The History and Process of Psychiatric Detainment

Speaker 6: [00:00:00] And welcome back to How To Be Patient, the podcast where we do more testing of patients really than teaching about it, or at least my testing of Margaret's patients. 

Speaker 7: Not today though. 

Speaker 6: Not today. And, and you know what, Margaret? 

Speaker 7: I'm freeloading today. Listeners. 

Speaker 6: This is, so we're, we're trying a new thing where one of us preps an episode and the other person just kind of blindly reacts to it.

So, so it's kinda like you're watching a live React video. We, we just get, just get, we're gonna do for 

Speaker 8: season three. 

Speaker 6: Yeah. Except instead of eating like a bowl of ramen noodles, you're just watching Margaret Fork through whatever. My brain had to come up with that day speaking obviously. 'cause this is a Preston episode.

I don't have an icebreaker for us. Okay. Well I guess the icebreaker is talking about how we don't have an icebreaker. No. How do you feel about me ice not having an icebreaker? Margaret? 

Speaker 7: How do I feel about it? Um, I feel good. Preston. I think I. I think I feel pretty good about it.

Preston is alluding to the fact that listeners, last [00:01:00] episode, the last couple weeks I've been working on suffer residency and ending my role as like one of the chiefs and like very deep in an Excel sheet and, and my brain has been other places besides the podcast, which is why Preston has kindly agreed to take the lead.

The last couple of 'em. Oh, she thinks 

Speaker 6: I'm kind. Yeah. She's been a freak in the sheets girl. The Excel sheets. 

Speaker 7: Why 

Speaker 8: you wouldn't the Excel spreadsheets cut editors. I'm not having any. You can say whatever you want about yourself, but you cannot say shit like that about me. 

Speaker 6: A spreadsheet hates to see Margaret come in.

Speaker 8: You can keep that in. 

Speaker 6: F 11 has been shaken since Margaret started punching those schedules 

Speaker 7: at the end of our last episode. Preston was like, we were talking about how it went and he was like, yeah, I thought it went really well. And I know I had, you had made the outline. You were like, Maggie, like how was that in terms of like reviewing it?

And I was like, I actually didn't look at the outline at all. I didn't read a, a single thing. And, 

Speaker 6: and that is so Preston coded and I was like, game respects [00:02:00] game. It was so, so proud that literally our producers 

Speaker 8: were like, good job Maggie. Calm down a little bit. Yeah. That's just weird. 

Speaker 6: Realize it's a little bit better that way.

Speaker 8: Honestly, if I just calm down 

Speaker 6: a little. Yeah. If, if we just chill out. And so I don't have a, a clean segue from chilling out. Nice to be locked up. But today our episode is gonna be on, um, the detainment and sometimes carceral process of psychiatric inpatient care. 

Speaker 9: Mm-hmm. 

Speaker 6: And we're actually gonna, gonna start all the way back from how far back medieval times.

So, I mean, like the restaurant? No, like the era. Oh, we'd be jousting. 

Speaker 8: Okay. I need not make jokes in this episode, but No laughing. 

Speaker 6: Yeah. This is a serious episode, Margaret. Only deal. We only ever talk about anonymous reviewer serious things in a serious manner. So, I mean, psychiatry history in general has a storied colorful past, and today we're only kind of looking at a slice of it.

[00:03:00] Um, just purely like the ways in which we detain people that suffered from severe mental illness. 

Speaker 9: Mm-hmm. 

Speaker 6: And, and I think it's important to kind of look all the way back to the beginning because we're also gonna be not only talking about the history of it, but how we approach it today in our process.

Because one thing that, um, people often come to us with questions about is, how does it actually work? If someone is concerned about me for my mental health, puts me on a mental health hold, and then I have to go to the hospital, like, what happens? How is this process even a thing? It's so kind of. Nebulous.

It's hard to look in from the outside and a lot of it doesn't make sense at first, so, so we were getting a lot of questions about this and I realize that to answer that you kind of have to start at the beginning. 

Speaker 7: Yeah. And I think it's also something that we don't talk a lot about or we don't have time to talk about necessarily with our patients.

And then also I think it's something that some places will teach us on in terms of training or med school. But it's like you're saying a long history and [00:04:00] something that modern psychiatry is shadowed by that, but we don't get a lot of time to talk about. 

Speaker 6: Yeah. Like, I mean, I've had patients that, that they're just like, I.

Why, why is the system like this? Like they'll ask me straight up. And actually, before even researching for this podcast, I didn't know the answer to a lot of these questions. It's almost like, you know, let, let me explain to you, to explain to you why it's like this. I would have to do an entire podcast with you.

So that's what we're doing, right? Now's what? This is that podcast. Yeah, precisely. So let's, in the beginning, let's begin with the years 1247 and we're in London. So at, at this time, the concept of mental illness really hadn't happened yet, but people were still experiencing symptoms and syndromes that we would today consider to be mental, mental illness.

So people are experiencing manic episodes, psychosis, um, depression, and all the like, but it was thought to be due to supernatural phenomenon or moral failures. So as you, as you can [00:05:00] imagine, where do you think a lot of these people wound up, 

Speaker 7: um, in. Jail or institutions like, I don't know, they would've called 'em asylums yet at that point.

So 

Speaker 6: they didn't have institutions yet. A lot of them were just kind of seen as the, the town lunatic. Mm-hmm. Or they were, were beaten or jailed and, and pre treated as outcasts in a lot of ways. The first time that someone actually tried to, um, create containment or custodial care for people in these settings was, um, in this priory in London, and it was called Bethlem Hospital, which was shortened to bedlam.

Speaker 10: Hmm. 

Speaker 6: And a lot of the, um, patients were, were still treated pretty poorly there, but it, but it was the first like real institution that was dedicated to keeping people that were like, um, described as insane or lunatics at that time. And actually because of all the chaos that happened there, um, it got a pretty bad [00:06:00] reputation and was known as this, like it.

Mayhem area, and that's actually where the term bedlum comes from. 

Speaker 7: Oh wow. What would they do there? Like, was it just like holding because they didn't, did they do like treatments? 

Speaker 6: So, um, I'm gonna skip over a couple hundred years because I, I don't know a lot about like the actual attempted treatments at this these times, but mm-hmm The idea was that uh, a lot of mental illness aligned with bodily illness was, um, described in humors.

Mm-hmm. And I would have to go brush up on my humors 'cause I'm not familiar with them. Like, lemme give my witch doctor mask on a little bit. But I remember there was still wanna 

Speaker 7: know the root cause of humors that 

Speaker 6: yeah, there were different types of humors that people were suspecting. So I think there was like a bodily humor in like earth and then there was like air, or like, it just felt a lot very like avatar, last Airbender type stuff.

So there was like a suspected humor in like air I think that was associated with mental illness. And so sometimes people would try to. They would just [00:07:00] spam bloodletting basically to see, to see if they could get it out, but then get out the bad humors and calm people down. And that was actually still continued in the 17 hundreds when we opened up our first state hospital in the us.

So, um, our good old Powell, Benjamin Franklin helped with opening up the eastern, um, state hospital. Famously 

Speaker 7: a friend of the pod, our first mentioned friend of the pod. 

Speaker 6: He, he really did a lot for us, um, 

Speaker 7: libraries, shout out. 

Speaker 6: So at, at the time that state hospital was meant to be, uh, applied to a lot of different things, but they actually started, um, engaging in some like psychiatric care.

And one of the, the additional, um, kind of founders and physicians at the hospital was Benjamin Rush. 

Speaker 9: Mm-hmm. 

Speaker 6: And he was considered like one of the, um. Prominent founding fathers of like mental illness as a condition or, or of, of psychiatry really. So a little bit about Benjamin Rush. He was, he was from this time when [00:08:00] they would, I think, dabble in like everything.

So, so I was reading about him and he like, he like described Dengue Fever as like, he was like the first person to describe it as a syndrome. But then like basically the next week was kind of made some presuppositions about how maybe alcohol dependence is like a sickness beyond just moral failure. And was like considered like one of the first people to suggest alcohol use disorder.

And I was like, damn, they really just did everything back then. Like my, like my guys like walking down the harbor and was like, I think this is dengue fever. And then he just goes upstairs and is like, yep, alcohol. Like this is alcoholism. 

Speaker 9: And he's like the first person to say that. I was like, no. 

Speaker 6: Yeah. But he, he also had a lot of, um.

Pretty poor takes too. So he, he had this idea that there was, um, it was therapeutic bloodletting, but it was, it was, he called like calming therapy or something. I, I forget the exact name for it. But basically when someone was in a manic episode, he was like, let's just bleed 'em to get the mania out. 

Speaker 8: Yeah.

Speaker 6: And it should calm them down, which it probably did, but [00:09:00] not in the way that they were hoping. Give them a little 

Speaker 7: anemia. Yeah. You're 

Speaker 6: basically just izing them by, tire 'em out, by taking out their vitality completely. And then they, they can't do manic things anymore. So from the kind of late 17 hundreds to the mid 18 hundreds, this was how a lot of psychiatric institutions were.

They would, um, essentially incarcerate people and then they would kind of run a lot of rudimentary like medical procedures on them that a lot of it was fruitless and wasn't doing a lot to help people. And then outside of that. People were living in, in squalor in poor conditions, a lot of them were put to these state hospitals indefinitely without any like real idea about where they would end up.

Like dispo I guess wasn't really a thing back then. 

Speaker 7: Yeah, no it wasn't. 

Speaker 6: Well, no. Yeah, it's like now I think we, we struggle with dispo. We call 'em dispo nightmares in the hospital. If you're not familiar, like just people that we don't know where to safely put this person outside of the hospital but don't resource.

That resource wasn't even consideration for them. [00:10:00] They're like, well just let 'em sit here till whatever, you know? I 

Speaker 7: wonder who got to go to those though. Like, because I know there's a book I read that's like on the, it's called Gracefully Insane and is a history of McLean Hospital and is just also a history of psychiatric practice.

'cause McLean as part of kind of MGH opened at the, I wanna say the be like 1810s or 1820s. Um, and it's interesting as they go through that history then I know that's a little bit after, 'cause we're in the 17 hundreds right now from what you're saying, but near it like. Who actually got to go even at that time of like, were the poor going, were the wealthy going?

I know it was different institution to institutions. Yeah, I think so. 

Speaker 6: If, if you were wealthy, they were more likely to be like confined to your house. 

Speaker 9: Mm-hmm. 

Speaker 6: And a lot of people just kind of like keep it hush, hush. Mm-hmm. Um, but the, the poor people were like, seen as public hazards were bought into these institutions, and then they were kind of just changed.

So they weren't put directly into the jail. They were [00:11:00] incarcerated, but like in the hospital. So they identified that there's some sort of illness to it. So I, I don't think this is like a place where you're seeing people as like actually getting treatment. Uh, in that sense. At this time, 

Speaker 7: were they like locked units or, you know, in this history of it?

Were they, you've said they were like chained. Mm-hmm. They weren't in jail, but they were like being kept from the public. Was it? 

Speaker 6: Yeah. So, so as far as I understand that like the intent wasn't to actively punish them, but you know how like today we have restraints and we have one-to-ones and things like that.

From what I understand, it was just very inhumane versions of those Yeah. Um, measures we have to subdue someone who can't really be redirectable or follow instructions. So it's like you, you keep wandering into the hallway or something. Well, I'm just gonna change you to this poll instead. Yeah. And so, so in general, these were somewhat crowded areas 'cause people didn't really have anywhere to go and they were congested.

They're pretty poor conditions. Mm-hmm. And, [00:12:00] um, in the late 1830s, um, this caught the attention of, uh, a woman named Dorothy Dix. So Dorothy was, um, a nurse who like took an interest in mental health and she was, um, very concerned with the, the poor quality of life that these patients had in these, um, hospitals and these wings.

And she began, um, very loudly advocating for the humane treatment of patients with mental illness. And, and she really kind of pushed for mental illness as a term in general and, and kind of argued that like, people who have sickness of the mind should be treated like someone to have people have sickness of the body.

Mm-hmm. And in 1841, um, after like lobbying several times, um, she, um, worked with Dr. Who was a psychiatrist from, um, 1808 to about 1890 to start developing these different asylums. Mm-hmm. And you've, you've probably heard of Keir KBR before. Um, he has like the Keir KBR method where he designed [00:13:00] these, um, humane hospitals.

They were supposed to be like morally uplifting. Mm-hmm. And they, they still were in line with the c the custodial view of psychiatric care. Like someone needs to be institutionalized, but he wanted to create a healing environment. You follow this thing called 

Speaker 9: mm-hmm. 

Speaker 6: Environmental determinism. So it, so if you look at his buildings, actually, they follow a wing shape.

Speaker 9: Mm-hmm. 

Speaker 6: And they, um, stagger the sections of the building so that light can get through into each hallway. So as you walk through, it's always well lit. It's always exposed to daylight. So patients. In addition to natural light, we'll get to do things like gardening and, um, walking through the lawn. And it's meant to be this like kind of serene supportive environment for patients.

Speaker 7: And, and by this you mean like the term I think you mentioned, but just to make it more explicit, was the like, idea of the moral cure, which was like also a, a kind of belief. Have you seen those memes that are like, I need whatever they gave to those Victorian children and books in the 18 hundreds? It was [00:14:00] like, send me to the sea, give me fresh wholesome vegetables and have me do like manual labor in the garden that would cure me.

Like people like that's, there's been many memes about this in the past couple years and that a lot of people is the moral cure lot. 

Speaker 6: Yeah. It's with Robert F. Kennedy. He's promoting, actually, I think he wants to send people to a farm. 

Speaker 7: He's not even, he doesn't wanna send us the sea. Like 

Speaker 6: Yeah. And, and like what's funny is there, there is some validity to that, but not in the sense that it's morally curing.

So a lot of people would. Um, get arsenic poisoning from their houses in Victoria Airs because green paint has arsenic in it. Yeah. So especially during like springtime when it's raining a lot, there's a lot of moisture on the walls. The arsenics coming off, people start to get sick so then their doctor would prescribe time in the countryside and they get away from the arsenic.

They're like, I feel so much better. Like, oh my gosh, the magic, 

Speaker 8: you just ruin some of those memes for people. 

Speaker 6: Yeah, yeah, exactly. Or like, um, people thought tomatoes were poisonous for a long time 'cause they absorbed the lead off of their [00:15:00] plates. 

Speaker 7: They are a nightshade. People kind of now are starting to get like, persnickety about tomatoes also.

But some of the wellness side of TikTok are like tomato. I mean. Okay. Unless you have interstitial cystitis, which is the one instance when I'm like, mm-hmm. Okay. But don't trust tomatoes. Got it. 

Speaker 6: Yeah. That's why we threw 'em at people on the stage when they're doing poorly too. So, like to hear this poison is stupid before you take it.

Speaker 7: Are you familiar with, um, related to, to the kind of like design, especially in the like early 18 hundreds of psychiatric hospitals, are you familiar with, um, the design change that they did out here at McLean? Um, that was the like de design part of it. Okay. Not totally designed, but some of it was designed by Olmsted, Frederick Law Olmsted, the person who liked Design Central Park and did some of the stuff in Boston too, and he ended up staying at [00:16:00] McLean at the end of his life.

Wow. But McLean is like a bunch of like, it was basically the same model of moral, the moral cure. That's like, let's put things on like this, like pastoral, like green rolling like lands. Let's make them each look like kind of small. Country houses. Of course, this was like, had periods where it was extremely fancy and was like not, this was not the like 

Speaker 9: mm-hmm.

Speaker 7: The low, like the least resource people were not going there. But, um, the point was that actually they didn't have this, like, there had been that design model in other psychiatric institutions that was like the sickest people at the furthest ends of the wings, as in like people who would be the most violent and difficult to control.

Mm-hmm. And as you got closer to the center, it was like people who were less that way. Um, and the model at McLean, that Olmsted at was part of advocating for. Like all these houses dodged along these hills instead 

Speaker 6: it's like, yeah, in instead of in in the wings, we'll just banish them [00:17:00] to the faraway hill.

Speaker 7: Yeah. There's some quote from someone who visited McLean in the 18 hundreds, and it's like, you would think this was like a gentleman's country club. 

Speaker 6: I mean, it sounds, I think it could morally cure my burnout. Maybe a little bit. You're like, my, I'm 

Speaker 8: okay. 

Speaker 6: Maybe that's what we should repurpose them for. So, um, back to kind like the story of Dorothy Dix and Keker Ride.

They're, they're building some of these hospitals. Um, the, the most famous one is in Trenton, New Jersey that Keker Ride made. Um, but he has a couple other asylums that he constructed. In 1854, Dorothy successfully lobbied for federal grant lands to be, um, attributed to state asylums, and it was the, the bill for the benefit of the indict.

Insane. So now, like a lot of these state hospitals are actually like. Dorothy D's name. 

Speaker 9: Hmm. 

Speaker 6: And the first time actually I came across her name was when I was in North Carolina, and you can find the, um, Dorothy Dix State Hospital grounds, which has now been turned into like [00:18:00] a park slash kind of like an art exhibit.

So they, uh, they let you roam the grounds and there's all these copper statues and, and trees, and there's like old houses and cottages are scattered around the asylum. It's, it's eerie, but it's interesting. Um, like there is the psychiatrist house. It's like, you can tell no, it's, it's labeled as a sign and there's nursing houses.

It kind of reminded me of like a military institution where like based on your rank on the, on-base housing, you get like a slightly bigger and better things. Yeah. So, so you could, you could tell who like the doctor's housing was, but they still lived in the asylum. Like if they were always on call and they would just come in to the hospital where something had go wrong and then they, they'd go back to their little cottage, which is like a hundred yards away.

Speaker 7: I mean, even like the term residency, is that like re trainee doctors lived in the hospital? We 

Speaker 6: reside in the hospital. Reside in the hospital. 

Speaker 7: But I mean, if you think about like medicine, like, I don't know, [00:19:00] like modern medicine is not more than like a hundred years old in terms of the modern training system.

Like mm-hmm. 

Speaker 9: It was 

Speaker 7: common for people to like, for like country doctors to like go see their patients or to have like part of their house be where they would see people up until like more modernization in medicine in like the late 18 hundreds. 

Speaker 6: Like I, I was playing Red Dead Redemption and I remember I went spoilers.

He gets tuberculosis and you go to the doctor's office and it's like, it looks like a, a parlor and it's like in the dude's basement. 

Speaker 9: Yeah. 

Speaker 6: And he is just like, yeah, I need money first. And then he like, looks in your mouth. He's like, it's tuberculosis and kicks out. And I was like, nice. No, it's just, it's crazy.

Like I couldn't imagine like having my basement just be my clinic. So, um. We have, we're, we're putting patients in all of these asylums. And this has kind of becomes the standard of care for almost the next a hundred years. Um, as, as we start to round out the 19 hundreds, we still don't have any [00:20:00] effective treatments for schizophrenia or bipolar really.

And all the psychiatric care is still custodial. So people are being sent to these in institutions and they just kind of stay there. And then right around, um, late 19 teens, big world event happens. We all went to war with each other. 'cause someone shot the Duke, France, Ferdinand and, and another friend 

Speaker 7: of the pod.

Speaker 6: Yeah. And so we, people start experiencing a lot of very severe mental illness. And then we're overwhelming com communities with people that have shell shock at the time. And then, you know, um, Freud starts describing it, and this is early, um. Notions or early kind of hints that we will be now describe it as PTSD.

So, so it takes, it takes one wave of, uh, overwhelming the, the population with injured vet veterans for us to create the va. Yep. But we still don't acknowledge mental illness as anything. Right. 

Speaker 7: Story is starting to at that point. 

Speaker 6: Yeah. [00:21:00] Until we get a second World war and then, and then do it again. The National Mental Health Act happens in 1946 when all these veterans again start coming back overwhelming the population with, um, their post-traumatic stress disorder, the trauma, and then, and everything that's like come out of these wars.

So if you think that people have ever been reluctant to acknowledge mental illness, just remember that it took us two world wars before. We're like, Hey, maybe, maybe PTS is a thing. 

Speaker 7: I'm resisting so hard making a, a World War III joke with the Kurt. Yes, 

Speaker 8: psychiatry. Big for psychiatry. Yeah. We, I mean, it legitimizes it probably because that bit, I do not advocate a world wari 

Speaker 6: No, I, I don't think anyone does.

And I don't think anyone's happy that World War II happened, but it, if something good came out of it, is that people acknowledge that mental health is a real problem. Yeah. And, and that's what the National Mental Health Act did, is it found a way to say mental illness is important, like physical illness.

And, [00:22:00] and it's because there was this severe dearth of doctors that were willing to go into mental illness in the first place. So, so you have all these veterans with severe uncontrolled PTSD and no one to treat them. So, so a part of that was legitimizing, um, mental illness. 

Speaker 7: And it was that a group, you know, population wise with power was sick.

Speaker 6: Exactly. No, it was a primary, it wasn't until the, the good old, like. Good old boys came back from Normandy where we like, oh, maybe this is a problem. 

Speaker 7: Yeah. 

Speaker 6: Yeah. And, and I wanna kind of add that at this time, like we, we've now expanded to doing things more than just blood lighting with patients. We've also been doing something called insulin shock therapy.

I don't know the exact, um, psychiatrist that proposed this, but there's this idea that epilepsy may be protective against schizophrenia. And someone kind thought like mm-hmm. Maybe if they have a seizure, they have less psychosis. We didn't have a way of inducing a seizure effectively at the time, but it turns out if your blood sugar tanks low enough, [00:23:00] you can get a seizure.

So people would just inject, um, patients with insulin, induce a seizure, then they would kind of sit in a coma for a little bit until the blood sugar came back up and they could recover. 

Speaker 7: We also had the malaria treatment. 

Speaker 6: Yeah, that was tough. And then that was tough. The other one, uh, the, the elephant or ice pick in the room, I should say, is the lobotomy.

That, that's a tough one to kind of walk off. And I want everyone who's, who's listening to know that, uh, history judges you with the lens of the present, not the lens of the time, because the guy that invented the lobotomy, uh, won a Nobel Prize for it. Yeah. And like it did what he said it would do. He is like it pacifies patients.

And it sure did. So it 

Speaker 7: really did. Yeah. 

Speaker 6: Yeah. So it, um, we've now acknowledged that mental illness is an issue, but patients are still in asylums. And then 1954, we have a really big breakthrough, and that's the invention of Thorazine. [00:24:00] 

Speaker 7: We, the sounds when he says, yeah, 

Speaker 6: thine changes the freaking game because now we have a medication that can actually treat psychosis.

So if, if you're not, um, a neurobiologist or a psychiatrist familiar with psychiatrists or familiar with psychiatry, a a lot of psychosis, and especially in schizophrenia, is mediated by overloading these dopamine receptors. It's related to the D two receptor specifically. And we finally found a medication that blocks that D two receptor.

And actually, it turns out when you, when you inject someone with this medication or give it to 'em orally, their psychosis starts to go away. The voices get quieter and they regain some coherence. And this is a huge win because all we've had before is just kind of locking people up. 

Speaker 7: Now there's or systemic things that kind of like Right.

I think in a lot of ways change their, maybe not in the case of the lobotomy. Mm-hmm. But like, obviously that was a blunt approach that didn't work. But the other things were like, [00:25:00] what if we just so altered their like attention ability and made them so sick that they're like not alert. And that was how we like, would mediate these like psychotic or aggressive symptoms.

Speaker 6: He hence like the bloodletting and other things. 

Speaker 7: Yeah. 

Speaker 6: Or the insulin coma therapy. So it, it's really interesting because now that Thorazine is on the table, we're shifting psychiatry from a custodial model to like a medical, biological model. We can identify illness and then we can treat with medications just like how other doctors do with their other ailments.

Mm-hmm. Whereas instead of just kind of babysitting and watching. So while we have this really positive thing at the same time, there's a lot of really negative sentiment that's building up towards psychiatry and these asylums. So we've already talked about the, the lobotomies, insulin shock therapy, the detainment, um, often without a lot of due process, but there's another really important player that comes in, which is Rosemary Kennedy.

Right. So, um, a little bit about her situation with the Kennedys is she was, she grew up with, um, probably, [00:26:00] um, what we would now describe as, um, cognitive impairment or learning disability. I think she really struggled to socialize and she was always kind of just like passed off as shy. 

Speaker 9: Mm-hmm. 

Speaker 6: Uh, especially in like public settings, but they wanted to keep her in the public eye.

However, as she started to grow older, there was a lot of worry that she might become disinhibited or sexually active in a way that could like, kind of hurt the Kennedy image as they're growing. So without, I think. I don't wanna, yeah. Allegedly. So, in, in secret, one of the other members of the Kennedy family took her to get a lobotomy in the early 1940s, and it went really poorly.

So during the lobotomy, um, she became incoherent, was no longer able to respond to questions. Uh, and then afterwards they, they actually aboard the procedure what was happening. 

Speaker 9: Wow. 

Speaker 6: And after that, she was no longer able to like, talk at all on her own. Walk it out. She, she completely lost all of her, like ADLs whereas, or her, her ability to execute, like just the activities of ordinary daily [00:27:00] living.

Whereas before she was able to do some things, but had this kind of like concern. This sat pretty, um, deeply with JFK and he felt very uncomfortable with a lot of the, uh, carceral. Asylums. Mm-hmm. He saw them as. Un helpful and, and had this like kind of personal connection to, to the ways in which like Psychosurgery really goes wrong with his family.

Yeah. So in, in combination with Thorazine coming out in 1954, so now we have this kind of treatment, he signed the Community Mental Health Act in 1963. 

Speaker 7: Mm-hmm. 

Speaker 6: I think 

Speaker 7: one other thing that's like pretty important in terms of the history of this, not as like, as maybe pertinent as those two, but still I think a factor is during World War ii, a lot of people from the psychoanalytic view, um, immigrated to the United States where their safety and [00:28:00] the psychoanalytic view of mental health is one that I value, but is also one.

Mm-hmm. That, especially at the time had flaws. So there was also this circulating this or like percolating idea more in the water of like, I. Psychiatric illness, especially like neurotic, mood, affective, but even to the extent where they would speak to like psychosis was 

Speaker 9: mm-hmm. 

Speaker 7: Due to kind of repression and something that could be talked through.

And, and I, I don't blame psychoanalysis at all for, for this necessarily, but I think again, it was a young clinical science and it was just another thing that was present in terms of our understanding culturally at the time of what does mental illness mean and where does it come from? A question we still don't totally have today.

Speaker 6: Yeah. These are the most challenging philosophical syndromes to describe and we have to work in like a moving model around it. And, and, and [00:29:00] I would say like everyone's model from the psychoanalysis to the, um, behavioral determinist is incorrect and doesn't fully capture the picture. And we have to like always keep adjusting them.

So I, I try to have a. A generous, like interpretation of, of people doing their best at the time. Mm-hmm. Because I, I imagine, um, I'll be looked back on, or psychiatry right now will be like talking with scrutiny in the next hundred years. Yeah. I mean, I pretty terribly, 

Speaker 7: I, I, I don't, I say this kind of like glibly, but I have said before offline, I hope that I look back on my care or other people look on my back, on my care for people and that it looks like, oh, she tried her best, but like, wow, her tools sucked.

Like, we're so much better now 

Speaker 8: at what we do. Yeah. That is my hope. So that is 

Speaker 7: my hope. Like 50 years, a hundred years from now. But 

Speaker 6: I hope they look at us like how, you know, they, the, um, cavemen that did trepidation for subdural hemorrhages. Yeah. Or subdural hematomas to be [00:30:00] like, damn, they, what they did was right.

But it was just with a fucking, you know, ice pick in a cave. 

Speaker 9: Yeah. Yeah. It was just had, and it didn't 

Speaker 6: stop the brain from herniating, but all crap, they had rocks. 

Speaker 8: Like that's what they had. Yeah. Yeah. So that, 

Speaker 6: that's like the hope I get from future psychiatrists. I, I hope I get, I hope I get considered like that.

Speaker 7: He used his rock to 

Speaker 6: the fullest. He, that man was, he could use that rock really well. 

Speaker 7: Before we keep going, I think we should take a break and after these ads, we will be back to continue on the history. 

Speaker 6: Okay. Yeah. And, and a lot of stuff changes after the Community Mental Health Act. So, so come right back.

Stay tuned.

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Speaker 7: And if you're leaving training like I am, you still have to be [00:31:00] preparing for the test that is the boards.

And now, you know, psych is a medical education resource to help us retain all our knowledge, get better, and get ready for these tests. 

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Speaker 6: And we're back with the fall of the Community Mental Health Act and other fun things. Oh, God. Now I can't say. So, um, Kennedy, uh, passes this act, right? And what it functionally does is it releases a lot of patients from the asylums, which, uh, it can be liberating for people that may were maybe were detained without due process or they're against their will and, and could function otherwise.

Some people were, were put into asylums based [00:32:00] on the conspiracy of their families, knowing that like no one was really gonna question it. But it also turned people with bipolar disorder, schizophrenia and other like uncontrollable severe mental illness out without any support or follow up. So this kind of like flooded society of people that couldn't really support themselves and they, a lot of them ended up either homeless or in jails or in other places.

Um. Then we kind of tried to learn ways to, to integrate them into our society while also applying safeguards and the rules of autonomy and mm-hmm. This is kind of where we enter modern care and psychiatry. And you'll notice, like before this, all these big mental health acts were like sweeping presidential decrees mm-hmm.

Or things like signed by Congress. That that's kind of stopped at this point. Now every like, little change, we'll, we make, well, we'll see when 

Speaker 7: this podcast 

Speaker 8: episode comes out. 

Speaker 6: Yeah. Unless there's a new one. Uh, [00:33:00] as soon as Trump gets bored with his guitar airplane and wants decide to take on mental health, so, so, but, but the point is like we, we kind of just start playing whackable with problems as they come up.

Now, 

Speaker 7: before we say the next one, I think the, like, kind of the ethical conflict that you've, you've said, but just to say it more simply mm-hmm. Like is the kind of one of the core, the two of the core. Practices in any form of medicine is like patient autonomy or freedom to choose um, and be beneficence. So like mm-hmm choosing the best for the patient.

So outside of psychiatry, this looks like if someone is like out of it, they come into the hospital in the emergency room and they don't have any family members with them, but they're like bleeding 'cause they've been in a very bad car accident. Usually in beneficence would be like doing what is like reasonably what would be the good for the life of another person to some extent.

Mm-hmm. Because autonomy's not really [00:34:00] able to be, is still balanced against that, but is like not really able to be respected. So in psychiatry this is like a constant like tug of war that is hard to know because our illnesses impact people's. Like capacity to make decisions, which I know all of you guys mm-hmm.

Who've ever consulted psych for capacity, evaluate that. I just said that. 

Speaker 6: Yeah. And it, it's true. Like we psych in medicine in general, we have these ethical axioms that we follow. Ideally, if anyone could make their own decisions that that's the best thing. Mm-hmm. We want the best for everyone. We also want the best for society.

Speaker 9: Mm-hmm. 

Speaker 6: So the kind of question of justice comes into play. And in an ideal world, we, we could support all these things the same. 

Speaker 9: Right. 

Speaker 6: But the dilemmas come up when they are pitted against each other. And I feel like I'm always in, in between two of those. Yeah. Psych. And, and that's actually where this first kind of case comes up, which is, um, a Supreme Court case, O'Connor versus Donaldson.[00:35:00] 

And this is in 1975 when, um, a patient was without due process, um, institutionalized for about, um, 15. No one really looked into what was going on. And, and the guy just kind of sat there for a long time. So when, when this ended up going to the Supreme Court, they, they made the ruling that there has to be some amount of due process and there has to be like, evidence that this person is, uh, a danger to themselves or other people if we're gonna put them in the hospital and we can't just throw people in willy-nilly.

Speaker 9: Right. 

Speaker 6: And then we have the Mental Health Systems Act, the American Disabilities Act, which are all just kind of like acknowledging mental illness as a part of this. Mm-hmm. And then we get into some other like, really important ones. So now the question is, okay, so now we can detain someone if we have due process that they're harmed to other people.

But can we force 'em to take medications? Can we force 'em to follow up? 

Speaker 7: What is, just to slow us [00:36:00] down? What does due process like mean in this setting? Because I feel like I kind of know what it means, like in the legal setting, but what, what does it mean in this kind of setting for psychiatry or in like the emergency department?

Things like that. 

Speaker 6: Yeah. So, um, the way we conceptualize due process here is, um, with like kind of the burdens of proof or evidence in the legal system. Mm-hmm. So, um, if anyone's talked about having, like probable cause before, beyond reasonable doubt, those are really common. Like things we've probably heard in the mainstream, those are examples of like different levels of proof that you have to provide legally.

So beyond reasonable doubt is like the highest level of proof, which is something to like convict someone of murder for. Mm-hmm. And, and it means that this is very strongly convincing evidence without any person having a doubt that is reasonable in of itself, which, which is a high standard to clear, but probable cause is just suspicion that something could happen.

Mm-hmm. And so this due process means that [00:37:00] someone like a police officer has to have probable cause. So some amount of suspicion or, or I believe it's like 50%. It's more likely than not mm-hmm. Is how they perceive it mm-hmm. To be a danger to themselves or other people. Were they not to be put into like inpatient care?

Speaker 9: Yeah. 

Speaker 6: So for example, if, if I make a statement, like if I, as soon as I leave this hospital, I'm going to kill myself, I'm gonna like walk into my garage and, you know, tie a noose around a ceiling fan. If I said to a police officer, they could reasonably say, I think it's, I think it's more than 50% likely that they're gonna be a danger themselves where they'll leave the hospital.

Speaker 9: Mm-hmm. 

Speaker 6: So I fill out this form that, that says I have probable cause, and then that, that form has to be like presented to, um, the hospital and, and eventually a judge if that's contested by the patient. 

Speaker 9: Right. 

Speaker 6: And that, that's kinda something we call an emergency detainment at this point. [00:38:00] So, so that would be kind of the due process that they receive.

Gotcha. 

Speaker 7: I think one of the parts of this too, I, I know we're gonna keep going, but I think this is true then, and it's true now, is you're, you know, training in Texas, I'm training in Massachusetts states on a lot of these things have different 

Speaker 9: mm-hmm. 

Speaker 7: Laws around mental health and around this kind of thing, which is something that people in psychiatry talk about.

Like if you get trained in a state and not somewhere else, like it can be a huge learning curve to understand the laws and restrictions, not let alone the care system. Um, in terms of these kind of how each state bends towards autonomy at, at all costs versus beneficence or, you know mm-hmm. Whatever at all 

Speaker 6: costs.

Yeah. And it's really interesting to see the differences, like, so I did med school in North Carolina and then now I'm here in Texas, and, and the process is, uh, decently different as far as the restrictions that, that are made and, and also how the judges rule in general. Yeah. 

Speaker 7: I was in Missouri and 

Speaker 6: now I'm in Massachusetts.

So like, [00:39:00] yeah, mental, mental illness is very state dependent. Um, so now that, so we, we have due process to bring people into the hospital, but now kind of the question of how do we safely handle people as they leave the hospital starts to come up. Hmm. So in 1999, um, this, uh, patient who was, um, had schizophrenia, he was admitted multiple times to different hospitals, but uh, would always refuse to take his medications and follow up.

Mm-hmm. I believe his name was Andrew Bernstein. He, uh, is discharged from a New York hospital and walks up to a woman and pushes her in front of the subway. And this is a really high profile homicide. Yeah. And in kind of the investigation of this case, they found that he, he kept getting hospitalized and it was with due process, but then he would just never take his medications when he left.

And then he was still becoming a danger to society. Like he couldn't be held. We don't have asylums to hold him indefinitely anymore. But also we couldn't force him to, um, be treated. And, and then this was kind of the result of that. [00:40:00] So there was a lot of public outcry and it caused this reform called, um, Kendra's Law, that was the name of the woman that died.

And this is that people can be compelled to medications, um, if they're continually like displaying that they're, um, gonna be a harm for themselves or other people so they can be compelled to medications in both like the inpatient and outpatient setting. 

Speaker 7: Yeah. The, I'm sure you're gonna talk about this, the outpatient setting of compelling medicine is, is a.

Tough, tough thing to do in terms of like, how do you actually have the resources and you know, kind of care settings to enforce that. Mm-hmm. Um, it sounds like this is a different thing, but kind of related is like the tarof rule of that, which is like the duty to warn if someone like states like Yeah.

Intention to harm or serious, seriously hurt or kill someone. And it was a similar case I 

Speaker 6: think. Yeah. That was in Berkeley. [00:41:00] 

Speaker 7: Yeah. Yeah. That we to, to end the sentiment, um, that like care teams have to provide warning if there's kind of reasonable, if there's a, if there's good reason to think based on the clinical in like setting or a situation that someone who is going to be released has said like, I'm going to hurt this person.

Or seemed at some point during their care. 

Speaker 6: Yeah. And then that's why like the homicidal ideation Yeah. Becomes very pertinent in, in our screenings. It it is a decently high threshold though. Mm-hmm. Like they have to have a, a specific person and like a time almost like it has to be like an imminent threat.

Speaker 9: Yeah. 

Speaker 6: Because there's been a lot of consults I've had for homicidal ideation where they're just like, you know, this person hurt my sister, you know, and mm-hmm. Why I ought to kill him. 

Speaker 9: Yeah. 

Speaker 6: That's all they can kind of like say about that. And, and then it becomes kind of murky at the end of the day. It's not [00:42:00] like a true, um, duty to inform because this person hasn't like formulated this plan that they're communicating to you.

Speaker 7: But I think this is like that gray zone, right? Like of these ethics coming into conflict with each other in psychiatry, because I think it could be easy to hear. I know you and I have talked about people hating on psychiatry from outside the club and there's, trust me, there's many reasons to hate on psychiatry from within the club and without outside the club, but.

The idea, it would be easy to hear what you just said and kind of say like, well that's awful. Like, why would you, like if someone said they were gonna harm someone, but they didn't have a plan, they easily could get a plan and they could go hurt this person. Like mm-hmm. You just are gonna send them out and not let them do, or let them do whatever they're gonna do.

And it is this ethical battle between autonomy and who ends up being like forced to stay 

Speaker 6: mm-hmm. Versus 

Speaker 7: beneficence, not just for the patients, but like for consideration of the community. 

Speaker 6: Yeah. And confidentiality. 

Speaker 7: Right. And you're limited, very limited, but like, it's very dependent on the laws of the state that you're [00:43:00] in.

Like I do you guys have in our like psychiatric, like emergency forced hold in the hospitals in Massachusetts it's called a section 12, and there's one of three criteria. One is, um, like. Significant risk of harm to self significant. Second one is significant risk of harm to others. And the third one is inadequate ability to like grossly care for oneself and 

Speaker 6: community.

Do you guys have that? So we have a, we have a order of protective custody and it follows the same three criteria. 

Speaker 7: How hard is, is it difficult to do? So I'm not talking and I don't think you're there to clarify though, this is like, not for going to the court and like seeking a judges, but for these, like I immediate, someone comes to the emergency room part, like do you think there's a difference in terms of like when you're in Texas versus when you were in North Carolina for like you had mentioned judges or level of evidence?

Speaker 6: Yeah. So, um, in submitting like the order for protective custody versus the involuntary commitment forms that we [00:44:00] would do in North Carolina, I noticed that in North Carolina people were actually more, more likely to side with the patient, um, and would be more likely to kind of let them go because, um, another.

One that we haven't gotten to but is, uh, Olmsted versus lc was another precedent that established that the patient has to be treated in the least restrictive level of care in addition to this due process. So that's, that's actually usually what the judges cite when they're kind of going off of this. So they, I've seen them ask a manic patient, well, are you gonna take your meds if you leave the hospital?

And they're like, oh yeah, but they haven't been taking their meds in the hospital. And we're kinda like, and then, then he is like, well, I think he can operate on a less restrictive level of care. 'cause he says he is gonna take his medication, so we let him go. 

Speaker 10: Yeah. 

Speaker 6: But then, like the judges in Texas, I found have been like a little bit more hardball with patients mm-hmm.

That are like, kind of take a, a higher threshold of like, competence on the patient's behalf mm-hmm. Before they kind of like [00:45:00] want them to leave. And so it, it, it's actually really fascinating to me because Texas is, and in general is this very like, um. Stay off my lawn, you know, everyone needs to respect my rights, right?

Like I'm, I'm the king in my castle, like, get outta my business government. Mm-hmm. But then as soon as you're mentally ill, Texas is like, what rights? 

Speaker 9: Mm-hmm. 

Speaker 6: You know, like, get 'em, get 'em behind bars, like off the streets. And, and funnily enough, I, I had some attendings that had worked in like Washington or Oregon, uh, and they said that it's the opposite.

It's really hard. It's much harder to, um, fill out orders of protective custody or whether the equivalent is there. I I, I can't verify that for certain. This is all just hearsay, but I've kind of found those to be like, kind of like fascinating differences that like liberal states would be harder to, to commit.

Someone in conservative states may, may be like quicker to, I think there are some parts 

Speaker 7: like we're talking about with this, like the history of mental healthcare, at least in the us like of. I think the [00:46:00] complexity of the subject and the, and the kind of situation of how to best be a community and care for one another with mental health concerns as part of the community that doesn't necessarily always split clearly, at least historically in terms of like, these politics make people do this.

Like there's just so many things that go mm-hmm. Into how people think about mental health and how we care for one another that it's, yeah, I think it's kind of unpredictable in terms of how things like end up state by state. 

Speaker 6: Yeah. And so kind of circling back to now the process that we have today there, there's kind of one final act I wanna talk about, and that's Cell versus United States.

So this is about, um, a dentist, interestingly. So, so Dr. Cell started experiencing some paranoid delusions and was actually initially brought in for, uh, Medicaid fraud and. He developed basically psychosis and was refusing to take his medications and was [00:47:00] incompetent to stand trial. Hmm. And because of this, the court actually compelled him to take medications like his antipsychotics to make him competent enough to like stand trial and face his charges.

So now in addition, so this isn't specifically like criminal cases. Mm-hmm. There's now another president for people to be given medications in order to be able to like, engage with the judicial, uh, punishment system or the court system in general. And then the only like really change that's happened since then, um, that not really change, but a marker is that we now have 9, 8, 8 or this the crisis line.

Mm-hmm. Which is very recent. This is, you know, 2020 to 2022 that we've been able to, to kind of roll this out for patients. 

Speaker 9: Yeah. 

Speaker 6: And that kind of like, kind of wraps up my history part of it. And now. We have these kind of floating precedents and this, this giant context over our heads. But for you in a mental health crisis or for a family member, what does that [00:48:00] process actually look like now?

Speaker 9: And so I, I'll kind of start with the scenario. Okay. So let's say, um, you know, the, there's 

Speaker 6: his, let's call him Michael Michael's, you know, living at home. And he noticed that his neighbor is kind of spying on him. He, he becomes, uh, you know, extra worried that there may be cameras planted around his house.

He starts kind of boarding up his windows. He, uh, starts hoarding water stops, stops going outside altogether, but feels that there's like cars outside that kind of watching him. And then, uh, you know, one day he becomes convinced that his neighbor has like, kind of shut off his water supply uhhuh. And he, he goes and confronts him and they get into a huge altercation.

Someone calls 9 1 1. So the police kind of show up and, and, and Michael's disorganized. He's talking about all these, these plots that are against him. Mm-hmm. And he, he's convinced that, that his neighbors are gonna [00:49:00] kill him. And he, and he says, you know, that he, he's gonna have to defend himself mm-hmm. In a violent way or whatever.

It means they're necessary. So, so the cop is, is clearly concerned about, you know, Michael and then says that, you know, he has probable cause mm-hmm. That he could be harm to other people or himself, you know? Mm-hmm. Uh, there are a lot of ways where people try to defend themselves and then they end up getting hurt.

Speaker 9: Yeah. 

Speaker 6: Because like, like I live in San Antonio, it's a dangerous place if you wanna just go, like, confronting people on the streets. Right. Not the best approach. And then, then they may look at his house and see that, um, you know, he's living in squalor. Mm-hmm. The, there's, the water was actually shut off by the.

The utility company 'cause he wasn't paying his utility bill. Mm-hmm. There's cockroaches over the floor, there's no food in the fridge. And it's clear this person like isn't really able to support themselves either or isn't, not necessarily clear, but there's a lot of suspicion Yeah. That's going on. So in Texas that that police officer would fill out what's called an emergency detention.

Speaker 9: Mm-hmm. 

Speaker 6: And that gives them about 48 [00:50:00] hours for that person to be seen by someone who is an expert in mental health. So, so it's really just the first part is just, does the cop have probable cause? Mm-hmm. That's kind of the initial part. Then he'll come to the emergency department and he'll be seen by an EM doctor and they'll call a psychiatrist Uhhuh, who has two days to do a full evaluation of the patient.

And I, I've always found that to be kind of like a weird timeline. Mm-hmm. What, what have you thought about that? 

Speaker 7: I don't know what the legal one is for Massachusetts. I know once they present to the emergency department, at least in my hospital system, that we have been told by legal for the hospital that once we get the consult they need to be seen by a psychiatrist within two hours.

Um, I don't necessarily think that's the state of Massachusetts 'cause frankly, like that's probably not possible in a lot of parts of the state. Um, it's possible in Boston to have that, but like not, whatever, not not other places. I think that [00:51:00] especially since COVID two days is a long time to spend an emergency department.

Speaker 6: Mm-hmm. Whether you're mentally ill or not. And that's essentially what society decided is, is tolerable. Mm-hmm. For some states that not a psychiatrist, not a doctor, but if a cop suspects you have mental illness, they can hold you for two days point play like period. 

Speaker 7: Yeah. I wanna say for the scenario that you're saying, just for people maybe who are not as much in the field.

The things that are kind of flags that I think do amount to kind of probable cause to hold someone from the story is the details you were giving around like the squalor and unsafety in terms of, at least in Massachusetts, I think also in Texas, like inability to care for self. We think about this a lot with like elder or geriatric psychiatry or elder services in general.

Um, that would be kind of the like third thing we mentioned of inability to care for self and then more pressingly than that. Although that frankly would've maybe been enough to do to, to [00:52:00] at least in Massachusetts to bring them in the hospital. But more pressingly is this kind of increasing unclear paranoia and defensive violent ideation even.

Speaker 9: Mm-hmm. 

Speaker 7: You know, for whatever reason, whether it's like psychosis, hallucinations, you know, there can be substance induced stuff that can happen with this. Like I. Towards others. Um, that is unpredictable by its nature is the probable cause part. I know you know that, but just saying that out loud for our listener.

Yeah. Just, just to 

Speaker 6: clarify. Thank you. Yeah. So, and, and that's, those are the exact things that I would kind of point out in my assessment, so. 

Speaker 9: Mm-hmm. 

Speaker 6: Um, if I'm the psychiatrist, go and assess this patient, I get the story from the police officer, I'd interview the patient and, you know, so if I'm engaging this, this person, Michael, and I see that he's responding to internal stimuli, so that'd mean he's like listening to voices or turning his head to things that aren't actually there.

Mm-hmm. He, he seems, you know, internally preoccupied, maybe he's kind of laughing or talking to himself, and then I ask him about what's going on and he, he gives me, gives me all of these, [00:53:00] um, stories about being pursued or being spied or, or, or we call these ideas of reference mm-hmm. Where he thinks that things are absolutely related to him that aren't necessarily related to him.

He may think that he's being, things are, people are communicating to him through the tv. So as, as. A psychiatrist who's doing this, you know, medical evaluation. I understand those things to be consistent with psychosis or schizophrenia. And then as, as a part of our protocol, we'll we'll call a family member or a neighbor and kind of try to get more of collateral.

A story collateral. 

Speaker 9: Yeah. 

Speaker 6: Yeah. So we, we call that collateral and we. Honestly, that's usually where I get a lot of the information. Yeah. It's very valuable. Yeah. The then, so like a lot of times the story may be like, yeah, like he, he was a nice guy. When I first met him, we didn't have any problems. And then about like six months ago he started acting more reclusive.

It started getting kind of weird. Our interactions got short. I noticed he wasn't really showering as much. Mm-hmm. I actually started to get kind of concerned about him 'cause there's a, you know, a pile of trash building up in his backyard. Yeah. Um, yeah. So, so [00:54:00] we would try to help out, but he never really wanted anything to do with us.

Those are all really huge red flags about this happening. And then, and then 

Speaker 7: there are clinical parts that, like the clinical overlaps with this like safety, you know, autonomy, danger question, which is like, what is the expected course of illness, right? Like, if you have someone who's like. 19. And they like tried PCP for the first time and they've been calm in the ED for two days and linear and their family, like you're saying is like, no, they're not like this at all.

I, I, I have no idea what that was and or a friend corroborates that versus you have a another 19-year-old who's been withdrawing and depressive and increasingly isolated and started to like board themselves in kind of like you're saying in this story. Right. Which, which, and it's a concern for maybe more of a schizophrenia spectrum illness, like what we expect and how much we do detaining wise like that there is that clinical [00:55:00] overlap.

Um, yeah. Which gets into the expertise case. I, 

Speaker 6: yeah. In this case, I don't expect this to be rev self reversible in this patient to immediately be better. Right. Like if this was substance deduced, right. For example, because, because people can do a bunch of methamphetamine experience psychosis and then within hours kind of.

I mean, usually they just kind of start sleeping. Yeah. They cocaine crack or they meth crash. And then it's like, but, but they're not armed for themselves or other people. They, they're just tired and hungry. And I, and I get it. Yeah. Um, so, but, but for this patient who's, who's kind of clearly experiencing psychosis, we would fill out based on those criteria that we talked about earlier.

So I would, you know, because he's making these, um, paranoid and, and delusional statements, uh, explicitly that he's going to harm his neighbor. Mm-hmm. That, you know, I need to defend myself, and then you, you need to provide evidence that he's actually doing those things. So, um, it's helpful to say like, you know, he, he was kind of swinging at this person, but that's hearsay, which is kind [00:56:00] of less helpful.

But if I saw him attacking a nurse or something else, or behaviors, that can be a part of the whole picture. 

Speaker 7: Or if you had like a police officer who was there, a family member and the neighbor there being like, yeah, he swung at me and threw this 

Speaker 6: like, yeah. Verified by multiple sources or something. And then we kind of talk about the, like, first of all, how organized he was with us in this conversation.

Like he, he's not, he's not oriented, he's not able to distinguish kind of reality from his own, like type of pathology or delusions. And then mm-hmm. We have this evidence of him not being able to like, execute the, the activities he needs to live at home. So those would be kind of the criteria. I'd fill this out.

And then once that order of protective custody is filled out, you submit it to a judge and the judge reviews it. And so, so ultimately the judge is the one who decides whether or not the patient is committed to the hospital. 

Speaker 7: Okay. So that's different than ours. Like if someone comes in, like if this person came into a hospital in Massachusetts, we, they would see us like [00:57:00] they would CED, they would consult us, they would see us and then we would say section 12 or not, and commit them inpatient.

Speaker 6: So we, we commit them inpatient while we wait for the judge's response. So you have a judge's response also during that. So. What we do is it, it's, we've committed them inpatient and we've applied for an, for an order of protective custody, but we, we actually only filled the application. So let's say it's like a Friday.

Mm-hmm. The, the court will come around on Monday or Tuesday. So it's like, okay, interesting. We'll hold you in the hospital over the weekend. We've applied for this order of protective custody, and then the judge will see you in court on Monday or Tuesday and review this with you. 

Speaker 7: That's interesting. So we don't do that.

That only happens if, like, we have someone who's on an inpatient unit for like a couple weeks and they're still very sick and they're not responding to anti-psychotics and like we're still really worried and they have no support system and they're still like, like that is when we say, okay, we're gonna file a section, like, I think it's a section eight B, which is [00:58:00] like 

Speaker 9: when 

Speaker 7: we do the, like, okay, we're gonna go to court.

So that for us doesn't happen for a majority of our patients. 

Speaker 6: Wow. So, so maybe I was wrong about Texas. They, they're pretty, pretty hardcore about like. Letting someone be committed even within the first week. So I've had patients that I know PC has applied for, and within 36 hours the judge dismisses it and they leave.

Speaker 7: Wow. Yeah. Ours are like, we have three business days before we have to decide if we would force them to stay longer, and then we would have to apply to court. But then also the time to actually get to court takes like, can it take anywhere? Depending on the court's docket from like a few days to a few weeks.

Mm-hmm. Um, so like if they're like, I wanna leave, but they have to be like, I wanna leave. 

Speaker 6: Yeah. Yeah, yeah. And, and then this is all saying, this is all assuming that every time we talk to this patient, um, he's saying, I don't wanna come into the hospital. Yeah. 

Speaker 9: Okay. 

Speaker 6: No. Part of this care is voluntary. Got it.[00:59:00] 

And, and like, and I guess I, I failed to mention this, but like when I go see the patients in the ED and I say, you know, Hey, like, I think it'd be good for you to come into the hospital. Yeah. There's some things that we can do about. Half the time or a good portion of the time, they kind of, they'll agree.

They'll be like, yeah, I've been really worried. I'm scared of all these things that happen. Can you please just help me with my mental health? And then we actually take away the emergency detention, we don't do anything else. Mm-hmm. And we just say, okay, now you're voluntary to come into the hospital. Okay.

Yeah. And then the whole process becomes different. Got it. Okay. This is only if they're adamantly kind of refusing it and this is against their will 

Speaker 7: if they're okay. So then if they're saying no for us, then in Massachusetts it's three business days. So if someone came in on a Friday, then there three days that they have where the team has to either kind of work with them and you know, discharge them at the end of that three day or go to court, like file for court.

Um, is three business days. So if you came in on Friday and they were like, I don't wanna be here, but the team is so worried that we're, [01:00:00] we admit you to inpatient on the section 12 and you don't sign a voluntary like I do wanna be here form, then you, it wouldn't be until, it wouldn't be until the next end of the next Wednesday that the team would actually have to file for Oh, a court like review on the person.

Speaker 6: I guess that's actually very similar to what we do. Is it? And Yeah. 'cause we, we, we file for the OPC, but, but like you still have a 72 hour waiting period usually. 

Speaker 9: Okay. 

Speaker 6: I just, I know is inconsistent with what I just said. Uh, sorry. The OPC has to be upheld mm-hmm. In court first, and then you get a certain amount of days before it expires.

It has to be upheld again. 

Speaker 7: Yeah. Ours doesn't have any court stuff until we've actually reached the three day and we're like, okay, fine. We're so worried we're gonna apply for court. Okay. See different law. See, but this is like the kind of stuff where it's like. It's actually very difficult that our mental health system is not more uniform.

Speaker 6: 'cause like Yeah. Now I'm, yeah. I'm like, I feel like I've confused myself now. I'm like questioning it. Like, how is my process? 

Speaker 7: I've gone like very deep in this during residency. [01:01:00] Um, and my mom's a lawyer in a mental health court. So like, I've gone very deep in this because I've gotten different answers from different people, like in different years of residency.

And so I like actually the person who is a forensic psychiatrist, um, who I work with, who we're gonna have on the podcast to talk about her work in the Carceral system and some of these questions of like actual, like incarceration, psychiatry, mm-hmm. And forensic psych. Um, but I asked, I asked her this because I was like, what do I actually need to know?

Speaker 8: Like, what, what is actually happening here legally? Because we don't know often. Like 

Speaker 6: Yeah. And, and, and I feel like I've, I've been eating like scrub up on my legalese for a lot of this stuff and, and like it's a lot of my medical decisions like. Extend, like directly into the legal system. 

Speaker 7: You know how you said Excel hates to see me coming.

The legal counsel at my hospital 

Speaker 8: also hates to see me coming. They hate to see my page. 

Speaker 6: Yeah. It's, it's really hard. [01:02:00] Um, they hate 

Speaker 8: to see my page coming. 

Speaker 6: And, and I think that that kind of almost sums up everything that, that I have to say about like kind of the, the inpatient commitment. Yeah. So, so as we, as we talked about, if, if someone kind of still refuses treatment this time, they're still found to be having problems and, and based on these criteria, court can compel them to longer stays.

Speaker 9: Mm-hmm. 

Speaker 6: And it can compel them to take medications. 

Speaker 9: Yeah. 

Speaker 6: And upon discharge can compel them to, to take medications outside the hospital. But those are all things that we kind of discussed before. Yeah. But, but that initial path of like people in the community place, the initial hold. It has to be given enough time for a psychiatrist to do the evaluation, and then psychiatrist's decision has to be overlooked by a judge.

Speaker 9: Mm-hmm. 

Speaker 6: Is the general trend that has followed in most states. 

Speaker 7: Right, right. Yeah. I think, I think as we kind of come to, there's a lot more we could talk about in this episode. Mm-hmm. And I think we will. And then 

Speaker 6: I'm, I don't [01:03:00] think I'm not qualified to talk about it. 

Speaker 7: We will talk about them with this forensics person and also like get more of your guys' feedback on like, what other specific questions you would want to know, um, about this.

I would say in general, in modern, in a lot of states and modern psychiatry, because we do not want to recommit kind of the sins of our past in the last 30 years of maybe overcommitting people. 

Speaker 9: Mm-hmm. 

Speaker 7: I think a lot of places, I don't know. I think there's, there's no easy answer to this question. 'cause there's risk on both sides of like autonomy and beneficence and, 

Speaker 6: and we've seen overcorrection on both sides.

Yeah. You know, we see how bad it is at Bedlam when people are chained and blood led, but we also see how bad it is and when we just kind of open the gates to the asylums and people are left offend for themselves and we add to, to correct back a little bit. 

Speaker 7: Yeah. And when we don't build things into like, like [01:04:00] if we don't have healthcare for, for everyone.

Right. That has been one of the big differences being in Massachusetts versus in Missouri is Massachusetts has one of the most robust, robust, like mass health systems. Mm-hmm. So that there is a lot more actually here than a lot of places in the us. Mass health. Mass health. Uh, but yeah, I just, I think that one of the reasons we wanted to do this episode is I don't think you, nor I nor a lot of psychiatry trainees like mental health, like staff, clinicians, like I.

This is like a lot very serious mental illness where someone is not themselves is very, very hard. Kind of any way you slice it, there's not really mm-hmm. An easy answer and there's not really a, a cure in a straightforward way. Yeah. 

Speaker 6: It's a hard question to form and it's even like messier question to try to answer.

Yeah. 

Speaker 7: Because I think either [01:05:00] way we can say even when we do this as well as possible in like the current science, it is a painful thing. And I think it's a painful some, it's painful for someone to be like psychotic. It's like the worst 

Speaker 6: part of my day, honestly. Yeah. Like, like straight up. I hate committing people against their will.

I hate being the extension of the legal system. 

Speaker 9: Yeah. 

Speaker 6: I understand that I have to do it and it's kinda like my duty as being this like representative of mental health. 

Speaker 9: Mm-hmm. 

Speaker 6: And I think the history and the context helps, but it sucks, dude. Oh my God. Ah. 

Speaker 7: And I think one of the things going as someone going into a child and like having worked.

Some months in child, child rotations and emergency rotations. It's like we experience a tiny fraction, I think, of what people who care about these patients experience when they have to be like, they're not doing well and I'm worried I'm gonna lose them if, if we don't do something that they're gonna be very angry at me for.

Speaker 9: Yeah. 

Speaker 7: And there's just, I mean, it, it [01:06:00] makes me almost kind of emotional to talk about it. There's just like not an easy answer for it. And that doesn't mean our field is perfect and that there aren't ways the system can be abused in ways that we want this to be better. But it's just a really, in some ways I think of it like caring in palliative, in like oncology or palliative care or any part of healthcare where you're like really getting to know people who are sick and we can't, we can't just like give them an antibiotic or give them a medication and like their illness is gone.

Like there's a grief in this work. 

Speaker 6: Yeah. Um. I think like when I see patients, you know, banging on, on our locked doors in, in a carceral feeling unit, the the ghosts of Bedlam are still with us. And same with, you know, cure rides, asylums. We, we have these antipsychotics, they often don't do a great job and we kind of dilute ourselves in having this biological model.

And we really, it's the custodial one a [01:07:00] lot of times. And or like you said, the palliative one. 

Speaker 7: Yeah. 

Speaker 6: And the, and it, it's strange to kind of look upon the modern psych board and think about how much history has brought us to this position. And, and I'm hopeful that we take some more lessons from our past because I, because I think we've completely abandoned the moral cure and I think there's room for that to come back, 

Speaker 7: bring back going to the sea.

Speaker 6: No, seriously, dude, like bring back, I go to these patient rooms, I'm like. A window, please 

Speaker 8: mething, God forbid a psych patient catch a vibe. Like, 

Speaker 6: yeah. That, that's actually why I even started my whole, um, nonprofit. Yeah. Propagations. Like we mm-hmm. We actually sent our first package out today. Awesome. We awesome.

We're sending headphones and books and clothes, just stuff to make things like a little bit nicer. 

Speaker 9: Yeah. Awesome. 

Speaker 6: So, um, I guess this is my unapologetic plug, but if you're not familiar, I have a, um, a nonprofit called Propagations. You can, it's on my link tree or at propagations if you wanna support us. And, and all [01:08:00] we do is we find ways to send things to psych wards to make them a little bit better just because VHS tapes and granite walls and no windows is like not the best way to handle things when you're in crisis.

And we can go full cure ride, but we, we try 

Speaker 7: not soothing, not soothing. I mean, I think we should go. Full, uh, full, like McLean style. Let's get these, let's get these houses on some hills. Let's get them ice. Like let's get some, there are all these pictures of like, people like ice skating, like McLean used to be much bigger than it actually is now, and there are pictures of like people ice skating and sitting on the lawns having picnics.

It was not a perfect place then either, but there are definitely these moments things you see, nor is 

Speaker 9: it now 

Speaker 7: where you're like, oh wow, like not bad. That is part of like whether you're experiencing psychosis or severe depression or not, like having ability to like access parts of being a human is important while you're getting care in an inpatient 

Speaker 6: facility.

Mm-hmm. Absolutely. Well said. [01:09:00] So, uh, uh, with that, I think that wraps up our episode. Thank you so much for listening. If you like the show, tell us what we think. If you want us to do more history type episodes, if you like this dynamic of a Preston episode to Margaret episode, let us know. We may turn this into a poll later where we can see whose episodes are more well, well-liked.

No, we doing and I can start sabotaging Margaret episodes actively. If you wanna come chat with us, you can find our, our podcast family Anywhere. I was on Instagram and TikTok at Human Content Pods. We also have. How to be patient on Instagram standalone. Now we're up to 1600 followers. We are vibing, DM us there.

I I usually take screenshots of your, um, messages and I'm, I'm putting them in a table of content ideas. This, this actually episode came from a DM from someone who wanted to know more about the car or like the psychiatric detainment process. If you wanna listen to us, that's awesome. You can find us on Apple Podcast and Spotify.

If you wanna watch us while we talk, you can go on YouTube where full episodes are available on my, um, channel at its pre. Thanks [01:10:00] again for listening. You can, we're your hosts. 

Speaker 7: Leave us reviews also help us in terms of Apple podcasts. I think maybe Spotify. I don't really know how Spotify reviews work.

Speaker 6: Leave us reviews everywhere. It helps us. 

Speaker 7: It does actually help us like we mm-hmm. Season two AKA us actually being like, we need to have, think about our metrics. 

Speaker 6: We need to business business advisor. But apparently this is supposed 

Speaker 7: to be a business you guys. Um, yeah. You can find Preston on his channels.

You can find me on bad art every day where I'm struggling to figure out how to integrate the fact that I am a doctor. Like I change my bio on there. Every 

Speaker 6: once in a while, I'll say it's OO Okay. Art about every other day. 

Speaker 7: Okay. She, she, 

Speaker 6: she doesn't post every single day. Well, I post on 

Speaker 7: Substack. Girl. You just dunno how to read.

Speaker 6: I don't have the attention span. You don't 

Speaker 8: have the attention span. You're, you're part of those co you're like, can chat GPT Read her Substack for me. 

Speaker 6: Okay. Well, before I outsource the rest of my thoughts, time to get through the intro or the outro. Thanks again for listening. We're your host, Preston Roche and Margaret Duncan.

Our executive producers are me, [01:11:00] Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To learn more about our program, disclaimer and ethics policy submission verification and licensing terms, and our HIPAA release terms, go to How to Be patient pod.com or reach out to us at How to Be patient Human content.com with any questions or concerns.

How to be patient is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.[01:12:00] 

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.