[Music] hi okay it's working thank you everyone for coming it's a pleasure to introduce dr renee binder um probably well known to many people in this room dr bender is a full professor in our department has been a long-standing faculty member ran our inpatient psychiatry unit for many years among other things and still comes up to cover a couple times a year which is much appreciated she started our psychiatry in the law colloquially colloquially known as the forensic psychiatry fellowship program here at ucsf in the 80s 2000 2000 ah more recent okay and was also more recently past president of the apa so and besides that has been a wonderful and appreciated mentor to me over many years so without further ado thank you for coming today thank you um so as um andrew mentioned i ran the impatient unit really starting in the 1970s and believe it or not in those days a patient would come in they will put on a hole and we could keep them there they could appeal their 5250 by going to san francisco general and some of them did go to those hearings um and while i was on the unit we started to have what now called probable cause hearings it used to be called dovi galino um hearings and um and then we started to have the reese hearings and my perspective uh oh and the patients rights advocates would come on the unit and talk to the patients about trying to get them discharged and my perspective was why are these people here and what are they doing and we're just trying to treat these people and they're trying to get in the way and that none of this made you know any sense and then you know they just have no business on uh doing that and that was uh my perspective for a while and what the talk and to some extent when i cover on the unit i think it's still people's perspective that all of these groups are basically a nuisance and it would be much better if they weren't around and why are there so many people where we can't put them on hold and their family members come to us and they're homeless and they're in the community and so what i'm going to present today is just a slightly different perspective because what i have learned is there are very good reasons for civil commitment laws there are movements um certainly in this state and around this country to make it easier to put people in the hospital to try and take them off the streets to institutionalize them people talk about how psychiatric mental state mental hospitals should not have been defunded and if only we had state hospitals we'd be back to the good old days and they really were not the good old days so um okay my disclosure so let's start out just with some of the the ideas behind civil commitment so a man comes into the emergency room he is a very high-powered ceo of a company and he has crushing chest pain he has enzyme changes and so the people in the emergency room say to him you're not going any place sir you know you have to go up you're having a heart attack and you have to be hospitalized on the um ccu um or else you're gonna die and in fact there's one in 10 chance that unless you come into the hospital you're going to die he says i don't want to come into the hospital i have a really important board meeting there are millions of dollars dependent millions and millions of dollars and just give me something and i am leaving okay can he leave yes why someone he has the capacity he knows what the risks and benefits are he knows he might die and he still wants to leave goodbye sir we wish you well um on the other hand a woman comes into the hospital she says i'm really really depressed her family brings her in she is suicidal she says i want to die but i don't want to come into the hospital we say to her you're at very high risk of committing suicide we can treat it or at least give us a chance to treat the underlying depression um can we put that person in the hospital same thing one out of ten chance of death can we so this ceo can leave who might die but this woman we're telling her it's not your choice you need to come into the hospital or just another example a gang member comes into the hospital he's just been caught by another gang member and the only thing he says is i want to get out and get him back can we keep him maybe does he have a mental illness we could say intermittent explosive disorder or maybe anti-social you know come up with something but he doesn't really have a mental illness and we're not here i mean there are a lot of dangerous people out on the streets unless they have a mental illness we really can't keep them in the hospital um okay so it's very very different and we're taking rights and institutionalizing a certain group of people whereas we're not a whole other group of people so the legal basis for civil commitment is first of all you can only hold someone if you're legally allowed to do it and it's is the person dangerous um how sure are you you don't have to be 100 sure to say they have a mental illness but you have to say something it can't just be this person is very very angry and the issue is is there a mental illness because again if there's no mental illness i mean a clear cut or at least sort of clear cut we cannot hold that person against their will so does anyone know who this is this is sort of the poster boy for civil commitment anyone know who this is we know who john hinckley is he's the one who tried to assassinate ronald reagan those people from new york may know who son of sam was who did these serial killings do you know who this person is okay so this is andrew goldstein oh buford farro did racially motivated crimes in in southern california so andrew goldstein was a man who had chronic schizophrenia was in and out some of the state hospitals in and out of the state hospitals in new york he kept he wanted to be in the state hospital because it was much nicer in the state hospital on the street and so he um uh had just been told well when there's a bed maybe we can get you in but you don't really meet the criteria for us putting you in a state hospital so he goes to a subway station in new york and he's looking around for something to do and i heard his confession um after he does the crime and he sees this blonde woman and then he kind of looks at her and says no not her and then he finds this other woman who's just standing on the subway platform her name is kendra webdale and he pushes her in front of a moving train and of course she dies he is i mean everybody sees it uh the police come and he says now will you take me to the hospital so this is the basis of kendra's law um kendra webb dale was a young woman i think she was in her 20s um who had what came from the midwest who came to new york never really rode the subways but she was writing it because she was on a dinner date sort of the kind of person that was very appealing and people and he didn't even know her he just chose her and her parents went to the legislature it became a huge thing and it was the development of kendra's law similar law in california called laura's law and kendra's law is the basis of outpatient commitment in new york when there was outpatient commitment um assisted outpatient treatment in california very very similar to kendra's law um in new york and the ironic part of it is that mr goldstein would not have been put on an outpatient commitment on the basis of kendra's law in fact he wanted treatment he wanted to go to the hospital but that was used as invasive the same thing for the perpetrator of the victim of um laura's law would not have been holdable under the criteria of outpatient commitment in california and in fact he had been evaluated shortly before he killed laura at an outpatient a mental health clinic police went to his house he didn't meet the criteria for 51.50 he said i don't have guns i'm not going to bother he was actually targeting a social worker in the clinic where laura wilcox worked and the last words out of laura wilcox's mouth before she was shot she was a college student who was just working there over the summer when he's here you better hide and unfortunately um she was shot so he didn't have the history that you need in order to be put on an outpatient commitment assisted outpatient treatment in california so let's just look at the history of involuntary treatment so this is a quote the number of persons distempered in mind and deprived of their rational faculties has increased greatly in this province some of them going at larger terror to the neighbors which are daily apprehensive of the violences they may commit so let's have a vote when was this written how many people think the 20th century the 19th century okay 18th century 17th century okay benjamin franklin so 1759 1751 so what benjamin franklin was saying was he wanted there to be a psychiatric hospital built in philadelphia there was one that was built that in fact it only recently closed down and so he was trying to appeal to the legislators and saying we have all these violent people we better have a psychiatric hospital to put them in when i hear about this i'm reminded some of the arguments um after there's a masked murder which of course the person who's likely to commit a mass shooting is an angry young man with a gun that's the typical prototype of someone but what you hear is everyone's saying we need more psychiatric we need more money for psychiatric care this is the mental health issue even though it stigmatizes people with mental health but i know it's been it was hard for me when i thread into the apa to say no we don't that's not the issue because of course you want more money it's always a good thing but that's not going to solve the problem um you know the issue of people on the street has been around for a very long time especially since uh the treatment has moved from state hospital to the community but here's another quote the right to restrain an insane person of his liberty is found in that great law of humanity which makes it necessary to confine those whose going at large would be dangerous to themselves or others so it was written by supreme court justices how many people have been 69 56 1845 okay 1782. so the massachusetts supreme court said it in 1844 again the same issue what are we going to do with these people who are clearly psychiatrically you so what's the legal basis for involuntary hospitalization there's really two criteria what is parents patrioti which means that society has a responsibility for those people unable to care for themselves it's a very patriarchal a very paternalistic um idea um parents patriotism father of the country and that if we see people in need we have the responsibility and the authority to provide services for them um and then police power the authority to prevent harm and governments do have police power we always want to make sure it's not abused but there are certain things there are laws you have to ride a bicycle um you have to have a helmet you know for a bicycle for a motorcycle seat belt laws that we have the path the authority to pro for even if people want to hurt themselves the authority to try and prevent it so there is legal reasoning against involuntary treatment so the constitution prohibits detention of a person against his will without procedural or legal safeguards and this is a really good thing right we we're in in the united states can't just pick people up and throw them in jail or throw them in hospitals privacy rights which means you can't touch someone people have the right to be private um the eighth amendment which has to do with cruel and unusual punishment and the fifth and fourteenth amendment a due process requirement when confinement is at risk you can't just pick someone up there has to be a whole process which of course is how we get into the hearings and the court hearings the now there has been a lot of abusive civil commitment so in yesterday's new york times there was an article about charles dickens it was on the in the first section kind of midway through and i thought wow this is just what i would be talking about tomorrow so charles dickens so we all love apparently in 1858 he separated from his wife of 20 years and he had an affair with a young actress ellen chernin and what the article said is that letters were found um which explain that he was very unhappy with his marriage um she had borne her 10 children and she had lost many of her good looks and was growing old that's what the letter said um and he tried to put her in an asylum a psychiatric hospital with assertions of his wife's the word that they used was languer which basically said fatigue yeah i'm sure you can do too much to take care of the kid and also of excitability um and that this showed and this was a key term moral insanity and dickens had a friend a psychiatrist thomas duke who happened to write a run a private asylum so he called up this guy and said i want my wife put away um and to his credit thomas duke refused to hospitalize her but what the article said if there were an awful lot of victorian physicians who would have hospitalized her that basically women were property if your husband said off to the hospital he would talk to the psychiatric hospital and after all you had all these kids and i had a little time taking care of them and you're not as attractive um and then dickens wrote about this psychiatrist and he called him this is one of his best friends initially a wretched being and he was a medical donkey okay and then there was the story of mrs packard in 1864. so in illinois there was a statute that provided for commitment of married women by their husbands quote without the evidence of insanity or distraction required in other cases so we put her on a railroad and sent her off to the psychiatric facility some historians think that this is the origin of the word to be railroaded and um she was there for three years and when she came back she was really angry and she was partially fought to change these laws and then of course in more recent history we have the whole history of soviet dissidents that in the old soviet union there were these terms ambulatory schizophrenia and it basically meant that you had political beliefs that were not consistent with communism and some of those people were also put in psychiatric hospitals so civil commitment in the 50s and 60s you needed to pair underneath the doctor and appearance patrioti you need treatment you don't know it we're going to put you um in treatment whether you like it or not you are presumed incompetent after civil commitment so at the same time as you are hospitalized a lot of your rights were taken away and in fact you had to go to probate court to be able to write contracts to be able to enter into any kind of agreement any kind of civil um confidence then we have the 1960s which was of course the civil rights movement for minorities and women and then we started to have in 1967 rights for juveniles because also parents could stick their kids wherever they wanted many facilities and so there was a landmark case which required due process for juvenile and that set the stage for civil commitment reform then in 1969 california had the first civil commitment statute we call it the lps does anyone know who lana and petra short work i know their name is on the legislation so they were three legislators mr lander mitchell pesters mr short and they um author broke this legislation and there was a move from parents patriarch we think you need to be in the hospital by whatever criteria we have to you have to be dangerous and dangerousness being a some kind of reason and you also have a mental illness in order to be in the hospital in 1970 there were other cases wyffy stiffney this came out of alabama so people were being put into the state hospitals there and they were just being warehoused so there was a supreme court decision that said if you're depriving someone of liberty you also need to provide treatment and the decision was written you have to have a certain kind of nutrition every day three meals a day you have to have a certain space around your bed i was um it was very directive um but again there was this whole movement of civil rights and that just because you have a mental illness doesn't mean that you don't have rights in 1972 lester v schmidt she was committed in wisconsin and um due process rights were established for civil commitment including you have to have mental illness and you have to have dangerousness and this statute said it has to be beyond a reasonable doubt so it's like if someone is convicted in a criminal case you they really have to be dangerous if you're going to take away their rights this is no longer stands in any um any place the standard right now is clear and convincing evidence which people said it's probably a good compromise to have to prove it beyond a reasonable doubt we'll have a lot of people out of the hospital who really should be there but you need a little more than just 50 so it's more like 75 and there are serious consequences of civil commitment including stigma in the decision they say that they quoted some research that said employers would rather hire an ex-felon than someone who was civilly committed there were other cases that went through the supreme court having to do with what how how should we use civil commitment so the requirements for civil commitment are you have to have a mental illness you have to meet the criteria of dangerous to sell from dangerous to others and three-quarters of states is also greatly disabled not in every state so if you ever practice in any other state you have to see what their statute says and grave disability is defined as it is in california i mean sometimes the wording in the statute is a little bit different unable to provide food shelter and clothing for yourself and then there has to be some degree of treatability that you can't just warehouse people if you're gonna put them in a psychiatric hospital but there's also been a whole movement that people have the right to refuse treatment and again if this is just a this was a different perspective for me but when you think about it you say thank god we live in the united states where we do have these laws in the supreme court decisions so in one case the quote was this is i'm justice cordozo every human being of adult years and sound mind has a right to determine what shall be done with his own body good idea and common law individuals who touch another for the purpose of treatment without the patient's consent are guilty of battery which means that you have to pay money civil damages and you can even be put in jail of course patients have a right to refuse surgery they have a right to refuse chemotherapy i mean if someone comes in and they have advanced cancer which is treatable the family can try and convince them to get treatment but we can't force anyone um to take treatment patients have a right to refuse medications based on religious beliefs so if you're a christian scientist and you don't want a transfusion even if the doctors think that you're going to die you can refuse it and there are all kinds of constitutional issues so it's really a balance of interest which is what civil commitment is all about so the family has interests the state have interest which is to restore mental health for the patient's own benefits safe institutional functioning this is also one of the things that when you're looking at it from the perspective of the state that if you have an institution you have to keep the institution safe you don't want to keep people in restraints all the time so you have to medicate them so that other patients and the staff are safe and then also cost saving so it's certainly better to have seven days of hospitalization in six months versus patients rights where disability rights patients rights say that people have the right to autonomy to privacy and a liberty interest and it really is a balancing of those two so can involuntarily hospitalize patients be medicated against their will and non-emergency situations can they yes who said yes if it's a non-emergency upon the inpatient unit patient is refusing the medications well if they do it depends on if they've been deemed competent or not that's right right but let's say they haven't had a wrist hearing yet okay can they be medicated no no until they're deemed incompetent so there's an interesting movie called 55 steps i don't know if anyone has seen it it has a good cast it didn't get a large distribution but it has helena bottom carter who plays um eleanor reese and then it has hillary swank who plays her attorney 55 steps refers to the steps of the california supreme court where it's about not being heard they kept the decision of the lower court but she said i can walk up the 55 steps anyway that's why they called it so it used to be you were brought into the hospital and you could not refuse medications um you know you when on a 72-hour hold it didn't matter whether you were confident or incompetent once just by being hospitalized on an involuntary basis you could be given medication so you can see that people who are involved in patients rights advocates they were looking for an ideal case to try and reverse that when the facts of the case would be very compelling and they found the case of ella harris so eleanor ruiz when it's reece versus saint mary's they're talking about saint mary's well i'm on standing street and this was a local case so eleanor reese had chronic schizophrenia um and she did well on mellorill this is what it says in the court decision they don't use the generic names which is thyritozine um so they called it malarial from 1969 to 81 and she really didn't need hospitalization so this is before the days of atypical antipsychotics the advantage of malarial is that it did not cause extra pyramidal side effects the disadvantage was that it caused a lot of anticholinergic side effects so you know people had like a static hypotension they had a very very you know dry mouth then you know sometimes dry eyes and the other thing is yet you could only use it up to 800 milligrams because otherwise it causes terrible you know cardiac arrhythmias so you could use malaria up to 800 milligrams and she was on it and she actually did very very well and in 1981 she developed bladder problems secondary to long-term miloral use and so people changed her antipsychotic um and nothing really worked and she kept on being re-hospitalized because um you know once the medication was changed during her 1982 hospitalization she was placed back on mellorow and what the chart notes say about it is because they didn't know what to do that well the bladder's damaged anyhow so what difference does it make again if you're a patient's rights attorney you're looking for a case like this that it just doesn't sound very good in 1984 she was put on mullendone which was sort of uh was popular for a few days a few years again before the atypicals were introduced but it was mid-potency similar to really in between like haloperidol and chloropromazine but it just didn't work so she stopped her medications and decompensated and needed re-hospitalization and the basis of the lawsuit was the 1984 hospitalization she was admitted as a voluntary patient with acute exacerbation of chronic schizophrenia she signed an informed consent for meds and she was tried on mo ban on navain and then mellaroo she complained that the mellorow was caught in debbie nance terrible stasis because they've had a lot of anticholinergic side effects and dry mouth and she said i think you've given me too much medication she became agitated and refused medication so she was forcibly injected and she was put on an involuntary hold on the involuntary hold what they wrote or she's delusional about her medications she thinks they caused her to die now she complained that the naveed caused dermatitis and swelling in her ankles and she agreed if you just stop the denying okay i'll take melloro and then she was put on a conservatorship because she was delusional about her medications and she was unwilling to accept voluntary treatment these were the criteria that they put on the conservatorship she was discharged to a boarding care home again she needed readmission her meds were changed to sarandol that's very similar um to melloro with orders for i am again she complained of swollen feet urinary problems shaking memory loss seizures and the notes say she's obviously delusional so disability rights patients right said she's delusional this is a perfect case to say even if you're psychotic and she was psychotic you still can know something about your medications and it doesn't mean that medications can be forced on you so the court said patients may be involuntarily committed yet remain capable of giving informed consent and then they also said and the courts in a lot of the courts are have an anti-psychiatry bias and this is an example treatment with antipsychotic drugs not only affects the patient's bodily integrity but the patient's mind the quintessential zone of human privacy and the task for the court is to determine whether a patient refusing medication is competent to do so despite his own mental illness so this is why we have the researching on every patient because of this decision that just because someone is dangerous themselves danger under the greatly disabled does not make them incompetent and if they agree to medications that's just fine but if they're refusing medications before you can medicate them you have to have a research the similar thing in the prison they call it a key hearing but you can't just medicate people just because the doctors think they know again as doctors we find that offensive but the courts are um saying that yes how exactly does it define an emergency okay so so in the decision it says a medical emergency is an exception and it's an exception to the whole principle of reform consent medical psychiatric emergencies justify involuntary medication hospitalization seclusion under strength you don't need a patient's consent for this when less restrictive environment is not appropriate so let's just take this example um a patient and this actually is an example from the you know so the patient had schizophrenia and an acute exacerbation also had um and um and amphetamine intoxication had positive symptoms of hearing voices you know and delusional and a history of violence to staff while previously hospitalized in the state this was a well-known patient who would come in after shooting back acutely psychotic and had assaulted step so the patient came into the unit and started to make verbal threats started to become agitated and not responding to behavioral intervention so the nursing staff would say you need your time out you need to go up to your room um here's a prn medication the patient said i'm not taking any prn okay patient has not yet become assaulted so there was an emergency staff meeting about whether this constituted an emergency or not and whether the patient could be given immense because they were refusing um p.o meds so do you think that this is a medical emergency um raise your hand if you think it's a medical verb did you just say the patient was not yet not yet by it okay he banged his hand you know his fist on the nursing station he was clearly becoming agitated nursing steps were also becoming concerned about it um and that's why there was a meeting and some people said this person is escalating we need to give them some medication other things like wait a minute you know with the risk decision you know it's only if the patient is is assaultive we can't give it to them so there was a meeting so so how many people think that um he that medications can be given that um this is an exception to rhys okay and how many people think no okay and the argument for no patient has not yet become assaulted let's just look at the definition of an emergency in race and years ago we used to have this in the nursing station an emergency exists when there's a sudden marked change in the patient's condition so that action is immediately necessary for the preservation of the life or the prevention of serious bodily harm to the patient or others and it's impracticable that's the word and the decision to first obtain consent so i mean i it was interesting because a lot of the staff and some of the people you know in you know who just responded think it's not quite an assault and maybe we shouldn't do it you have to look at what the intent of the decision in the risk decisions that if someone is about to attack someone or they're you know they're about to you know you don't have to wait until they actually do it in those cases you do give emergency medication but when you can wait you should wait because the person has the right to refuse so i mean you have to document i'm giving the person i am medications because this is an emergency there's a sudden mark change in the patient's condition it's my belief that action is necessary for the preservation of life or to prevent seriously bodily calm but this clearly fits within that and so there shouldn't be confusion about that when it's defined as a medical emergency you can medicate the person it's just when it's not the person can work it seems like like in the emergency department they can hack the patient give them the meds they can do that and on the inpatient side it seems like it's a harder process not that they're not allowed to legally but the actual physical action of giving the meds i am it takes longer to make that decision well if if the if it's understood the intent of the race decision it shouldn't be hard of course it's hard to give ins and people get hurt patients get rid of the staff get hurt so you have to know what you're doing um in terms of giving the person and making sure that nobody gets hurt working in a team you know and all of those things okay so what are patients reactions to involuntary treatment and there haven't been a lot of studies about it some of the best studies have shown that when people feel coerced they don't like it but positive pressures they like a lot better persuasion inducements high respect concern there's lower perceived coercion which makes sense you want the kid to do something you know you can bribe them or give them positive reinforcement that often works better i mean everyone is going to feel better about it um over and and when you hear like there are some bills right now in california legislature to broaden the criteria of the involuntary commitment trying to make it easier to bring people in and the argument that's used is um and there are people who will come forward and say i was forced into treatment and i don't know what was wrong with me i am so thankful because i took the treatment and now you know please um you know i mean it was really a good thing but the opposite is true also and a study that was done showed 50 felt um forced medications were a good idea 40 and some of the people who were involved in patients rights advocates they'll tell you stories they were teenager and their parents put them in in an institution and it was just the worst experience you know of their lives and they don't want to see it happening um to other people so it's not really clear-cut the thank you you know it's not always the response it is the response of some people we did a study up on the unit where put people in um in seclusion and then as they were getting ready for discharge we had we gave them a questionnaire and we said um you know how did you feel about being secluded and we compared it to other experiences because both them are an involuntary hold being transported to the hospital by the police the whole idea about being on an involuntary hold the whole idea about being in a psychiatric hospital comparing to the experience of being in seclusion and about two-thirds of the patients felt that seclusion bothered them more than other experiences surrounding hospitalization and what i thought was very interesting was 50 percent of the people had no idea about why they were even secluded and the reason why that's interesting is because of standard operating procedure that you say to the patient this is why you're being put into seclusion you check them in a few minutes this is why you will put into seclusion this is what you need to do in order to get out but i guess when you're just so agitated and you're just in the room you don't even notice it where some people don't they don't even hear what the staff are saying there are proposals about having proxy decision makers and advanced directives the idea being that when people become competent when they're no longer psychotic that they should have an advanced psychiatric directive who said that says if i'm ever if i ever become manic again please please you know i'm damaging my life i'm spending all my money i'm ruining my marriage or my relationship please put me in the hospital and that people should um do that at the point where they're confident sounds wonderful i mean the problem with it is that then the person comes into the hospital you show them the advanced directives and they say i'm revoking that i don't want that right now or the other problem there was a case out of vermont hargrave versus vermont so this woman who had been hospitalized um had a psychiatric advance directive and the person that she put as her proxy decision maker health care proxy was the patient's rights advocate so she becomes psychotic again and the parents you know the the patient's rights advocate says she told me she doesn't want to be in the hospital doesn't want to take medication the parents get very upset what are you talking about this is our daughter she needs hospitalization patience myself again our health care property where her parents but she had designated that the person she wanted to make the decisions with patients rights advocate so went all the way up to the um vermont supreme court and um they said if the whole idea of a health care proxy is you decide what you want done and who's making the decision if she wants patients rights advocate it doesn't matter what the parents want so you kind of have to be careful what you wish for in terms of what it will say in these there are malpractice claims related to involuntary treatment there are claims about false imprisonment if you're going to put someone in seclusion you need to document i mean now we have all these forums and it's um you pretty much have to document it but there has to be some kind of a good reason where of course we always have good reasons but where a third person is going to read it at some point that it's pretty clear that least restrictive interventions were used before that and that was the only thing that was indicated at this point a point in time to prevent harm to self or others um oh an involuntary treatment like you said the person was psychotic and they really weren't psychotic and i've been involved you know in some of these cases the person should have been on the allegation they should have been on a neurological unit or you know or something like that and they will put on a psych unit but you have to i mean you just have to go through the records and see that it was it seemed to be the best place because if the person is very agitated neuro usually isn't going to take them there are also malpractice claims more malpractice claims associated with failure to institute involuntary treatment the most common cause of malpractice people know what it is in the united states psychiatric malpractice patient suicide yeah suicide yeah that's the most common thing so you know the issue was bought in all of these cases you have the the parents who just lost someone or spouse you know who lost someone and they were saying this person was clearly suicidal they should have been hospitalized and so they bring it to a consultant to review from the you know consultant was there a suicide risk assessment um did anyone even think that this person could be suicidal and then make an informed decision and that was the right thing to do um failure to diagnose a tree oh and abandonment um okay so what to do um if a person needs hospitalization or if they're suicidal you first have to understand the legal and ethical principle again the criteria for involuntary treatment are a little bit different in each state so you have to wherever you're practicing and of course in california's danger of the selfies to others and brave disability there is a duty to protect um a statute that if someone makes a threat to hurt someone else that there is a duty to try and protect the victim you can discharge that duty by informing law enforcement and making efforts to contact the potential victim but another thing you can do is to hospitalize the person the principles of informed consent the principles of confidentiality when it's okay to deprive liberty when an emergency situation is defined and that you can give involuntary medications you can hospitalize people you can do all sorts of things but only when the emergency continues with all malpractice the issue is documenting what you were thinking and how you balanced the rights and benefits the risks of it and then um the benefits of it so that it was a judgment call and that's why you did what you had to do no one afterwards is able to second-guess you i mean they may try but it never holds in a court of law as long as there is a pretty good documentation and whenever you have questions legally to get consultation and that's incredibly easy when you're working i'm a reporter and you're only impatient you know there are tons of people around it's a little bit harder um if you're in private practice um you know you call people they're not available you have to make a quick decision but it's really important to do that and certainly supervisors family members are an incredibly important part of making decisions i get calls from residents um in the emergency room you know faculty back up and whether they should release someone they want to release someone and the family member is saying no no no we don't want to take them home we're concerned that the person is suicidal doesn't mean you're going to hospitalize him but you better think really really hard about it before you let him go you need to find out what the exact concerns are of the family member and help alleviate the concern because if the patient does go in and does something to someone else or themselves remember it's going to be the family members who are going to bring the lawsuit and they're going to say i told the doctor the doctor didn't listen to me so you know when a family family members often know much more than we know they don't always you know patients aren't honest with them but sometimes they do and at least you need to listen to it and evaluate it and you're going to go against family members that have a very good reason and have consultation before you do it so i'm going to stop there so that i can leave time for questions about civil commitment yes i was really struck by how many of the case examples were um women plaintiffs and so i'm wondering if you could speak to gender bias within involuntary confinement and involuntary medication as well as race and past biases it is a wonderful question um uh i'm a past president of the council on the psychiatric association um the california side this is not a secret to the people in the cpa who were really pushing bill for um for moore's law i mean they were behind it for all kinds of involuntary commitment and i am very aware of the research related to it um and there is a lot of research out of new york that says that outpatient commitment kendra's law is applied much more to african-american um patients than it is especially to white people now the advocates say we're talking about a population that has chronic schizophrenia that's homeless that maybe doesn't have access um to care and that will wind up in hospitals and that's why outpatient commitment is applied to those segments of the population so that's the counter argument um we developed a resource document and a position statement where we this is from the american psychiatric association where we spoke about it and we said the res it's not that basically the research is unclear but when you're applying it or thinking of applying it to populations who have a lot of other social factors who have to be aware of this how it's perceived by those populations especially that you're taking people's rights away that you're locking them up it's not just how anyone would respond to it but a population who already has a history of incarceration slavery or you know whatever that you have to be super sensitive i think some of these cases that have wound up i'm not sure you're right a lot of them are women um i mean my theory is again if you're a lawyer not the people themselves who are bringing it they have to find those lawyers that they find particularly verbal you know women who are willing to do this um and really fight for their rights but not all the cases that involve um women and uh there are a lot of orlando cases that involve men too yes uh so what's your perspective on sb1045 why don't you explain what that is so it's scott weiner's housing conservatorship bill where folks who are homeless for more than a year and 51.50 eight times or more in one year but generally cannot be conserved because maybe meth plays a high role in their acuity it would expand the capacity to conserve them mostly as outpatients you know again it's explaining different sorts of things someone has been hospitalized that many times you know that's a different story outpatient commitment awards while kendrick law is not that controversial when it's used to extend hospitalization so someone who has been in an acute hospital multiple times and then they're getting ready for discharge and you know they're just gonna come back to put them on a conservatorship is not that controversial and in fact in new york when the best studies have been done most of the cases of putting people on assisted outpatient um treatment some people think that's an euphemism assisted outpatient treatment that should be outpatient commitment but anyway that most of the cases have been that the re the time that it's controversial is when it's prevented so someone is in the community they don't yet meet the criteria for involuntary commitment and you're predicting that they will based on history but it's rarely applied that way in new york because it's so complicated it takes months to do it you have to go to court you have to get you know people to see them so it's just a really complicated process where it's pretty easy once they're on an inpatient unit to kind of put them on a conservative shift i think yeah i was wondering about your thoughts about how people are operationalizing great disability it seems like things yourself and others are kind of more clear in some way but we're getting a lot of people to think so many of these homeless people and they're clearly desperate in dire straits how do we go about thinking about whether somebody should be conserved because so you know the idea when there have been studies about outpatient commitment um what the studies have generally shown is that first of all it has to be for a while it has to be at least six months so someone has to stay you know in the treatment and that the reason why it works is you're mobilizing a system around the person you're getting them treatment resources and that that is a really good thing that in states who have outpatient commitment statutes and there aren't any resources no one ever uses it because what are you going to do you could tell someone they need to go to treatment and then you can't get them into treatment so it's a good thing to be able to say we are going to take responsibility for you we're going to provide housing we're going to provide drug treatment we're going to provide psychiatric care we're going to provide case management but that is a really really good thing if you can mobilize your system to take care of of course and some people say that if you have intensive case management services where you're really trying to engage the person the issue is do you need that legal leverage and that's where the controversy is that you need the resources and you need them applied and you need the case management and we have pretty good resources in a city like san francisco i mean a lot of places in the country have terrible um resources and that that's what makes things work and anything we can do to get people engaged in those resources and to get the resources care about this individual to say this person is your response hey you know resources whether it's through behavioral health court or whatever this is the responsibility of the system to take care of this individual but that works very very well and that people respond to that you know we're gonna we're gonna help you out and we're going to meet you where you are you know that's the other thing so very very helpful yeah um can you recommend any resources for making these decisions of patients with anorexia so kind of determining what was a medical emergency what would constitute a medicare emergency that would justify like you know medical hospitalization or refueling so again you um it's sort of i mean in the race decision gives the act rewarding but it depends on the documentation if the clinician says it's a medical emergency or a psychiatric emergency nobody is going to say no it wasn't but it's kind of like well you're reading my note and you're saying no i was there i defined this as an emergency i mean who knows you know someone drops down on the street you start pounding on them if you're you know you're there and you think that they need cp you know it's kind of like so if there was a reasonable reason to think that this was an emergency you're never going to get in trouble but again a lot of it is the documentation in my opinion this was a medical emergency this was a psychiatric emergency a lot of times they see treatments they'll start with using treatment later on like as they're starting to get more stable exactly you know that just then that's a different story and then you have to kind of work with the person or a conservatorship can help with that just learning about the logic and the legal precedent of these med consent forms that we use in inpatient psychiatry like before starting in the anti-depressant or what have you when it's obviously protected by the law from like without a wreath they can obviously refuse the meds but it seems to me that if you were to actually do like a capacity evaluation on a lot of these patients so you're having concise consensus that they don't necessarily have the capacity and are those actually is that actually a legal thing or is this just sort of how the hospital protects yourself the idea being that you have to explain to a person was you know that everyone has the right to make a decision what they want to their own body and you have to give them a list of what the risk benefits the alternative treatments including no treatment but we know i mean it's a little ludicrous you know you go to see your dentist and make you decide to consent you don't really need it that you know if your tooth is hurting yeah yeah i could die during you know the extraction but i'm not really worried about that you know it's kind of like you assume or you know when people sign into market wrong um if you look at the consent form it has all these things about students working on you it also has things in there about some of the data being able to be used by the development office i was shocked to find that you know kind of thing the idea that if you had bill gates you know hospitalized the development office would want to know so maybe they could you know kind of approach him for some money and i mean i never made that happen but it is it's on the consent form and that's how you protect it by having it on the consent so people don't really complete it um you know even even when you're giving consent to fly in a helicopter or to go on a climbing wall or something like that and the risk managers tell the company i know if i fall because it's poorly constructed but actually you still can't sue even though you say there's no luck it's just interesting that it's only for psychiatric minutes not like any other medicine no you have to give consent for all kinds of medications yeah yeah oh well i'm just trying to think in the hospital no you consent for procedures that have to be done right there's just a general context for hospitalization you can refuse it though but people usually don't if the doctor thinks it's indicated so there is a higher thing you know things that have been traditionally used just to try and equalize those and things like that again whether it's a good or bad thing depends on your perspective yeah you mentioned the closing of the state institutions and how people are starting now to think back more fondly on that and i've seen a little bit of both in the new the recent closing and then the idea that the permanent support housing that is supposed to replace that hasn't and you're leading people on your own and i'm curious what you think about which way that's going do you think it will swing back towards a type of state institution or more for something so people like very much for involuntary hospitalization getting people off you know i mean a lot of stuff he says is good and some of it um maybe the research doesn't support it but when he talks about how many people are in jails and prisons versus how many people were in the state mental hospital and the point that he's making is as the population of the state mental hospital went down in in the 60s and the 70s the population of jail and prison except it's not really the comparison group right now you have to take in you know the people who are in community treatment and are using other resources i mean what people get out of that is therefore we should build up state hospitals i mean the state hospitals you know we're not great we're not great places i mean lively portal we have an old building but we have terrific treatment you know we have terrific staff you know who are working here it's still not pleasant to be there we know about all the medication errors that happen and you know people don't have freedom to do things it's not good to be hospitalized um you know it used to be after you had a baby you were in the hospital for a week after you had back surgery after you had a heart attack people said the more you could get hospitalized the better it was now people say get out of the hospital you're gonna get you know you've got to get up and walk you're gonna get hospital-based infections you know it's just very unpleasant and it's not only that cheaper but it's also much healthier get the newborn mom home as quickly as possible you know so that she doesn't get a uterine infection or something so the thinking has changed about that okay yes i'm just curious um about the psychiatric advance directives i know california we don't have those legally yet so just what do you have any experience with yeah so the issue is you know what i said is first of all even if somebody has that it's used as a therapeutic tool the person says i don't want to come into the hospital let me just show this to you i know you know you're in a state of mind right now and you're really scared you know you rather use the word scared rather than paranoid but you know they're really frightened but let me just remember we spoke about this you know so it can be very very very helpful but the problem with it is what are you going to do if someone said i want to go to the hospital and then they're saying i revoke that i don't want to do it you know it's like involuntary ect we can get a court order to do it but we're sort of relying on the person going along with it but we don't take people who are screaming you know trying to fall over the cuckoo's nest you're shocking me i'm like you know i'm not going to wield them you know we just kind of hope working with them and again if you give people the right the psychiatric advantage as in this case um in vermont sometimes they'll say i don't want to delegate somewhere so but overall it's a good idea because it forces people to engage with the patient while they are confident and say let's just talk through what just happened and what we can learn from it together and what you want to happen next and that's very powerful okay thank you [Music] [Music] you