance of getting over to that other side where they say “thank God I didn’t succeed.” And that’s all I am going to say about that. The rest is between my wife and me.

You are advocating detaining someone who has not necessarily committed any crime, without due process of law (a trial), for expressing an opinion (that they are better off dead/ wish they were dead), based only on hearsay.

If they had tried to bargain with a suicide threat they deserve to have a trial for what I presume to be extortion under the law.

If they announce to you that they plan to jump off a bridge tomorrow morning you may have an argument for civil commitment but expressing the opinion that they are better off dead is no more proof of suicide than telling your mother in law to “drop dead” is proof of attempted murder.

1st 5th and 6th amendments seem to be fairly clearly trounced on in your description.

This is of course skipping over the moral questions of a right to self determination (do people have the right to off themselves), and the basic human right to choices in healthcare and a system that often drugs people against their will.

From your comments below I do not believe that you are as extreme as the article makes it sound but I think that you are still very far removed from the morality of a free society. I think you are trying to help people but don’t agree with how. I am equally sure that most of the people involved in the soviet revolution were trying to help the workers, and most of the English people in the colonial days thought that the British Empire was helpful to the savages.

As a fair hint to freedom: If anyone is pleading with you to not ruin their professional life and lock them up without a trial and with no proof you need to look closely at what you are doing especially when you are just doing what someone told you to. Like others have said: you are responsible for the morality of your own actions even if it is “legal” in your state.

To wrap this up, it may be morally better to choose safety over freedom. There are plenty of countries that choose that path but ours is not yet one of them. You are entitled to the opinion that our country should move to that, I recommend you try to have a constitutional amendment grant all sorts of exceptions to the bill of rights so you can lock people up “for their own good. Right now we have a constitution and history of placing individual rights over what is most “safe”.

 You have your three categories.
1. Suicidal and incompetent (by your claim)
2. Criminal and manipulative
3. Actively attempting suicide.

Even if we agree with you that the first category need immediate psychiatric help and are not competent to make decisions any other patient would have the right to have their family make decisions about their care. How do we impose a permanent legal harm on them before we know if they fall in that category? Unless the person admits to being suicidal we are talking about removing the vast majority of a persons civil rights and their liberty with no trial based only on one statement by one witness with no guarantee that they don’t have an axe to grind. You make a reasonable argument for commitment for the people that need it but fail to address how to determine those people. Remember that this has lifelong consequences like removing the right for them ever to buy a gun even if it is later shown that they never said anything suicidal in the first place.
How is it that the same medical profession that honors DNR paperwork believes that they have the right to force their help on others in all cases?

For the second group they deserve a full jury trial. By your own account they are criminals that are harming someone else but you are not the judge or jury to punish them even though you obviously want to be. Again, even if they fit your description you are ignoring the issue of if they said it or not. I will not claim that it is in any way defensible to emotionally manipulate another in such a cruel way but we still have to prove that even those accused of the most vile acts are guilty before we lock them away. That whole “Innocent until proven guilty” thing is inconvenient but vital to a free society.

There are three things to address in the third category:
    1. The original post was concerning verbal statements
    2. If they don’t give it away in the first place this never becomes a question
    3. There are considerably less question on proof when an active attempt is interrupted than when someone claims that a threat was made
I am genuinely sorry for your loss but that doesn’t mean that I will agree with your conclusions. There is too much potential for abuse when anyone can have anyone else locked up just by lying about them being suicidal.

My personal opinion is that in any case where a person contests involuntary commitment they should have a chance for a jury trial even if they have to be held under suicide watch until they are committed by a jury. It appears to have the best safeguards for due process on one side while still being likely to stop a suicidal person and get them help. There are some difficult questions about bail in such a situation but it is better than giving away all civil rights anytime it is “for our own good”.

 First of all, the EMTs and medics are not detaining anyone.  We have a say; but the police are doing the detaining (police must fill out the involuntary hold form, not the EMTs), and even they are not “locking them up”.  The involuntary hold must be approved by a licensed doctor or psychiatric professional; i.e. someone who IS qualified to place the person into one of the three categories.  When AD talks about taking someone in, he’s talking about taking someone FOR EVALUATION, not for the hold itself.

For my part, I do a lot more of what you’re accusing AD of: I do a lot of transfers from EDs to lock-down psych facilities for the actual hold (or longer).  In my experience, the people brought in by police/ambulance are always either significantly altered (i.e. hallucinating or psychotic) or have physical evidence of a suicide attempt (lacerated wrists, overdose, or setting their hair on fire).  Neither police nor ambulance people want to put someone on an involuntary psychiatric hold; from a cynical perspective, the hold paperwork is a huge pain in the ass, and it’s easier to just drop someone at the ED (or in a holding cell) and pass the buck to someone else.

Yes, people get put on involuntary holds that shouldn’t be; but in my experience they fall into two categories. The first are people who voluntary walk into the ED who somehow convince the experts that they’re a danger to themselves (e.g. make a credible threat).  The second, and most infuriating IMHO, are children being committed at the parents’ request.

I know the plural of anecdote isn’t data; but I’ve done a lot of those transfers and, at least out here in California, the system seems to work properly.  The ones police and ambulance bring in for involuntary holds are either seeking help (suicidal gesture vs. serious attempt) or truly are not competent to make decisions on their own welfare.

One may well ask: “How can you advocate breaking some laws and
obeying
others?” The answer lies in the fact that there are two types of laws: just and unjust. I
would be the first
to advocate obeying just laws. One has not only a legal but a moral responsibility to obey
just laws.
Conversely, one has a moral responsibility to disobey unjust laws. I would agree with St.
Augustine
that “an unjust law is no law at all.”
Martin Luther King Junior

You are responsible for choosing the morality of your own actions.  You may be doing so but ILTtim is correct that law does not define morality even though morality “should” limit law.

 The argument here is still that of someone removing the liberty of another just to protect themselves. It is one of the weaker arguments for this on here ethically  but one of the strongest to many people who are concerned with their own life.

Removing someone else’s freedom is not justified to cover ones own ass. It may be justified on other grounds.

And if fighting it the way you’d have us do it results in us being unemployed and unable to provide for our families, and subject to various criminal and civil penalties?
Would that be morally acceptable to you?

There are a number of ways of fighting within the system without choosing a frontal assault doomed to fail.

I can’t disagree with any of that statement.

I guess the difference is that the times I feel my actions are morally justified in following that law far outweigh the times I feel it is an injustice, and I see no point in sacrificing the good I do for a protest doomed to fail.
Kelly Grayson

 Yes that is one outlook but if you look back at the original article it is about dragging someone off if they mention the idea in a conversation with someone not about someone calling a suicide hotline. Even if they do that asking for someone to talk to is no the same as asking for the help of being locked up.

 On the questions of if we are talking about being detained this is a clear example. Someone is being threatened with being attacked by multiple security guards, tied up and injected with medication because they allegedly said something when they were drunk. Using unnecessary medical treatment as a threat to detain someone is low. If they were arguing about wanting to leave so that they could go kill themselves you would have more high ground but if they are just saying that they don’t want to be locked up against their will then it is less defensible.

 Yes, people are responsible for their own words. But they have rights.

What happened to the semi driver is a horrible thing but we should not lock up anyone that MAY someday do something horrible.

Choosing to follow a law that is wrong, silly or unjust to yourself is a personal choice. Following a law that is an injustice to others is morally wrong. I can’t think of any time that I have imposed an injustice on another under cover of law.

Whenever someone is detained against their will they are being deprived of liberty. This is allowed under many laws and it is morally acceptable only somewhat less often then it is legal but to claim that liberty has not been deprived when you lock someone where they do not choose to be is a prima facie fallacy.

Anytime you do not hear the words yourself but still judge them to have been said you are acting in place of a jury.

 While I also agree that Detroit EMT’s remarks sound unprofessional, you’re missing a very important point.

The patient is threatened with the security guards and medication ONLY IF HE THROWS A PUNCH.  In other words, only if the patient becomes a physical threat to the EMT will he be subject to restraint by the guards and RN.

For my part, I’ll usually explain that there is a legal piece of paper that says they will go with me.  If they’re reasonable in their arguments, then I’ll usually talk to them about how to most quickly get released and how to avoid another psych hold in the future.  However, the instant they cock their fist or take a kick at me, they get the “Sit down or be tied down” ultimatum.  I’ve had colleagues hospitalized due to assaults by patients like this; and a lot of the patients are thinking, “I’m on a psych hold, I can’t be arrested for what I do right now.”

That is generally every EMT/Medic’s breaking point.  Call us whatever vile name you want, shout anything to anyone in hearing; but if you become a real physical threat, the game changes.

Just to be clear here: the only people we drug are those who are CLEARLY not in possession of their mental faculties, and the state of their physiologic arousal poses a danger to themselves and the rescuers. The why’s and wherefores are long enough for a blog post in itself.

When we sedate someone, they are almost without exception people who are violent, and I’m not talking about those who say, “I’m not suicidal, I don’t care what someone else said, and if you try to take me against my will there’s gonna be a fight.”

For *those* people, there is only a struggle if they wish one, and the physical force is limited to restraining the patient safely. Blows may be struck, although I fervently hope not, but rarely by me or the other EMT’s. Mostly it’s done by overwhelming numbers and speed sufficient that no blows CAN be struck. And once the patient is restrained, all of that ceases.

Obviously, I find those struggles distasteful, but I will not shrink from them if that is my only option.

The sedation is reserved for patients in a heightened state of physiologic arousal called “excited delirium.” Most often it is caused by mental illness and a combination of stimulant and/or hallucinogenic street drugs. Sedation for THOSE patients is essential, and quickly,
because the fight does not end once they are restrained. They fight
against their restraints, all the way to a physiologic death spiral.
Most of the “Tazer deaths” you read about in the papers were patients in
excited delirium. The Tazer probably had little to do with it, but they
don’t issue sedatives to cops because they don’t have the training to
administer them safely.

We do.

In those cases, the sedation is LITERALLY to save the life of a patient
who is obviously mentally incapacitated.

Otherwise, we don’t sedate your garden variety psych patient – and most
especially the ones we think were speaking in anger or the heat of the
moment, or those accused by third parties – for one simple reason:
psychogenic drugs make it damned hard to separate the sheep from the
goats once we arrive at the ED. It’s impossible to reliably assess a
depressed patient’s emotional affect if they’re sedated, and thus
impossible to judge if the patient needs to be committed or not.

Sedating the violently psychotic patients actually makes it *easier* to
assess them, because once sedated it is far easier to communicate with
them. Kind of hard to ask a patient, “So, how are you feeling?” when the
patient’s hallucinations make the caregivers look like face-eating demons.

Well, generally they have ambulances and fancy equipment that costs many thousands of dollars to go along with the spiffy uniforms, but I get your point.

The acid test: If their uniform does not bear coffee stains, and the EMT does not look tired and slightly rumpled, he’s probably a friggin’ impostor up to no good, or a supervisor, whichever.

Shoot those on sight.

 I also won’t use chemical sedation as a threat.  If I’m using chemical sedation, it’s because the patient is violent beyond reason and neither discussion, threats or even forcible restraint will reduce their violence.  Usually there’s some drug involvement, though I’ve seen it arise from PTSD.

As for imposters, I know of no state that allows EMS alone to take a person off the street on an involuntary psych hold; the police must ALWAYS be present and make the final decision to send the person to the ED.  From there, it’s up to the doctors and mental health professionals.

 Matt, not shifting responsibility.  You asked how to deal with the potential for imposters; if there’s an EMT at your house trying to claim a psych hold without police to back him up, something’s wrong.

My patient, my ambulance, my responsibility.  I take that VERY seriously.

While that is a small problem as it exists now can you see the potential for more and more of these borderline issues being regarded as reason for commitment. The potential for those who refuse treatment for ADHD being defined as a danger to others? Or the danger of any political radical to be defined as Antisocial or any of the other labels and shown to be a danger to others. It is not the biggest danger to liberty and free speech in this country but it is certainly something to be watched very closely.